Practice Guideline Briefs

Treatment of Infantile Spasms

Am Fam Physician. 2004 Jul 15;70(2):399-400.

Treatment of Infantile Spasms

The American Academy of Neurology and the Child Neurology Society have released new guidelines on treating infantile spasms. “Practice Parameter: Medical Treatment of Infantile Spasms” appears in the May 2004 issue of Neurology and is available online at http://www.neurology.org/cgi/reprint/62/10/1668.

Infantile spasms, also called West Syndrome, is a rare disorder that usually begins in infants four to six months of age and stops by the age of two to four years. The spams are a type of seizure associated with sudden flexion or extension movements. Infantile spasms rarely respond to the usual antiseizure medications. Most children with infantile spasms have developmental disabilities later in life.

The authors of the guideline reviewed all of the scientific studies on the topic. According to the authors, there are not many well-designed, prospective studies on infantile spasms, and more research is needed to answer many questions about the treatment of this disorder.

According to the guideline, adrenocorticotropic hormone is probably effective for the short-term treatment of infantile spasms. However, there is not enough evidence to recommend the optimum dosage and length of treatment. There also is insufficient evidence to determine whether oral corticosteroids are an effective treatment for infantile spasms.

The drug vigabatrin is possibly effective for the short-term treatment of infantile spasms and is possibly effective for children with tuberous sclerosis. The evidence suggests that the vision of children taking vigabatrin should be tested regularly, because the drug can affect the retina.

There is insufficient evidence to recommend other treatments for infantile spasms, and there is insufficient evidence to conclude that successful treatment of infantile spasms improves the long-term prognosis, according to the authors.

Dystocia and Augmentation of Labor

The American College of Obstetricians and Gynecologists has released a practice bulletin on dystocia and augmentation of labor. “ACOG Practice Bulletin Number 49: Dystocia and Augmentation of Labor” appears in the December 2003 issue of Obstetrics and Gynecology and is available online at http://www.greenjournal.org/cgi/reprint/102/6/1445.

Dystocia, characterized by the slow, abnormal progression of labor, is the leading indication for primary cesarean delivery in the United States. One out of every 10 women who give birth in the United States has had a previous cesarean delivery. Because many repeat cesarean deliveries are performed after primary operations for dystocia, an estimated 60 percent of all cesarean deliveries in the United States are attributable to dystocia. With decreasing rates of vaginal birth after cesarean delivery, dystocia is the leading cause of both operative vaginal delivery and cesarean delivery and their accompanying complications.

Despite the high prevalence of labor disorders, considerable variability exists in the diagnosis, management, and criteria for dystocia that requires intervention.

Among the recommendations are the following:

• Patients should be counseled that walking during labor does not enhance or improve progress in labor, nor is it harmful.

• Continuous support during labor from caregivers should be encouraged because it is beneficial for women and their newborns.

• Active management of labor may shorten labor in nulliparous women, although it has not consistently been shown to reduce the rate of cesarean delivery.

• Amniotomy may be used to enhance progress in active labor but may increase the risk of maternal fever.

• Radiographic pelvimetry alone as a predictor of dystocia has not been shown to have benefit and, therefore, is not recommended.

• Intrauterine pressure catheters may be helpful for women when the evaluation of contractions is difficult because of such factors as obesity.

• Women with twin gestations may undergo augmentation of labor.

Recommendations for Exercise After Stroke

The American Heart Association; Council on Cardiovascular Nursing; Council on Nutrition, Physical Activity, and Metabolism; and the Stroke Council have released a scientific statement on exercise for stroke survivors. “Physical Activity and Exercise Recommendations for Stroke Survivors” appears in the April 27, 2004 issue of Circulation and is available online at http://circ.ahajournals.org/cgi/content/full/109/16/2031.

The statement is the first attempt to provide exercise guidance to stroke survivors. Stroke care has traditionally focused on acute stroke treatment or rehabilitation during the first few months following stroke. According to the statement, at least 20 minutes of aerobic exercise, three to seven times a week, can help reduce the risk of recurrent stroke.

An estimated 700,000 people in the United States experience a stroke annually, and about one third of those are recurrent strokes. Strokes can reduce the ability to exercise, and depression (that often accompanies stroke) can suppress the motivation to exercise. These problems can create a “vicious circle” of further decreased activity and greater exercise intolerance, leading to secondary complications such as reduced cardiorespiratory fitness, muscle atrophy, osteoporosis, and impaired circulation to the lower extremities in stroke survivors.

Physical activity is a cornerstone of risk-reducing interventions for preventing and treating stroke and myocardial infarction. Moreover, exercise can improve the quality of life among stroke survivors by strengthening muscles and improving mobility—all with the goal of restoring function.

Stroke survivors should undergo a complete medical history and physical examination before beginning an exercise program. Special adjustments may be needed, such as adding handrails or harnesses to exercise equipment.

The guidelines recommend that stroke survivors engage in 20 to 60 minutes of aerobic exercise such as walking three to seven days per week. The exercise can be done in 10-minute intervals with the goal being at least 20 minutes per day.

Stroke survivors often have muscle weakness, so the statement recommends strength training with light weights or resistances that allow at least one set of 10 to 15 repetitions to be performed. Strength training should be done at least two to three days per week and should include eight to 10 different exercises involving the major muscle groups.

The body is often less flexible after a stroke, which can make raising arms, moving legs, and performing various activities of daily living more difficult. Stroke survivors should do stretching and flexibility training before or after aerobic or strength training sessions on two to three days a week. Because stroke survivors often have balance problems, which put them at risk for falls, the statement suggests two to three sessions each week of balance or coordination exercises.


Copyright © 2004 by the American Academy of Family Physicians.
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