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Galen is one of those authors who have been rediscovered by classicists and students of ancient philosophy alike buy finax 1 mg with visa symptoms yellow fever, be it for his literary output purchase finax 1mg free shipping medicine prices, his mode of self-presentation and use of rhetoric buy cheap finax on-line medicine 54 543, the picture he sketches of the intellectual discount finax 1mg without prescription symptoms exhaustion, social and cultural milieus in which he works and of the traditions in which he puts himself, and the philosophical aspects of his thought – both his originality and his peculiar blends of Platonism, Hippocratism and Aristotelianism. Galen’s work, voluminous in size as well as in substance, represents a great synthesis of earlier thinking and at the same time a systematicity of enormous intellectual power, breadth and Introduction 29 versatility. In chapter 10, I shall consider Galen’s theoretical considerations about pharmacology, and in particular his views on the relationship between reason and experience. Although in the field of dietetics and pharmacology he is particularly indebted to the Empiricists, his highly original notion of ‘qualified experience’ represents a most fortunate combination of reason and experience; and one of Galen’s particular strengths is his flexibility in applying theoretical and experiential approaches to different domains within medical science and practice. Among Galen’s great rivals were the Methodists, a group of medical thinkers and practitioners that was founded in the first century bce but came to particular fruition in the first and second centuries ce, especially under their great leader Soranus. Although their approach to medicine was emphatically practical, empirical and therapy-oriented, their views present interesting philosophical aspects, for example in epistemology and in the as- sumption of some kind of corpuscular theory applied to the human body. Regrettably, most works written by the Methodists survive only in frag- ments, and much of the evidence is biased by the hostile filter of Galen’s perception and rhetorical presentation. Caelius has long been dismissed as an unoriginal author who simply translated the works of Soranus into Latin. However, recent scholarship has begun to appreciate Caelius’ originality and to examine his particular version of Methodism. This overlap not only concerned the ideas, concepts and method- ologies they entertained, but also the ways and forms in which they ex- pressed and communicated these ideas, the modalities of dissemination and persuasion, and the settings in which they had to work and present 32 For a collection of the fragments of the Methodists see now Tecusan (2004). I touch here on a further aspect in which the study of ancient medicine – and philosophy – has recently been contextualised, and in this case the impetus has come from a third area of research we need to consider briefly because of its particular relevance to the papers collected in this volume, namely the field of textual studies or, to use a more recent and specific term,‘discourse analysis’. One only needs to point to the twenty-two volumes of Kuhn’s¨ edition of the works of Galen or the ten tomes of Littre’s´ edition of the works of Hippocrates to realise that ancient medical literature has been remarkably well preserved, at least compared with many other areas of classical Greek and Latin literature. While much philological spade-work has been done to make these texts more accessible, especially in projects such as the Corpus Medicorum Graecorum or the Collection des Universites de France´ , many parts of this vast corpus of literature, to which newly discovered texts continue to be added, still await further investigation. There still is, of course, a great basic demand for textual studies, edi- tions, translations, commentaries and interpretative analyses – and in this respect, the triennial conferences on Greek and Latin medical texts have proved remarkably fruitful. Yet apart from this, there is an increasing in- terest being taken in medical, scientific and philosophical texts, not just because of their intellectual contents but also from the point of view of linguistics, literary studies, discourse analysis, narratology, ethnography of literature (orality and literacy), rhetoric and communication studies. This is related to a growing scholarly awareness of the communicative and com- petitive nature of Greek medicine and science. Greek doctors, philosophers, astronomers and mathematicians had to impress their audiences, to per- suade them of their competence and authority, to attract customers and to reassure them that they were much better off with them than with their rivals. Medical, scientific and philosophical texts functioned in a specific setting, with a particular audience and purpose, and served as vehicles not only for the transmission of ideas but also for the assertion of power and authority. These developments have given rise to a whole new field of studies and questions regarding the ways in which knowledge was expressed and com- municated in the ancient world: the modes of verbal expression, technical idioms, stylistic registers and literary genres that were available to people who laid a claim to knowledge (healers, scientists, philosophers) in order to convey their views to their fellows, colleagues and their wider audiences; the rhetorical strategies they employed in order to make their ideas intel- ligible, acceptable, or even fashionable; the circumstances in which they Introduction 31 had to present their ideas, and the audio-visual means (writing facilities, diagrams, opportunities for live demonstration) they had at their disposal; the interests and the expectations of their audiences, and the ways in which these influenced the actual form of their writings; and the respects in which ‘scientific’, or ‘technical’, or ‘expert’ language or ‘discourse’ differed from ‘ordinary’ and ‘literary’ language and ‘discourse’. After many years of considerable neglect, the last two decades have thus seen a significant increase in attention being given to the forms of ancient scientific writing, especially among students of the Hippocratic Corpus, but also, for example, on Latin medical literature, with some studies focusing on ‘strictly’ linguistic and textual characteristics, while others have attempted to relate such characteristics to the wider context in which the texts were produced. First, general trends in the study of rhetoric and discourse analysis, in particular the study of ‘non-literary’ texts such as advertisements, legal proceedings, minutes of meetings, political pamphlets and medical reports, the study of rhetoric and persuasive strategies in apparently ‘neutral’ scien- tific writings, and the development of genre categories based on function rather than form have led to a growing awareness among classicists that even such seemingly ‘unartistic’, non-presumptuous prose writings as the extant works of Aristotle, the Elements of Euclid and the ‘notebook-like’ Hippocratic Epidemics do have a structure which deserves to be studied in its own right, if only because they have set certain standards for the emergence and the subsequent development of the genre of the scientific treatise (‘tractatus’) in Western literature. It is clear, for example, to any student of Aristotle that, however impersonal the tone of his works may be and however careless the structure of his argument may appear, his writings nonetheless contain a hidden but undeniable rhetoric aimed at making the reader agree with his conclusions, for example in the subtle balance be- tween confident explanation and seemingly genuine uncertainty, resulting in a careful alternation of dogmatic statements and exploratory suggestions. The study of these formal characteristics has further been enriched by a growing appreciation of the role of non-literal, or even non-verbal as- pects of communication (and conversely, the non-communicative aspects of language). Aesthetics of reception, ethnography of literature and studies in orality and literacy have enhanced our awareness of the importance of 34 For more detailed discussion and bibliographical references see van der Eijk (1997), from which the following paragraphs are excerpted. Here, again, discourse studies and ethnogra- phy of literature have provided useful instruments of research, for example D. Hymes’ analysis of the ‘speech event’ into a number of components that can, not without some irony, be listed according to the initial letters of the word speaking: setting (time, place, and other circumstances), scene (e. A recent German collection of articles on ‘Wissensvermittlung’ (‘transmission of knowledge’) in the ancient world gives an impression of the kind of questions and answers envisaged from such an integrated approach. At this point, a most fortunate connection can be perceived between linguistically inspired approaches within classical philology and the recent surge of a ‘contextual’ approach in the history of science, whereby the text is seen as an instrument for scientists and practising doctors to use to define 35 Hymes (1972) 58ff. Introduction 33 and assert themselves, to establish the position of their profession and to gain authority and power. Again, the variations the Hippocratic Corpus displays with regard to the use of rhetoric (not only the well-known Gorgianic figures of speech but also argumentative techniques, analogies, metaphors, etc. Such an awareness has led to greater caution in the establish- ment of doctrinal ‘parallels’ or ‘inconsistencies’ between different works of the same author, which would have been used as evidence of a development in doctrine or even as a basis for declaring a work genuine or spurious. Such caution is inspired by a consideration of differences in genesis (single or multiple authorship), status (e. Thus it has been attempted to relate varying degrees of philosophical sophistication in some of Plato’s dialogues to differences between the au- diences for whom they were intended (as indicated by the contribution of the interlocutors),41 and something similar has been attempted with regard to differences in method – and to some extent also doctrine – between the three treatises on ethics preserved in the Aristotelian Corpus. Similar formal characteristics of medical and philosophical texts affecting the interpretation or evaluation of particular passages and their relation to other passages in the same work or in other works lie in the field of ‘genre’, where, again, the sheer variety in forms of expression is particularly striking. When, how and for what purposes prose came to be used for the transmission of knowledge in the late sixth century bce and why some writers (such as Parmenides and Empedocles, or in later times Aratus and Nicander) preferred to write in verse when prose was available as an alternative, is not in all cases easy to say. Yet the Hippocratic Corpus provides opportunities to gain some idea of the process of text-production and genre- formation, and one can argue that medicine has played a decisive role in the formation of scientific literature. The variety of forms of writing referred to above is manifest already within the Hippocratic Corpus itself. Airs, Waters, Places; On the Sacred Disease ; On the Nature of Man), show a degree of care and elaboration on account of which they deserve a much more prominent place than they now occupy in chapters on prose in Greek literature. Here we do have a large body of texts generally agreed to be by one author (although there 41 Rowe (1992). Yet any general account of Aristotle’s philosophy is bound to begin with a discussion of the problems posed by the form and status of his writings. Do they represent the ‘lecture notes’ written by Aristotle himself on the basis of which he presented his oral teaching? Or are they to be taken as the ‘minutes’ or ‘verbatims’ of his oral teaching as written down by his pupils? Certainly, some characteristics of his works may be interpreted as evidence of oral presentation;44 and with some (parts) of his works it is not easy to imagine how they might have been understood without additional oral elucidation – although this may be a case of our underestimating the abilities of his then audience and an extrapolation of our own difficulties in understanding his work. However, other parts of his work are certainly far too elaborate to assume such a procedure. A further point that has attracted considerable attention is the relation between orality and literacy. Although the details and the precise signifi- cance of the process are disputed, the importance of the transition from orality to literacy for Greek culture and intellectual life can hardly be over- stated. Since the majority of the Hippocratic writings were produced in the late fifth and early fourth centuries bce, the Corpus testifies in a variety of ways to this transition. Thus it can safely be assumed that several treatises, especially the older gynaecological works On Diseases of Women and On the Nature of the Woman, which contain long catalogues of prescriptions and recipes, preserve traditional knowledge which has been transmitted orally over a number of generations. Moreover, several treatises explicitly refer to oral presentations of medical knowledge, such as the author of On 44 For examples see Follinger (¨ 1993) and van der Eijk (1994) 97; for direct references to the teaching situation see Bodeus (´¨ 1993) 83–96. Such a situation is almost certainly envisaged by the au- thors of the two rhetorically most elaborate works preserved in the Corpus, the already mentioned On the Art of Medicine and On Breaths, in which Gorgianic figures of speech and sound effects abound, such as parallelism, antithesis and anaphora. However, the oral transmission of medical knowledge not only served the purpose of self-presentation to a larger, non-specialised audience, but also had a didactic, educational justification: medicine being the practical art it naturally is, the importance of oral teaching and direct contact between the teacher and the pupil is repeatedly stressed. Thus both Aristotle and his medical contemporary Diocles of Carystus acknowledge the usefulness of written knowledge for the medical profession, but they emphasise that 48 The author of On Ancient Medicine begins his work by referring to ‘all who have attempted to speak or to write on medicine and who have assumed for themselves a postulate as a basis for their discussion’ (1.

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Reserpine (1) Reserpine eliminates norepinephrine release in response to nerve impulse by prevent- ing vesicular uptake. It depletes norepinephrine from sympathetic nerve terminals in the periphery and in the adrenal medulla. Mental depression, sometimes severe, may result, especially with high doses; use of reserpine is contraindicated in patients with a history of depression. Vasodilators relax smooth muscle and lower total peripheral resistance, thereby lowering blood pressure. This effect is probably mediated by increasing K+ efflux and decreasing Ca2+ influx, and increasing the production of nitric oxide. Minoxidil acts to increase K+ efflux, which hyperpolarizes cells and reduces the activity of L-type (voltage-sensitive) cal- cium channels. The accumula- tion of cyanide and risk of toxicity are minimized by concomitant administration of sodium thiosulfate or hydroxocobalamin. Administered by infusion, it is a useful drug in the control of emergency hypertension. Drugs used to treat pulmonary hypertension (1) Ambrisentan (Letaris) is a selective endothelin A receptor antagonist used to treat pul- mory hypertension. Drugs used to treat erectile dysfunction (1) Drugs in this class include sildenafil citrate (Viagra, Revatio), tadalafil (Cialis), and var- denafil hydrochloride (Levitra). Chapter 4 Drugs Acting on the Cardiovascular System 91 (2) Viagra was originally developed as an antianginal and antihypertensive agent but proved very effective in treating erectile dysfunction. The most serious adverse effects are cardiovascular: arrhythmias, heart block, cardiac arrest, stroke, and hypotension. Dietary or pharmacologic reduction of elevated plasma cholesterol levels can reduce the risk of atherosclerosis and subsequent cardiovascular disease. The exact factors linking elevated cho- lesterol levels to heart disease are not yet known. The association between cardiovascular disease and elevated plasma triglycerides is less dra- matic, but it is becoming more recognized. Cholesterol is a nonpolar, poorly water-soluble substance, transported in the plasma in par- ticles that have a hydrophobic core of cholesteryl esters and triglycerides surrounded by a coat of phospholipids, free cholesterol (nonesterified), and one or more apoproteins. Diseases of plasma lipids can be manifest as an elevation in triglycerides or as an elevation in cholesterol. In several of the complex or combined hyperlipoproteinemias, both triglyc- erides and cholesterol can be elevated. These drugs include lovastatin (mevinolin) (Mevacor), simvastatin (Zocor), pravastatin (Pravachol), and fluvastatin (Lescol), atorvastatin (Lipitor), and rosuvastatin (Crestor). Inhibitors of cholesterol biosynthesis are effective in reducing choles- terol levels in familial and nonfamilial hypercholesterolemias. These drugs may also interfere with in- tracellular localization of certain oncogenes and thereby reduce the incidence of some cancers. Mechanism (1) Nicotinic acid can exert cholesterol- and triglyceride-lowering effects at high concentra- tions (nicotinamide cannot do this). Adverse effects (1) Nicotinic acid commonly produces flushing and an itching or burning feeling in the skin, which may reduce compliance. This is mediated by prostaglandin and histamine release and can be diminished by taking aspirin 30 minutes before taking nicotinic acid. Gemfibrozil (Lopid) (1) Gemfibrozil is a fibrate that is more effective than fenofibrate in some circumstances and has some unique biologic activities. Cholesterol is absorbed from the small intestine by a process that includes specific transporters that have not been completely characterized. Ezetimibe appears to block one or more of these choles- terol transporters, reducing cholesterol absorption. Ezetimibe used alone produces a reduction in plasma cholesterol of about 18% and about a 10% decline in triglyceride levels. When combined with a statin, reductions in plasma cho- lesterol as high as 72% have been reported in clinical trials. Ezetimibe appears to be well tolerated, with the most common adverse effects being fatigue, abdominal pain, and diarrhea. These agents include cholestyramine (Questran), colestipol (Colestid), and colesevelam (WelChol) a. Structure and mechanism (1) Bile acid sequestrants are large copolymers (resins) of hydrocarbons that can bind bile salts. Adverse effects (1) These agents are generally quite safe, because they are not absorbed in the intestine. A patient with a long history of cardiovascu- (D) Nifedipine lar disease develops worsening ventricular (E) Propranolol arrhythmias. A 16-year-old boy is brought to the hospital (A) Quinidine by ambulance following a car accident causing (B) Propanolol serious head injuries. Funduscopy reveals retinal dam- (D) Methyldopa age, and you administer nitroprusside via infusion. A patient is admitted into the emergency 72 hours and you notice the patient becoming room and manifests ventricular tachycardia fol- increasingly fatigued and nauseous. Which of the following nitroprusside drugs would be best to quickly control the (B) Negative inotropic activity of nitroprusside condition? His past medical work-up to diagnose the cause of a large multi- history includes a recent myocardial infarction nodular goiter develops atrial fibrillation. You decide that a medication side effect is the most likely cause of this (A) Verapamil patient’s symptoms. A 57-year-old man with atrial flutter is ini- (D) Digoxin tially treated with quinidine to control the ar- (E) Quinidine rhythmia. He is released from the hospital, and while his condition improves, sporadic arrhyth- 7. Which of the following drugs prescribed preclude the patient in the above might be used as an adjunct to quinidine in the scenario from taking it, you switch him to ther- treatment of the atrial flutter?

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Meningovascular syphilis tends to occur on average seven years after initial infection and results from inflammatory damage to the blood vessels in the subarachnoid space buy discount finax line medicine man 1992. This causes a series of primarily small-artery strokes 1 mg finax sale treatment ibs, often somewhat slowly evolving buy generic finax treatment 5th toe fracture, typically accompanied by chronic headaches from the meningitis order 1 mg finax with mastercard medications 2 times a day. One to two decades after disease onset other patients will develop “general paresis of the insane,” a more diffuse picture thought to result from a combination of chronic hydrocephalus and parenchymal gummas. Finally, some patients will develop tabes dorsalis two to three decades after initial infection—primarily a disorder of the dorsal roots (which cross through the chronically inflamed subarachnoid space). These same patients often develop parenchymal inflammation in the midbrain causing Argyll Robertson pupils. Oral doxycycline (200 mg daily for four weeks) is recommended and used as an alternative in penicillin-allergic patients, despite a paucity of supportive studies. Listeria Listeria is a widely prevalent organism that only rarely causes human disease. Infection most often occurs by exposure to contaminated food, most often dairy products. Infections are particularly problematic in pregnant women (causing miscarriages) and newborns (causing disseminated infection). Neurologic involvement takes several forms, most typically meningitis, being the commonest cause of bacterial meningitis in the immunocompromised and the second most common in healthy adults over age 50. The clinical picture of this meningitis is often more indolent than in other meningitides; patients appear less ill and the time course is more protracted. The organism is very sensitive to ampicillin and penicillin, but perhaps because of its intracellular location, slow to respond. Consequently, gentamicin is often added for synergy and treatment is typically prolonged. Diagnosis is generally by measuring either cold agglutinins or specific antibody titers. Viral Brain Infections Herpes Simplex Encephalitis Human herpes viruses, similar to polioviruses, differ from many other encephalitis-causing viruses in that they have just one host—humans. Because of this it is at least theoretically possible to eliminate these pathogens entirely—primarily through effective vaccines. While sufficiently potent vaccines are not yet available for herpes simplex, this strategy has eliminated smallpox and hopefully will eliminate polio in the not too distant future. Unfortunately, this approach cannot eliminate the innumerable other viruses, such as West Nile and rabies, which are zoonoses, existing in multiple species. Even with successful vaccination, the best that can be hoped for with zoonotic infections is temporary protection of the immunized individuals, not permanent elimination of the virus and therefore the disease. Periodically the virus will migrate back down the axon, causing a recurrent cutaneous eruption. The sensory neurons of the trigeminal nerve, which innervate the lips, also innervate the meninges of the middle and anterior cranial fossa. Experimentally, reactivating virus can be shown to migrate centrally, affecting the medial temporal and frontal lobes, the primary site of involvement in herpes simplex encephalitis. Two important (and probably interrelated) functions of the medial temporal lobes are olfaction and memory. Early manifestations of this necrotizing, localized infection often consist of focal seizures manifest as olfactory hallucinations and perceptions of deja vu or jamais vu. Often a diagnosis is not made´ ` until the patient has a generalized or at least focal motor seizure. The diagnosis should be considered in a previously healthy individual with abrupt onset of altered mental status and fever; headache is present in most. Since other brain infections can be clinically similar, confirmatory testing is necessary. Its major complication is renal toxicity; this risk can be decreased with aggressive hydration. The role of steroids is unclear, without substantial evidence supporting their use. Other Herpes Viruses Neurologic complications used to accompany about 1 of every 10,000 cases of chickenpox (19). Cytomegalovirus can cause 160 Halperin ventriculoencephalitis and dementia in the immunocompromised. Ebstein–Barr virus has been associated with a similar clinical picture, but has not been shown to respond to acyclovir or other antivirals. Unlike herpes, West Nile is one of the large group of diseases referred to as arthropod borne, or arboviruses. West Nile appears to have been brought to the United States by infected birds and was originally recognized for being highly lethal in some but not all bird species. Key to the transmissibility of any of these infections is its production of prolonged viremia in some host species, and the presence of mosquitoes or other vectors that feed on both the infected reservoir species and on humans (22). This interspecies promiscuity is essential to the transmission of this large group of pathogens, which can persist in the environment in reservoir hosts, and periodically infect humans when a large group of nonimmune individuals is exposed. Since there are hundreds of asymptomatic or minimally symptomatic infections for every neuroinvasive case, “herd immunity” normally takes over after the infection is present in the environment for a period of time—presumably the reason the incidence of cases has moved like a wave across the United States from east to west since its initial introduction. West Nile is a flavivirus (the family that includes and is named for Yellow Fever virus), a broad group that includes dengue, tick borne encephalitis, Japanese encephalitis, and St. In the Middle East, serologic studies indicate up to 40% of the population has had asymptomatic infection. Disease severity increases with age, with most mortality occurring in individuals over 50. Neuroinvasive disease causes meningitis; a polio-like syndrome of flaccid lower motor neuron–type weakness occurs in about half. Involvement of the brainstem and basal ganglia appears to be common with extrapyramidal syndromes, tremors and ataxia occurring with some frequency. Rabies Fortunately human rabies is extremely rare in the United States, with typically 1 case per year nationwide. However there is a significant incidence among animals, and when human cases occur, there often is some delay in diagnosis, resulting in additional individuals being exposed, and then requiring prophylaxis. Transmission requires transfer of virus-containing secretions or tissue through mucosa or broken skin. Since the virus has an affinity for the muscle endplates, infection is particularly efficient when a bite introduces the virus directly into muscle. Once introduced, virions are transported within axons to the dorsal root ganglion neurons and multiply, then on to the spinal cord and brainstem. Once the virus is in the nervous system, patients develop fever, anxiety, muscle aches, and nonspecific symptoms. Neuropathic symptoms ranging from itching to pain may develop at the inoculation site. In the former, patients develop a Guillain Barre–like picture, with fever, sensory and motor symptoms, facial involvement, and sphincter dysfunction. More common is the encephalitic form in which patients develop inspiratory spasms, precipitated by any Encephalitis and Its Mimics in Critical Care 161 contact with the face, including trying to drink (hydrophobia).

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Conclusion: rehabilitation therapy showed the effect on geriatric residents who We determined that short-term vibrator stimuli has the potential to were considered to be “not disabled” among those who transferred improve dyskinesia through this case order finax paypal symptoms of kidney stones. In this case proven 1mg finax denivit intensive treatment, the enhanced proprioceptive information induced by vibrator stimuli may improve dyskinesia order 1mg finax mastercard symptoms 0f low sodium. Material and Methods: A trunk fexion and extension and the specifc ranges of motion review was performed by obtaining publication of all papers from have been recommended to objectively assess muscle function in various databases reporting on postural control and gait pattern in chronic low back pain patients discount 1mg finax with amex symptoms 5 dpo. The keywords age (<40 versus 40 to 60 versus >60 years) and sex related differ- used for literature searching were ‘postural control’, ‘balance’, ences during a standardized trunk fexion-extension task. Material ‘spatiotemporal gait parameters’, ‘diabetes mellitus’, and ‘diabetic and Methods: A total of 216 patients [62 aged 60–90 years (33 peripheral neuropathy’. The searching was limited to English, aca- females), 84 aged 40–59 years (44 females), and 70 aged 18–39 J Rehabil Med Suppl 55 Poster Abstracts 217 years (34 females)] performed testing by holding static positions tive method of gait training. The lumbar extensor mus- chronic stroke patients who were more than six months post-stroke cle activity and the ranges of motion at the hip and lumbar spine participated in this study. All participants were randomly assigned were recorded and calculated from L5 and T4 levels. Ridge regressions investigated mill training, foot switches were attached to the participants’ heel the impact of physical-functional and psychological variables on and Microsoft visual C++ 2011 software was used. Results: Measurements pants started to walk and make an initial contact on their less af- revealed highest muscle activity at standing in the oldest and fected side, the software sensed the foot pressure through the foot the female group. Patients over 60 years showed lowest activity switch and provided real-time auditory stimulation for the partic- changes from standing to the half (increments) and from half to the ipants. Patients in the treadmill group received had higher gross trunk ranges of motion than males. Conclusion: This standardized trunk fexion- sessment of static balance and gait abilities: Balancia (software), extension task involving isometric test positions is feasible for Timed Up and Go Test. Results: Signifcant differ- pattern and the kinematics changed according to age and sex. Kigawa2 ods: Five patients who had subacute hemiplegia over 3 months, 1Hanno City, Japan, 2Hanno-Seiwa Hospital, Rehabilitation Cent- less than 12 months after they were diagnosed as stroke patient by er, Hanno City, Japan, 3Saitama Medical University- International physician were participated. In addition occupational performance satisfac- walking with lateral Nordic pole and T-cane in the stroke patient. After walk speed was stable, we caluculated integrated vale of myoelectric potential (mV. Kim2 support the weight with use of T cane, which could cause the risk 1Sahmyook University, Physical Therapy, Seoul, Republic of Ko- of carpal tunnel syndrome. Tekin1 Introduction/Background: The purpose of this study was to meas- 1 Gulhane Military Medical Academy - Haydarpasa Research and ure the effectiveness of a rehabilitation program in a population of Training Hospital, Physical Medicine and Rehabilitation, Istanbul, patients with ataxic neuropathy and to determine the infuence of age on the gains observed in static and dynamic conditions. Mate- Turkey rial and Methods: Twenty two patients with characterized bilat- Introduction/Background: Spasticity in stroke patients is one of eral sensory ataxia were included in this study. It may affect patients’ self-care and criterion was proprioceptive loss with a decrease in joint position activities of daily living and disrupts the patient’s appearance, bal- sense at the big toe level or reduced turning torque perception at ance and walking pattern. All had clinical, electrophysiological and histologi- of focal and multifocal spasticity such as streching, bracing, oral cal data corresponding to a well defned polyneuropathy. Material and Methods: The instrumental evaluation of balance and gait was performed us- A 57-year-old woman with 41 months history of stroke resulting ing a force Platform and a Locometre. The rehabilitation program in right hemiplegia was admitted to our outpatient clinic. She had consisted of 15 sessions (three sessions per week for fve weeks, spasticity of the elbow, wrist and hand on the right side. Botulinum each session lasting 2 hours and 30 minutes) comprised of differ- toxin injection treatment was planned but we applied dry-needling ent exercises aiming to improve sensory perception, and static and before botulinum toxin injection. Results: Patients were divided in two subgroups pronator teres, fexor carpi radialis, fexor digitorum superfcialis corresponding to a middle-age group (medium age =55 y) and an and profundus were needled with 0. Needling was applied using fast-in and fast-out method control assessed using the three clinical tests improved similarly during 30 seconds for each muscle. Results: Dystonia on the wrist in both groups (Two ways Anova training x age, training effect and fngers was observed immediately after dry needling. Degree of spasticity was measured were able to increase the contribution of sensory afferent with a sig- same, 15 minutes after the dry needling, in comparison to baseline. Chang- Conclusion: There are some reports demonstrating positive effects es in instrumental data were note signifcant. We experienced dys- results show that ataxic patients can improve their balance with tonia and nondecreasing spasticity with dry needling in our case. We believe that there is need for further studies in the larger group Nevertheless, an age effect can be pointed out as older adults un- of patients, with control groups and longer follow-up periods of less younger do not succeed to improve sensory integration during patients, in order to reach a defnitive judgement on this issue. However, there is a paucity of data on the and alternative therapies, played a vital role for stoke patients. How- actual practice amongst the rehabilitation physicians in the coun- ever, the intrinsic mechanism of different modalities of acupuncture try. In order to decrease the effect of post-stimulation of email to practicing rehabilitation physicians working in Malaysia. This study obtained the approval from the Ministry terclockwise for 1 min at a rate 60 times per minute. In this study, the col and one respondent was unsure of the availability of the proto- therapeutic effectiveness of phenol motor point block in patients with col. Material and Methods: Twelve patients the future development of the local spasticity management program. A sig- Sahmyook University, Physical Therapy, Seoul, Republic of Korea nifcant positive correlation between therapeutic effectiveness and Introduction/Background: The purpose of this study was to inves- presence of self-exercise (ρr=0. Although the of the intervention on the paretic upper extremity 3 sessions per week effect of Botulium toxin A injection is different from person to per- during 4 weeks. Material and Methods: Forty,26 and 17 chronic stage of stroke beta power, concentration and activation. The frst time injection was per- (C4) and Beta power (C3 and C4), concentration (F3, F4 and C3) formed at 1380 days after the onset of stroke, while the average in- and activation (C4) (p<0. Introduction/Background: Spasticity, defned as a velocity-depend- Domen2 ent increase in tonic stretch refexes, disturbs activities of daily living 1Sasayama Medical Center Hyogo College of Medicine, Depart- in patients with cerebrovascular disorders. We report a patient with subarachnoid 2 3 4 hemorrhage who underwent orthopedic selective spasticity control Ogino , M. Material and Methods: A 41-year- ment of General Medicine and Community Health Science, Sasay- old man suffered from subarachnoid hemorrhage (Hunt & Kosnik ama Hyogo, Japan, 2Sasayama Medical Center Hyogo College of grade 5) due to the rupture of an anterior communicating artery an- Medicine, Department of Rehabilitation, Sasayama Hyogo, Japan, eurysm. He underwent the craniotomy clipping and lumboperitoneal 3Nishinomiya Kyouritsu Rehabilitation Hospital, Department of shunt surgeries for the treatment of hydrocephalus, which he devel- Rehabilitation, Nishinomiya Hyogo, Japan, 4Hyogo College of oped later. He was discharged on the 239thday and returned home, but was admitted in our hospital for further rehabili- Introduction/Background: The evaluation of the spasticity is essential tation on the 256th day. However, there is no established quantitative evaluation of the lower limbs were very diffcult to treat and had limited the knee the spasticity currently. We recorded M-response, H-refex and T-refex ure score improved by 21 points at discharge, compared to that at by tibial nerve stimulation of the affected side before and 4 weeks admission.