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When a nerve impulse arrives at a synapse, chemical substances are released. These are neurotransmitters, which are stored in pre-synaptic vesicles. On release they cross the synaptic cleft and bind to receptors on the post-synaptic neuron. Binding of neurotransmitter with its receptor is very brief, but it brings about stimulation or inhibition of the post-synaptic neuron. See Figure transmission.

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The site of decarboxylation of levodopa in patients with Parkinsons disease is uncertain, but it may be that there is sufficient enzyme in the remaining dopamine nerve terminals or that conversion takes place in other neurons as they also contain decarboxylase enzymes. Release of dopamine replaced in this way must be very abnormal but most patients seem to benefit. Improvement takes about two to three weeks. Hypokinesia and rigidity are both reduced but tremor is not. Overall, there is improvement in facial expression, manual dexterity, gait and speech.

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Resistance to them can occur by several mechanisms. Vancomycin also inhibits cell wall synthesis by a slightly different mechanism at an earlier stage. This antibiotic is still effective against most strains of MRSA and has to be given intravenously because it is not absorbed well enough to be effective orally. It is useful in patients who are allergic to penicillin. Adverse reactions to vancomycin are fever, rashes and rarely ear and kidney toxicity.

The most common side effects of imidazoles are irritation and itching of the skin. Some imidazoles are known to interact with oral hypoglycaemic drugs by enhancing their activity and they may increase the risk of myopathy with lipid lowering drugs statins. Some imidazoles enhance the anticoagulant properties of warfarin. However, these interactions are unlikely with topical application. Systemic administration of imidazoles is often necessary for tinea of the nail.

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A hybrid of ON DNA and mRNA forms, which prevents translation of the mRNA. This means that the effect of the original oncogene is blocked. Cancer cells produce enzymes that can breakdown the extracellular matrix between normal cells and allow cancer cells to invade and spread in normal tissue. New drugs are being developed that inhibit these enzymes. In order for tumours to grow they need to develop a blood supply.

This leads to increased amounts of acetylcholine available to interact with remaining receptors and so improves the ability of muscles to contract. An example of an anticholinesterase drug is pyridostigmine. Side effects of these drugs include excessive salivation, muscle twitching and abdominal pain, nausea and diarrhoea. Anti-inflammatory corticosteroids, for example prednisolone, can be used to suppress the antibody formation in myasthenia gravis. They should be used together with anticholinesterase drugs and once an improvement is seen the dose should be decreased.

Specialist knowledge allows the physiotherapist to explain to patients in these situations how to take their medication for best effect and could help improve compliance. A GP or a consultant, whichever is relevant, would have to be involved in the initial development of a CMP and review process so that physiotherapist could prescribe medication as appropriate for individual patients. Extended scope practitioners are clinical physiotherapy specialists with extended roles who see patients referred for assessment, clinical diagnosis and management. Their work often encompasses tasks that may previously have been undertaken by a medical practitioner. Areas of extended scope practice include rheumatology, paediatrics, orthopaedics, neurology, respiratory care and musculoskeletal medicine.

Initially, episodes of inflammation last only a week or so with no symptoms in between. However, untreated acute attacks occur more frequently and chronic inflammation results in damage to affected joints leading to stiffness and limited mobility. Attacks of gout usually develop very quickly. The first attack often occurs in the middle of the night with the sufferer waking up with extreme joint pain.

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