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Claire Henchcliffe, MD, DPhil, trained at Oxford University, England, where she completed her doctoral degree in Molecular Biology, prior to post-doctoral neuroscience research at the University of Cambridge, England, and the University of California at Berkeley. This article presents management considerations in patients experiencing LD-related motor fluctuations via a case study of a patient experiencing motor fluctuations in more advanced disease and while receiving combination therapy. A 68-year-old woman with a 5-year history of PD presents to her neurologist with complaints of early-morning slowness and stiffness, as well as calf muscle spasms and toe cramping.
The patient is a homemaker, is very active in several charities and community organizations, loves to read, and belongs to several book clubs.
The patient is worried about her health and concerned about being able to maintain her independence. An alternative to the narrowing of the therapeutic window hypothesis has been proposed after a retrospective analysis of data from 3 studies of the effects of 2-hour LD infusions in patients with idiopathic PD.6 Investigators found that onset and offset of the antiparkinsonian response and dyskinesia were similar when dyskinesia first emerged.
Our patient is active and involved in either part-time work or community activities, and has a diagnosis of PD with motor fluctuations. Treatment decisions for these types of patients should be individualized, based on patient-related factors, including comorbidities, age, and cognition, with the goals to minimize adverse effects from any selected PD medications while providing convenient therapy regimens to which they can adhere easily.
Fahn S, Oakes D, Shoulson I, et al, for the writing committee of the Earlier versus Later Levodopa study. AZILECT® (rasagiline tablets) is indicated for the treatment of Parkinson's disease (PD). AZILECT is contraindicated with meperidine, tramadol, methadone, propoxyphene, dextromethorphan, St. Dietary tyramine restriction is not required during treatment with recommended doses of AZILECT. Concomitant use of AZILECT and antidepressants is not recommended; serotonin syndrome has been reported with concomitant use with an antidepressant or MAO inhibitors. Patients treated with AZILECT and other dopaminergic medications have reported falling asleep while engaged in activities of daily living, including the operation of motor vehicles. Patients receiving AZILECT with adjunct therapy have reported orthostatic hypotension, especially in the first two months of treatment. The most common side effects as monotherapy (AZILECT 1 mg, placebo, respectively [%]) include flu syndrome (5, 1), arthralgia (7, 4), depression (5, 2), and dyspepsia (7, 4). The most common side effects as adjunct to dopamine agonists (AZILECT 1 mg, placebo, respectively [%]) include peripheral edema (7, 4), fall (6, 1), arthralgia (5, 2), cough (4, 1), and insomnia (4, 1). The most common side effects as adjunct to levodopa therapy (AZILECT 1 mg, 0.5 mg, and placebo, respectively [%]) include dyskinesia (18, 18, 10), accidental injury (12, 8, 5), weight loss (9, 2, 3), postural hypotension (9, 6, 3), vomiting (7, 4, 1), anorexia (5, 2, 1), arthralgia (8, 6, 4), abdominal pain (5, 2, 1), nausea (12, 10, 8), constipation (9, 4, 5), dry mouth (6, 2, 3), rash (6, 3, 3), abnormal dreams (4, 1, 1), fall (11, 12, 8), and tenosynovitis (3, 1, 0). Male 23-year-old intramural soccer player diagnosed with postconcussion syndrome resulting from a fall. Assessment and treatment were completed in two sessions of 45 minutes spaced two days apart. Using the Balance Error Scoring System (BESS) and self-report, the outcome measures showed diminished concussion symptoms and regained ease in range of motion in the cervical area. Positive results for this case highlight the potential importance of massage therapy work to reduce headache, dizziness, and nausea in concussion recovery. The CDC describes TBI as injury caused by a bump, blow or jolt to the head or a penetrating head injury that disrupts the normal function of the brain, with severity ranging from ‘mild’ to ‘severe’.
To address the American Academy of Neurology’s call, this case study describes the results of a manual therapy treatment approach for mTBI.
This retrospective mTBI case study illustrates the application of massage therapy techniques in efforts to allow the atlanto-occipital joint to correct into preferred anatomical position for a patient with diagnosed post-concussion condition with persistent symptoms. A 23-year-old male graduate student sustained a head injury during an intramural soccer game.
After three weeks he returned to the health clinic as he was experiencing continued symptoms including headache, nausea with movement (such as leaning over to tie shoes), and difficulty concentrating on computer tasks.
The massage practitioner’s intake procedure included review of the patient’s medical chart, patient’s general health and history of the event, treatment since the trauma event, and patient complaints including intensity, duration, and frequency of signs and symptoms.
Once the patient was on the table, palpation of the pelvic, cervical, and shoulder region was done to assess muscle hypertonicity and strength in these areas.
One month following the injury incident, the patient received two massage therapy sessions focused on concussion care, each 45 minutes in length.
The patient was observed and evaluated for postural balance, specific cervical symmetry, pain level, and symptoms at each session prior to applying treatment.
The patient lay clothed, in a prone position on a massage table for the start of each treatment. After work on the pelvic girdle was complete, as indicated in Table 2, the muscle groups and fascial tissues surrounding the erector spinae were “warmed” using gentle massage strokes.
The patient was then asked to turn so that he lay supine on the table and the focus of the massage techniques moved to the cervical and cranial region. The atlanto-occipital imbalance was addressed at the end of the treatments with experienced palpation (which can detect vertebral transverse processes at C1) serving as an essential component. From a level position, the practitioner used visual observation on the sagittal plane to assess whether one transverse process was more posterior and one more lateral. The practitioner held with the index finger on the transverse process of the atlas, stabilizing it through the patient’s movement of rotation for a pinning and stretching effect of the attached muscles. The patient took a deep breath at the end of ROM, held the position for 15 seconds for relaxation, and then slowly returned to forward facing position. To detect lateral glide of the cranium, the practitioner gently provided traction to the cervical area to extend the muscle and fascia. It was observed that one side moved laterally more than the other, and a second pinning and stretching technique toward the more flexible side was used in an effort to reduce hypertonicity. Fascial tissue in the posterior and anterior cervical area was addressed with effleurage, petrissage, friction, and fascial release, followed with manual lymphatic drainage in the neck area to conclude the treatments.
To insure stability and to record the postural balances and tests, the patient returned a week later for a discharge appointment from the postconcussion treatments.
Although no further follow-up visits or assessments were scheduled as part of the treatment plan, additional follow-up was possible due to patient visits to the clinic for other services which afforded communication between the practitioner and patient. The patient initiated cordial contact again six months later, stopping by the clinic to “check-in,” report his improved status, and thank the therapist. This case study documents a specific massage intervention to address postconcussion treatment and demonstrates the utility of such an approach in restoration of the atlanto-occipital joint to anatomically preferred placement for symptom reduction. These dysfunction factors may emerge as concussion symptoms of headache, dizziness, and “fuzziness”.
There are clinical implications for delivery of this type of intervention in concussion treatment. This case study demonstrates the potential benefits of massage therapy techniques for concussion related symptomology. Online pharmacies are strictly regulated in the United Kingdom by several government agencies that oversee the healthcare industry: the Care Quality Commission, the General Pharmaceutical Council, the Medicines and Healthcare products Regulatory Agency and the General Medical Council. The regulating agencies are there to ensure the highest standards in online healthcare, we as consumers must ensure we only deal with regulated healthcare services as it is in our best interests. The Care Quality Commission (CQC)The CQC is the official regulator of private healthcare in the UK including online clinics.
Pharmacies and chemists that dispense and despatch medicines are regulated by the General Pharmaceutical Council (GPhC).
The MHRA has responsibility for standards of safety, quality and performance of medicines and enforces strict rules on advertising. Services below are CQC registered, employ GMC doctors and post medicine from GPhC registered pharmacies.
Yes - there is legal framework in the UK for doctors to issue prescriptions online for delivery in most European countries. Estimates vary, but around 40% of men suffer from ED, also known as impotence, at some time in their lives. Erectile dysfunction is not always the result of any other illness and it sometimes happens to men who are otherwise very healthy and medically fit. Middle aged men who are troubled by erectile dysfunction often have no one specific problem which explains their symptoms. Anything which affects the circulation, such a high cholesterol or high blood pressure can cause impotence. Text books divide erectile difficulties into few types - circulatory causes (vascular) or erection difficulties caused due to problems with the nervous system (neurogenic) or due reduced hormone levels (endocrine) or even those caused by emotional or psychological factors (psychogenic). ED and diabetes: Diabetes not only affects the blood circulation in the body, it also affects the nervous system. ED and alcohol and smoking: Not every man who smokes or drinks alcohol suffers from ED, but it is known that men who do smoke and drink alcohol are more likely to get ED. ED and cardiovascular diseases: Most number of heart ailments happen due to either narrowing of arteries or due to reduced blood supply to the heart because of some blockages in the arteries. All men with erectile difficulties should inform their doctors about it as it could sometimes be an indicator to general problem with circulation. Online clinics can provide advice and information, and assessments of ED and can be a reliable source of genuine medication, but care must be taken to use only reputable clinics.
ED is also considered to be a warning for problems in the blood flow which can cause other major ailments.

At times, ED can also be caused as a result of some previous surgery or as a side effect to certain medicine and in both the cases it becomes imperative to tell the doctor as quickly as possible so that he can find both the cause and solution of this problem.
The most popular and common treatment given by doctors to ED patients are pills containing PDE5 inhibitors, such as Cialis, Viagra or Levitra. These pills are often combined with psychological counseling of the patients which helps them cope with their stress, anxiety and other such concerns.
There are other treatments apart from tablets, which may be more appropriate in some cases, for example, where erection problems starts after an operation, or results from spinal injury or where PDE5 drugs are ineffective or are contraindicated. Counselling can be effective when the erectile problems are more situational and emotional. Testosterone injections were a popular treatment in some parts or the world a few years ago and are coming back into favour with some doctors in the UK. When obtaining medication online it is important that checks for contraindications are undertaken and that only genuine tablets and not fakes are supplied. These tablets are available online from reputable clinics although prices vary greatly and care is needed in selecting an online clinic to ensure only genuine medication and not fakes are obtained. PDE5 inhibitors are truly special amongst all medications in that they almost exclusively work in the correct areas of the body when the man needs it with minimal side effects. All the 3 PDE5 inhibitors work only if the man is aroused - they do not cause automatic erections and neither are they aphrodisiac. These oral medicines increase a chemical that promotes blood flow in the penis thereby causing healthy strong erections.
As with any medication, tablets should be used with care and on the advice of doctors, and the patient information leaflets which are included in pill packs should be followed.
Related InformationPenile InjectionPenile injection is one of the oldest yet most effective therapy for dealing with erectile difficulties. In this modern age of medicine, someone who is suffering from erectile dysfunction can quite often be treated with oral medication.
Heart Attacks can be fatal whereas erectile dysfunction does not cause any true danger to life.
In his early twenties, he was involved in an incident in which he was attacked, and seriously damaged the nerves in his left leg. This was followed up with a long process of chemotherapy, during which he suffered two cardiac arrests. Session 2: I did dry cupping and massage cupping on all over back, , shoulders, biceps and triceps.
Session 4: I did dry cupping on back, neck and shoulders to increase circulation and lossen muscles. I performed the first session of hijama for general detox, and a little pain in the trapezius area. Please give us feedback and leave comments below about what would you like to read about next insha Allah. Download your FREE introduction and guide to Hijama Therapy and learn why it is one of the most powerful forms of treatment. That's why we created this comprehensive peer-to-peer resource of Parkinson's disease expertise—an expedited way to search information within the neuroscience community. She received her medical degree from the College of Physicians and Surgeons of Columbia University, NY, and completed her Neurology Residency and Movement Disorders Fellowship at New York Presbyterian Hospital. Henchcliffe is a member of medical organizations including the American Academy of Neurology, Movement Disorders Society, and Parkinson's Study Group, and is a fellow of the American Neurological Association. Also considering the age of this patient, she may be on multiple medications for other age-related comorbidities. Practice parameter: treatment of Parkinson disease with motor fluctuations and dyskinesia (an evidence-based review).
Monitor patients for new-onset hypertension or hypertension that is not adequately controlled after starting AZILECT. However, patients should be advised to avoid foods containing a very high amount of tyramine because of the potential for severe increases in blood pressure, also referred to as hypertensive urgency, crisis, or emergency.
Massage practitioners who specialize in rehabilitation deal with a variety of injury cases that involve concussion, including those incurred by falls, motor vehicle incidents, and sports injuries.
Massage therapy techniques were applied to injury areas by a Licensed Massage Practitioner. In the presence of such outcomes, massage therapy may also have a supportive role in a person’s return to function after concussion.
TBI results from external causes of falls, motor vehicle incidents, sports, and military incidents.
Massage practitioners who specialize in rehabilitation of patients’ medical conditions deal with a variety of injury cases including those incurred by falls, motor vehicle incidents, and sports injuries. This case study provides a clinical care example of massage therapy to address concussion related symptoms in an effort to educate the therapeutic massage and bodywork field and promote future research. The patient sought care from his primary care provider at the university’s student health center.
He described his thinking as “fuzzy”, and reported that he was unable to operate a fishing boat and was only able to focus on data analysis for 15 minutes at a time.
Table 1 outlines the assessment tools, methods, and rationale used in the completion of this case study. A foundation principle for this case’s treatment plan is the concept that when there is imbalance in the symmetry of the body or body part, antagonist muscles contract in an effort to pull the body back to anatomically preferred position. These sessions were administered two days apart at a medical center clinical massage office.
One week after the second treatment application, the patient returned for a follow-up appointment during which information was collected but no massage intervention was applied.
In acknowledgment of its role to provide a base for spinal structure and function, treatments began with the pelvic girdle and moved up the body to the cervical area.
The shoulder girdle muscle groups with cervical attachments were then massaged using effleurage, petrissage, circular frictions, linear frictions, fascial releases, and tender point releases to reduce hypertonicity to normal tonus. The same massage techniques highlighted above were used to release fascial and muscular tissues, specifically the suboccipital muscle and ligamental attachments. Bilateral palpation of the transverse processes of the cervical vertebrae was done to note the positional balance, rotation or glide and hypertonicity of attached muscles. Moving slowly and gently, the patient followed the verbal prompt to rotate his head to the right. Effleurage and gentle friction were then applied with the intention to release contracting muscle and fascia tissues.
Firmly supporting the head with both hands, keeping traction level, and moving laterally, she asked the patient to contract lateral muscles to assist movement in each lateral direction.
Severe muscle hypertonicity extended bilaterally in the shoulder girdle, reducing range of motion in the cervical and shoulder joints. During such an encounter one month after the patient’s discharge from care, he reported in person that, after the treatments, he had incrementally returned to his normal student course work load, daily computer use of several sessions of 2 hours apiece each day, and short periods of physical conditioning, including fitness running, swimming, and light weights. An anatomical review of the cervical and cranial brain stem structures(22) highlights the complexity and wide-spread effects of trauma to this area during concussion.
In conjunction with the incongruous relationship between the cranium and atlas, there may be an asymmetrical alignment of the eyes and inner ears, which affects balance and produces symptoms of headache and dizziness, as well as nausea and vomiting. The techniques used in this case study are not those typically taught in foundational massage and bodywork programs. More specifically, it is the clinical judgment of this bodywork practitioner that massage therapy techniques restored ideal alignment of the atlanto-occipital joint for the patient described.
For the mentorship and excellent workshops teaching about balancing the body, my thanks to Paul St. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths 2002–2006.
Symptomatology and functional outcome in mild traumatic brain injury: results from the prospective TRACK-TBI Study. Pilot of a novel intervention for postconcussive symptoms in active duty, veterans, and civilians. Hyperbaric oxygen therapy benefit in traumatic brain injury (TBI) [Lecture at BIALA New Orleans 2013].
Reduction of current migraine headache pain following neck massage and spinal manipulation.
Consensus statement on concussion in sport: 4th International Conference on Concussion in Sport held in Zurich, November 2012.
Summary of evidence-based guideline update: evaluation and management of concussion in sports. All UK online doctor and pharmacy services providing prescription-only medicines must be registered by law. Some of them which have a negative impact on erection are stress, age and certain illnesses. Impotence can be caused due to both physical as well as psychological reasons affecting men.
Good erections occur when there is a good blood supply to the penis and the blood vessels are working well. On the other hand the circulation may be fine, but the signals going from the brain to the blood vessels of the penis via the nervous system may be faulty in some way. When it is not controlled with the right treatment and within the right time period, this illness is known to cause ED in men.

This happens because smoking is known to negatively affect the blood circulation in body and alcohol creates hormonal imbalance and poor sleep quality, which can lead to impotency. When the arteries begin to narrow, this is not restricted to arteries around the heart only, the ones in the pelvic region also get affected and that is why a lot of heart patients suffer from ED. Often the doctor may prescribe PDE5 inhibitors like sildenafil and ask to refrain from smoking and encourage to adopt a healthy lifestyle. That is why any erection problems should not be ignored and you would be well adviced to consult your GP as soon as you observe any such issues. But, since the blue pill was the first to arrive on the scene, it is still the most popular oral PDE5 inhibitor and most men start with the blue pill. Here, he is going to share a case study of one of his patients who had lots of medical and personal complications. He has no control from the knee down, and has to wear a brace to support his foot when he walks. After extensive treatment, he has been cleared of the cancer and recovered from the heart problems. When I spoke to him the next day, he reported an increase in sexual energy and definite improvement in vision, as well as pain relief in the trapezius area.  I performed Hijama according to the Hijama Nation course guidelines for ED. We invite you to return often to this curated network of articles and videos to easily find neurologists' perspectives on Parkinson's disease, treatment options and ongoing discussions with your colleagues. He reported that his headache pain was in the 8–9 level range on a 10-point scale in which 10 is most severe. The physical assessment involved postural observation to assess for any imbalances or asymmetries in the pelvic girdle, shoulder girdle, cervical area.
Using massage techniques, the practitioner focused on release of myofascial tissues, reduction of hypertonicities in muscle groups with origins in the cervical area, and insertions in the shoulder girdle such as levator scapula, sternocleidomastoid, and scalenes. Following this, gentle caudal traction to the spine was provided while cradling the cranium in both hands. During this process, the practitioner instructed the patient that he was in charge of his movements and that, if he had any pain or discomfort, he was to stop. These severe muscle hypertonicities presented in both anterior and posterior aspects of the cervical region.
In addition, he mentioned that he was able to complete activities of daily living, operating trucks and fishing boats, performing fitness activities of soccer and running, enjoying social activities of viewing movies on screen and playing cards, as well as handling his work on computer screens as he had done prior to the head trauma. The following may also provide insight into the possible underlying mechanisms responsible for the positive outcomes highlighted by this case study. Facilitating return to preferred anatomical form through therapy allows for function restoration. Rather, advanced massage or manual techniques are needed to learn these treatment mechanics, and can be best found through specialized workshops involving physical manipulation techniques.
There was a reduction in pain, muscle hypertonicity, headaches, and reduced medication use, as well as improved balance, posture, cervical range of motion, mental focus, and physical activity. Unfortunately, only a few diabetic patients are able to get the treatment sponsored by NHS and the ones that are eligible, receive limited tablets every month. Another important fact is that it is considered to be very risky to combine alcohol and ED medications in the body and one should be careful to not do something like this.
Heart patients are often prescribed nitrate containing medications and they are known to hamper the working of ED medications if taken at the same time. Medications can also be injected directly into the base of the penis to produce short-lived erections in difficult to treat cases. It lasts for a few hours and the effects are noticeable within an hour of taking the tablet if the man is sufficiently aroused. Along with Cialis and Levitra, it is a very effective drug for one of the most troubling conditions men suffer from, erectile dysfunction.
After the first session of hijama, he mentioned that he had also been suffering from Erectile Dysfunction for the last two years. Her research interests are in biomarkers and novel therapeutic development, including cell-based therapy. The American Academy of Neurology (AAN) recognizes concussion as a clinical syndrome of biomechanically induced alteration of brain function, typically affecting memory and orientation, which may involve loss of consciousness.(16) The Consensus Statement on Concussion in Sport(17) says that concussion is “due to a complex pathophysiological processes affecting the brain, induced by biomechanical forces”. The patient also reported motion sickness with car or boat travel, which was particularly troubling because he did field work for his graduate research aboard a boat. At this point, the provider, familiar with the concussion and trauma work of the author, referred the patient for massage therapy treatment.
Then standing balance was evaluated using the static postural stability clinical test, Balance Error Scoring System (BESS),(20,21) which involved standing on two feet and then one foot with eyes closed using both a hard and soft standing surface. Table 2 outlines the position, techniques, objectives, and rationale used in planning the individualized integrated body treatment.
Briefly, his range of motion, balance, and physical symptoms had all resolved with no adverse events. This case study demonstrates a complete return to preconcussion activities and function with no continued symptoms following a short and specific massage series. In addition, experience with head trauma is important and likely best found through medical massage and rehabilitation medicine environments. The massage therapy approach used in this case study is a reproducible and efficient intervention for practitioners with advanced training in physical manipulation techniques and sensitive palpation skills. Therefore it is important to control diabetes as soon as possible and with the right medications. Cialis on the other hand can stay in the system and have the potential to work anytime if the man is aroused during the following 36 hours. I understood that he was probably too embarrassed to mention it in the original consultation, and suggested that we could do a specific treatment for that.
After the Hijama session, he felt an improvement, but only for a few days, then back to normal. The atlanto-occipital joint can be slightly subluxated as a result of concussion trauma impact. The headaches were accompanied by nausea and difficulty concentrating such that they interfered with normal functioning and daily tasks.
There were no other modalities applied to the patient other than prescribed massage therapy.
The BESS evaluation has moderate to good reliability to assess static balance which includes feedback functioning from visual, somatosensory and vestibular systems.
The patient was unable to perform any elements of the balance testing, even with eyes open.
The complexity and length of care needed to address the biomechanical effects of concussion depend on the trauma’s severity and extent. The positive findings from this case study provides preliminary evidence for massage therapy techniques to be used as an intervention for concussion-related symptomology, especially in cases of subluxation of the atlanto-occipital joint.
It is for this reason that the medicine is termed the weekend pill and might be better suited for unplanned sex.
The importance of addressing positioning of the atlanto-occipital joint in the treatment of concussion is apparent in the biomechanical studies of head trauma by Viano(18) and Unterharschneidt(19) that demonstrate the multidirectional movements of the cranium in relationship to the atlas in the atlanto-occipital joint during a trauma event.
Treated at the scene with ice compresses, he was sent for medical evaluation which indicated no fractures or bleeding. Scoring is based on the number of times the person commits errors including opening of eyes, removing hands from hips, lifting heels or forefoot from surface, moving hips more than 30° of flexion or abduction, stepping, stumbling, or falling, or staying out of the testing position more than 5 seconds.
When the patient moved from vertical to horizontal or vice versa, it intensified the vertigo and nausea. The location of the impact, head kinematics, as well as age, gender, sport or trauma setting, neck muscle strength and flexibility, are variables that factor into the severity of the concussion. The nonpharmacologic treatment approach used in this case study needs further research examination to better determine its effectiveness in meeting the American Academy of Neurology’s call(16) for new interventions to improve postconcussion treatment.
I did some further research on the condition and more consultation with him before the next session.
Overall, he was happy with the treatment he received and was very impressed with the technique which I used, and the information which I gave him about the treatment. The head kinematics include rapid head displacement, z-axis rotation, and neck tension up to the time of maximum strain in the midbrain.(13) It was the premise of this case study that a subluxated atlanto-occipital joint can be effectively returned to its anatomical position using soft tissue massage and manual therapy techniques to reduce concussion symptoms. The patient denied seizures, worsening headaches, vision changes, hearing loss, difficulty with speech, memory loss, and loss of strength or sensation in extremities.
The primary care provider prescribed several medications for symptom resolution, as well as rest. Through palpation and visual assessment of the atlanto-occipital area, an imbalance and incongruity in the interrelationship of the C1 and cranium positioning, strength, and balance in supporting structural muscles were observed. He eventually disclosed that it was memories of previous relationships that were making him feel guilty. He has had Hijama before from one other therapist, and in comparison, he preferred the treatment he received from me, because I had a more holistic approach, looking at diet as well as treatment, Alhumdulillah.

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