R. Fraser. Pennsylvania State University at Altoona.

Chapter 9 • Rehabilitation and Re-education (Movement) Approaches 339 that of radial contraction order evista 60mg free shipping. Radial contraction is also known Willard (1996a–c) explains that once a sensitization as a precursor to movement in the human organism buy evista 60mg low price, has occurred at a spinal segment purchase 60 mg evista with mastercard, that facilitation can such as the transversus abdominis feed-forward be maintained by just a very mild afferent input to the mechanism (Richardson et al 1999) generic evista 60 mg with visa. Singular radial cord (and can perpetuate for several days after the contraction and expansion may initially have devel- initial stimulus has gone due to plastic changes within oped as a primitive means of phagocytosis. Such sensitization will become more ‘plastic’ the longer the sensitization is maintained. This 2 or 3 months of pain (and cumulative afferent drive to movement pattern eventually combined forward the cord), that person may consult a therapist for movement with digestion, where previously diges- treatment. At this point, even if the therapist were able tion was bidirectional and therefore would have com- to ‘magic’ the tissue trauma away, the patient would promised attempts at forward movement. Equally, contraction clearly requires a nervous system to if that patient were to start to feel better and so use orchestrate it, leading to the advent of chordates. To Hence, the focus should not be on the symptomology, prevent the body from telescoping in on itself, a rigid but on a return to function. This takes the focus away from the dimensions is not optimally controlled across the 4th symptomology and concentrates it on the etiology dimension of time. This is clearly in line with ance or dysfunction in any of the three movement naturopathic principles as outlined in Chapter 1. While this approach may be time- effective and is not un-useful, it does mean that pre- Muscle imbalance physiology scription of treatment – corrective stretching, corrective mobilization, corrective exercises and other nutrition Muscle imbalance physiology was first described by and lifestyle advice – may be somewhat non-specific. Muscle imbalance was mainly embraced progress is difficult to gauge with such subjective by the physiotherapy community, though in recent approaches. Nevertheless, this pain patients, it is critical to provide a focus on return- author considers identification and correction of ing function as opposed to getting rid of dysfunction. This means that a patient can make great strides Perhaps one reason for the decline in interest in towards a return of function, yet may still have a muscle imbalance is that, as with nearly all clinical similar symptom profile. This phenomenon may be entities, to find a ‘textbook’ case is less common than explained neurophysiologically through the process finding a partial case. When under stress, the body will migrate to its Fast twitch preponderance Slow twitch preponderance position of greatest strength – which is why Fatigue early Fatigue late dynamically loading the patient can help to identify dysfunctional postural patterns. This subjective assessment approach provides Mobilizer dominance Stabilizer dominance little incentive for the patient to perform prescribed corrective exercises – especially in Superficial Deep the absence of pain. Outer unit Inner unit In Chapter 4 there is some discussion of what con- Global stability Local stability stitutes ‘dysfunction’ of a somatic tissue and the point is made that pain does not have to present for a tissue Multi-articular Mono-articular to be dysfunctional. Hence, it is entirely possible that Lengthen/weaken Shorten/tighten a patient may attend with a muscle imbalance (which represents a biomechanical dysfunction) yet have no pain. Nevertheless, any muscle imbalance disrupts the optimal axis of joint motion (a spatial or three- we may be able to see improvement – even though dimensional dysfunction) which will, over time, result the patient may be able to feel little difference. The fore, the means to assess joint position, joint range of point at which the sufferer feels pain is the point at motion and length–tension relationships objectively is which the rate of damage exceeds the rate of repair critical, in order to manage patients effectively and (see Fig. Interestingly, even among these experts, there load it is useful to have, at the very least, a Swiss ball, was still some confusion regarding muscle classifica- but ideally a cable column and a squat rack with tion. So, under tradi- Cranz 2000, Janda 1978, Williams & Goldspink 1973, tional practice, we are only left with observationally 1978). After stretching the facilitated lumbar erector assessing the condition then treating and making (thereby inhibiting it), it would no longer fire with the exercise recommendations to the client, which, in rectus abdominis during the sit-up maneuver (Janda itself, has some serious shortcomings. This approach depends on a very subjective it can create disrupted function at a range of joints (in assessment – which is wide open to bias. Chapter 9 • Rehabilitation and Re-education (Movement) Approaches 341 c b a d e Figure 9. It is not uncommon to hear that a those over 65 years of age (Chek 2004b); hence a therapist works with a mainly elderly population, naturopathic approach is surely to prevent such falls. Swiss ball training can condition the tilting reflex – In fact, the therapeutic truth is that, if a given individual something moving under the body. This is technically is unable to sit on a Swiss ball (with three bases of what happens when the interface between the ice and support) then, theoretically, they should not be able to sole of the shoe meet – the water on the surface of the stand (two bases of support) and certainly should not ice moves and the foot slips over it. Therefore, Swiss be able to walk (one base of support for 80% of the ball conditioning is ideal for training fall prevention in the gait cycle). To walk, therefore, is far more neurologically elderly in a slippery (tilting) environment, whereas a demanding than sitting on a Swiss ball. In fact, clinical experience suggests 342 Naturopathic Physical Medicine that it is extremely rare in the symptomatic popula- ment syndromes and/or capsular instabilities (see tion to find any patient that does not exhibit at least Fig. Upper crossed syndrome, like lower crossed syn- Lower crossed syndrome (see Chapter 6, drome, is essentially a gravity pattern. This is also known as Muscles that are commonly considered to be short a pronation pattern. At the • Supra- and infrahyoid group lumbar spine, lordosis is enhanced, meaning that the • Middle and lower fibers of trapezius low back is held in relative extension. Across time, this will lead to increased microtrauma, The classic osteokinematic coupling of an upper instability and pain in the hip joint, predisposing to crossed syndrome is a forward head posture (ventral degenerative change. Interestingly, lower crossed cranial glide), an increased 1st rib angle (dropped syndrome is more frequently observed in women – sternum), protracted shoulder girdle, flexed cer- which may help explain the higher incidence of hip vicothoracic junction and an increased thoracic problems in elderly women (Baechle & Earle 2000). Since lordosis is increased in the lumbar spine, greater Arthrokinematically, this means that the cervical loading is placed through the facet joints (see discus- lordosis tends to flatten with a compensatory hyper- sion below under ‘Neutral spine philosophy’), extension in the upper cervical spine to maintain the meaning that they are more prone to cumulative eyes on the optic plane (horizon). Spinal pathologies, such as spon- rib angle creates a flexion stress onto the 1st thoracic dylolysis, spondylolisthesis, foraminal stenosis and vertebra rotating it forward into sagittal flexion – with spinal stenosis, are more common in the extended the potential end result being a ‘dowager’s hump’. The dropped sternum means that the ribs are held in a flexed or ‘exhalation’ position. This may be prob- lematic for those with athletic requirements or with Layered syndrome breathing disorders. With the rib cage in exhalation, Muscles commonly considered short and tight in the the thoracic spine moves into sagittal flexion and, layered syndrome are as follows: across time, may develop an extension restriction due • Hamstrings to contracture of the anterior longitudinal ligament, • Gluteus maximus among other structures. The protraction of the shoul- ders, with or without thoracic extension restriction, • Thoracolumbar erectors disrupts the optimal instantaneous axis of rotation of • Upper fibers of trapezius the glenohumeral joint, and may result in impinge- • Suboccipitals. From the left: optimal posture, layered syndrome, layered syndrome with a sway, lower-crossed and upper crossed syndromes, lower and upper crossed syndromes with a sway Muscles commonly considered to be long and weak workplace. This may hold very little truth, but also in the layered syndrome are as follows: should be put into the context of evolution. Since chairs are known to have been used since 8000 bc • Hip flexors (rectus femoris and iliopsoas) (Cranz 2000) and it takes somewhere in the region of • Lumbar erectors 100 000 years for the human genome to change by • Thoracic erectors 0. Osteokinematically, the pelvis is posteriorly tilted, How the body does adapt is by changing its length– and the lumbar spine is flat with extension at the tho- tension relationships about the pelvis and trunk, the racolumbar junction leading into a thoracic kyphosis most common clinical adaptation being one towards and forward head posture. As the rib cage approximates the posture of the upper quarter is very similar to – and, in pelvis, so the anterior oblique slings (of anterior inter- some cases, indistinguishable from – an upper crossed nal oblique fibers through the linea alba to the contra- syndrome (see Fig. Reciprocally, the lumbar erector group will held in relative extension (and therefore may feel and be held in a lengthened position. Consequently, this posture is commonly a laying down of sarcomeres in a muscle that is held associated with lumbar disc injury clinically. Another example is the office worker who likes to Term Definition spend her weekends playing hockey. She must train her body to survive the relentless load of gravity on Creep The slow movement of a material that her back and neck during her seated work hours and becomes viscous due to shear stresses still be well conditioned enough to not ‘crash’ her Stiffness A material’s resistance to deformation biomechanics when she suddenly takes on the highly competitive unpredictable environment of the hockey Strain The amount of deformation that occurs pitch at the weekend. In most ball sports this is an early skill to be that does not retrace the force–length taught as a prerequisite to moving the feet quickly in tension curve traced when the force was response to the opposition’s play. It is the energy lost from the and habitual use of this stance, result in quadriceps tissue during this transaction dominance and a whole host of common sports inju- Elasticity The property of a material to return to its ries associated with such a posture – such as anterior original form or shape when a deforming cruciate ligament injury, meniscal tear, Achilles injury force is removed and plantar fasciitis (Wallden 2007). Hence, in condi- Viscosity The measure of shear force that must be tioning to survive his sport, such a sportsman must applied to a fluid to obtain a rate of use movement patterns and loading that help to deformation. In the the context within which the naturopathic triad is past, this potential difficulty has be circumnavigated embraced. If the objective of work in this field is to by describing ‘short and tight’ or ‘long and taut’ in the prevent injury and to realize potential as well as to same phrase, but ‘stiff’ also implies that there is resis- treat injury, then what is stated above still holds true. Hence the more sarco- Structural length versus functional tone meres in parallel, the more stiffness a tissue will have, One of the reasons that the popularity of evaluation whereas additional sarcomeres in series may result in of muscle imbalance may have dwindled in the little or no change to tissue stiffness.

Pathology and pathophysiology themes This is a weekly one hour diagnostic slide confer- that are shared across many species are covered cheap evista 60mg amex, ence which focuses on the discussion of histologic particularly those relevant to mouse genetic models and electron microscopic examples of unknown and human disease order cheap evista. Participants describe A survey of the use of animals in research with the cases generic evista 60 mg amex, give differential diagnoses purchase evista without a prescription, and discuss emphasis on biologic, nutritional and disease etiology and pathogenesis with the guidance of fac- factors which may interfere with interpretation of ulty members. The course provides a comprehensive, fully integrated coverage of the molecular basis of 260. The course will Opportunities to carry out special studies and emphasize small group learning and problem solv- research in various branches of molecular genetics, ing. The student will participate in “Journal Club”, immunology, and microbiology will be made avail- in which important papers in the front-line biomedi- able not only to candidates for advanced degrees cal literature will be discussed. Arrangements related to basic science concepts will be held at for such work must be made with individual mem- various days and times. The course aims course in Biochemistry or Cell Biology is strongly to expose students to some of the great experi- recommended. Recent topics have included: Ribosome function; molecular mechanisms of protein folding, evolutionary signifcance of introns, translation. Second quarter; 17 lectures; Tues & Growth and differentation factors in mammalian Thurs 9:00-10:30 a. Molecular biology of vision; developmental This short lecture course will cover fundamental neurobiology. Problem sets will be an integral learn- Molecular genetics of tumor suppressor genes ing tool in this course. The lecture portion of this Molecular basis of olfaction; mechanisms of course is repeated as part of Graduate Immunology neurogenesis. Third and fourth quarters, Proteolysis in membrane bilayers; cell signaling every other year. Open to students Prerequisite: Basic knowledge of molecular and who have had Medicine 250. Scheherazade and viral diseases, such as structure, replication, and virus-host cell interactions for the major virus Sadegh-Nasseri. This is an introductory course designed to provide Studies molecular biology of selected human graduate students with a comprehensive survey of pathogens in detail as examples of virus-induced modern cellular and molecular immunology. Student evaluation based on mid-term course consists predominantly of lectures but also and fnal exams. Discusses bacteriophage An advanced seminar and reading course devoted and baculoviruses and their use in vector biology, to the molecular and cellular mechanisms under- as well as viral vectors in gene therapy and anti- lying synaptic transmission and the regulation viral agents. Professor of Molecular Microbiology and The Sub-internship in Adult Neurology is an elec- Immunology tive rotation for students wishing additional expe- J. Faculty from multiple depart- Prerequisite: Basic clerkships in Neurology and ments. This section of the new Genes to Society course An elective clerkship in Pediatric Neurology is integrates content across several clinical disci- offered on both inpatient and outpatient Pediatric plines (neurology, neuropathology, neuroradiology, Neurology services. Examination of the nervous system, formulation of clinical problems, and initial triage and manage- E 5. Pediatrics may be requested as a Neurology peripheral nerve disease and focus for the inpatient ward experience at the East electromyography. All courses are dysfunctions; restless leg syndrome; circadian also open to students of the third and fourth rhythm disorders. Central issues include Cell fate specifcation and differentiation in the mentoring, misconduct in science, preparedness mammalian auditory system. Preparedness for a career in science Nerve muscle interactions in health and disease. Students outside the program Spatiotemporal regulation of protein kinases and may take this course independent of Neuroscience second messengers. This is the second half of a four-quarter course on * Holds primary appointment in Neuroscience; all oth- the cellular and molecular basis of neural function ers hold primary appointments in another department. Lectures will be A weekly lunchtime talk on current literature topics presented by faculty in the Neuroscience, Neurol- of special interest. Graduate students receive close ogy, Biomedical Engineering, Psychology, and faculty guidance in preparing presentations. When reg- Students in the Neuroscience Training Pro- istering for this course, please indicate the course gram are required to complete six elective number for which you will serve as a teaching courses by the end of their second year. This course will consist of lectures and discussions This is the frst half of a four-quarter course on concerning the application of molecular techniques the cellular and molecular basis of neural function in the study of neurologic and psychiatric illness- and the neural basis of perception, cognition, and es. Topics covered in this half include (1) analysis of abnormal genes, protein products and development and structure of the nervous system, neurotoxicity. Neuroscience, Neurology, Biomedical Engineering, Psychology, and Cognitive Science departments. Prerequisite: Completion of Neuroscience Cogni- The course will also include discussion sections tion I or consent of course director. Topics include patterning, differentiation of neurons and gila, mor- guidance mechanisms, target selection, synapto- phogen and growth factor signaling mechanism, genesis, dendritic growth, target derived signals, neuronal polarity, among others. Examples from activity dependent plasticity of synapse formation, vertebrate and invertebrate model systems will be and regeneration, among others. This course is designed to complement vertebrate and invertebrate model systems will be The Cellular and Molecular Basis of Neurodevel- covered. The structure and function of neurotransmitter related dysfunction of the nervous system, and neu- receptors, ion channels and synaptic vesicle pro- rodegenerative disorders such as Alzheimer’s and teins will be discussed. In addition, the molecular Parkinson’s diseases, are becoming major con- mechanisms involved in the control of synaptic cerns in our society. Recent advances in under- transmission such as the trans-synaptic regulation standing the molecular and cellular underpinnings of the function and expression of synaptic proteins of nervous system aging and neurodegenerative will be examined. Three hours per dispose to age-related neurological disorders, and week plus assigned reading. The course Classical studies elucidating the mechanisms of will consist of several introductory lectures and action of psychoactive substances led to seminal subsequent sessions in which hot topics in the feld discoveries about how the brain works. Thus, this course will be directed not only at present papers describing recent advances in this students who study the retina, but also to neurobi- dynamic feld of research. The third part of the course will focus ing critical features of a cell death pathway followed on diseases affecting retinal ganglion cells, focus- by journal review of recently published seminal ing principally on glaucoma, but also covering other papers. Kolodkin, Schramm, and A seminar and reading course devoted to current Sockanathan. Neural coding, the neural representation understanding the generation, logic of neuronal of images and information, and the neural mecha- connectivity in the spinal cord. Previous topics nisms of pattern recognition, association, percep- included an in-depth assessment of the corticospi- tion, memory and attention will be discussed. Future topics will include development and from the literature in each of these areas. First and A seminar and reading course that covers current second quarter every year. Visual, chemical and auditory Fusiform Face Area of the cerebral cortex we have transductions will be covered. It excels at recognizing objects and students not on their memorization of minutiae but substances, reconstructing space, analyzing sound on their understanding of fundamental principles. The neural mechanisms underlying these abilities are studied by a large community of systems and The goal of this course is to train neuroscien- cognitive neuroscientists. This research has gener- tists to effectively and clearly communicate ideas ated a rapidly evolving feld of high-profle discover- about nervous system function to a general audi- ies and lively debates between competing labora- ence. This course aims to convey a clear sense about neuroscience and shall interact with estab- of this feld by focusing on current experimental lished science writers. More importantly, they shall and conceptual controversies regarding organiza- develop, research and write both news and feature- tion and function in the vertebrate nervous system. Enroll- ed by two or more recent papers (selected by an ment limited to 10 students. Directed, independent reading and discussion of This is a seminar and reading course devoted to current neuroscience literature in a personalized the discussion of different type of stem cells.

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This time is not to be taken for granted; if not utilized correctly order evista 60 mg online, it may directly contrib- ute to poor outcomes and inefficient resuscitation purchase evista with a visa. At the same time generic evista 60mg with amex, the signs of the various shock states are unmasked and clues to the underlying diagnosis may be elicited cheap evista 60 mg free shipping. Although a definitive diagnosis is often not made initially, it is almost always possible to direct resuscitative efforts toward a particular class of shock. When problems are encountered in the primary survey, they should be addressed immediately. For example the airway may be temporarily managed with the chin-lift and bag-valve-mask ventilation, or definitely managed with endotracheal intubation. A—Airway When approaching the airway, the clinician ensures that cervical spine precau- tions are in place if trauma is a possibility and determines whether the airway is patent, protected and positioned adequately. The clinician: Observes for level of consciousness, drooling and secretions, foreign bodies, facial burns, carbon in sputum Palpates for any facial or neck deformities and checks for a gag reflex, and Listens for hoarseness or stridor. Findings Diagnostic Implication Drooling, stridor Upper airway obstruction Decreased level of consciousness Unprotected airway Diminished gag Facial burns Unstable airway (potential obstruction) Facial instability Airway management in the primary survey may be as simple as positioning of the airway using the chin lift or jaw thrust maneuvers (used when cervical spine insta- bility is a concern). It may also involve the placement of nasopharyngeal or oral airway devices and the application of supplemental oxygen. In cases of obstruction, foreign bodies may need to be dislodged using basic life support maneuvers or manu- ally with suctioning and Magill forceps. Definitive airway intervention, such as oral endotracheal intubation (with or without rapid sequence technique), nasotracheal intubation or a surgical airway (e. C—Circulation To assess the circulation, the clinician: • Palpates the pulse for rate, regularity, contour and strength. Pulses should be checked in all four extremities, and if absent, central pulses (femoral and carotid) are palpated. Also, palpates the skin for temperature, moisture and the briskness of capillary refill in the extremities. They may also include the administration of fluids and blood products, electrical and pharmacological therapy for dysrhythmias, pericardiocentesis and, in some cases, such as penetrating trauma, emergency thoracotomy. If at all 1 possible, it is desirable to obtain a cursory assessment prior to use of paralyzing agents. The clinician: • Assesses the level of consciousness, using the Glasgow Coma Scale. Eye Opening Motor Verbal 1 None No movement No sounds 2 To pain Decerebrate postutre Moans 3 To command Decorticate posture Words 4 Spontaneous Withdrawal from pain Confused 5 Localize to pain Oriented 6 To command Minimum Score = 3 (severe coma); Maximum Score = 15 • Observes the pupils for size, symmetry and reactivity to light, and observes all four extremities for their gross movement • Palpates rectal tone by digital examination Findings Diagnostic Implication Coma, unilateral dilated pupil, Cerebral herniation hemiparesis Pinpoint pupils Opiate, cholinergic or clonidine overdose Pontine lesion Dilated, reactive pupils Sympathomimetic overdose Dilated, unreactive pupils Anoxia Anticholinergic overdose Deviation of eyes to one side Ipsilateral cortical lesion Contralateral brainstem lesion Decreased rectal tone Spinal cord injury Other neurological insults, seizures, toxins Rigid extremities Neuroleptic malignant syndrome Serotonin syndrome Tetanus, strychnine poisioning Interventions in the disability segment of the primary survey are often limited to airway, breathing and circulation, as these all affect neurological function. Pharmacologic therapy is directed at causes of altered levels of consciousness, such as the administration of glucose for hypogly- cemia, naloxone for suspected opiate overdose and thiamine for Wernicke-Korsakoff syndrome. E—Exposure Often described as “strip, flip, touch and smell”, exposure means not only com- pletely undressing the patient, but also looking for other important clues. The clini- cian should: • Expose the entire surface area of the patient • Inspect and palpate the back for abnormalities, using cervical spine precautions to roll the patient if there is a possibility of trauma. Also, inspect the skin for rashes, other obvious lesions and signs of trauma • Note any particular odors about the patient, and • Measure a rectal temperature Emergency Resuscitation 9 Findings Possibile Diagnostic Significance Hyperthermia/Hypothermia Hypovolemic (severe dehydration) Distributive shock (e. This may be as simple as placing a warm blanket on the patient or as involved as invasive rewarming procedures in the unstable hypothermic patient. Hyperthermic patients may simply receive acetaminophen, or, in the case of severely elevated tem- peratures (>105˚ F), aggressive mechanical cooling measures may be necessary. Resuscitation Phase History Historical information should be elicited from either prehospital personnel, fam- ily members as well as patients themselves. Historical elements may point to a par- ticular class of shock or underlying process. Some findings, however, such as altered mental status and chest pain, may be simply a result of inadequate tissue perfusion and not the key to determining the cause. Identification of a class of shock present will help guide the initial resuscitation. For example, a history of bleeding, vomit- ing, diarrhea or trauma will immediately alert the clinician to the possibility of hypovolemic shock and the need for rapid volume administration. A history of heart disease, especially with the symptoms of paroxysmal nocturnal dyspnea or orthop- nea, are highly suggestive of a cardiogenic shock state. Important clues on history 1 Critical historical elements Bystander resuscitation Rescue breathing Chest compressions Automated external defibrillation Medical alert/identification bracelets Medications brought in by paramedics Old medical records/electrocardiograms Organ donor identification/drivers license Paramedic and bystander observations Patient’s clothing/belongings for medications/devices/recreational drug paraphernalia Presence of possible toxins on scene Response to prehospital interventions Oxygen Fluid challenge Electrical therapy Medications Positioning Vital sign trends and neurological status changes in prehospital phase Historical clues in shock states: History Possible Class Of Shock Preceding chest pain, Cardiogenic shortness of breath Obstructive Orthopnea Cardiogenic Any new medication Distributive (anaphylactic) Vomiting and diarrhea Hypovolemic Hemorrhage Hypovolemic Rash Distributive (anaphylactic, septic) Intravenous drug use Distributive (septic) Cardiogenic Indwelling devices (catheters, lines) Distributive (septic) Chronic debility/neurologic disease Distributive (septic) Hypovolemic Trauma Hypovolemic (hemorrhage) Diagnostic investigations or the use of a new medication may suggest distributive shock. Bedside Diagnostic Investigations The nature of emergency resuscitation precludes the type of methodical diagnos- tic workup that is possible in less critically ill patients. Each diagnostic tool must be evaluated for its ability to change the course of the resuscitation. Near immediate results are essential, and tests should not interfere with life-saving interventions. Secondary Survey As the severity patient’s condition on presentation increases, so does the relative importance of the physical examination. Thus, both primary and secondary surveys in resuscitation are primarily directed at physical findings. Diagnostic investigations in resuscitation Continuous monitoring 1 Pulse oximetry Pulse oximetry is considered “a fifth vital sign”. It is tremendously helpful when it can be recorded accurately; however, in severe shock states diminished pulses and cool extremities may make it impossible to obtain. A progres- sive alteration in mental status has a broad differential diagnosis, but within the context of an individual resuscitation its signifi- cance is often clear. In shock states, it may represent worsening cerebral perfusion or hypoxia and the need for more aggressive resuscitative efforts. In patients with intracranial pathology, it may represent brain herniation and the need for lowering intracranial pressure, especially when combined with localizing signs. When toxic, metabolic and endocrinologic derangements are present, worsening electrolyte abnormalities or hypoglycemia may be present and a multitude of interventions, ranging from simple dextrose administration to hemodialysis may be necessary. These may indicate the need to search for an occult injury such as a fracture or penetrating trauma that may change the direction of the resuscitation. Pain can also be used as a guide to the success of resuscitation, as is the case when chest pain and dyspnea resolve with adequate treatment of myocardial ischemia or pulmonary edema. Continuous cardiac Continuous telemetry is essential in any resuscitation to monitor monitor for life-threatening dysrhythmias and responses to treatment. Attention is directed at signs of myocardial infarction and ischemia, electrolyte derangements and clues to other life threatening pathologies such as decreased voltage in cardiac tamponade or signs of acute right-sided heart strain in pulmonary embolus. Bedside laboratory tests Blood glucose Critically low blood glucose results from many different life- threatening processes and must be addressed immediately. The finding of high blood glucose is similarly important and may help tailor early resuscitative efforts. Blood glucose should be measured in all patients with altered mental status and, when abnormal, frequent rechecks are indicated. Continued 1 Hemoglobin or Both of these tests express hemoglobin concentration and, as hematocrit such, can appear misleadingly high in acute hemorrhage before volume resuscitation has occurred. These tests are subject to error, and repeat and serial values should be obtained when they are utilized to guide resuscitation. Pregnancy test A positive serum or urine pregnancy test may lead to a diagnosis of the underlying pathology in a critically ill female. In addition, this finding may affect decisions made during resuscitation with respect to monitoring, emergent procedures, the selection of medications and imaging studies and disposition. Blood type and This is an essential test that must be performed to facilitate crossmatch treatment with blood and blood products in a multitude of resuscitations, both traumatic and non-traumatic. Bedisde electrolytes The availability of blood electrolyte analysis at the bedside is increasing and very helpful. Knowledge of the electrolytes in the first few minutes may enable critical interventions to be started early. In some cases, such therapies should be started even before electrolytes are available (e. The pH and base excess values obtained from blood gases (including venous gases) may also be used as an adjunct to gauge the severity of shock states and response to resuscitative efforts. Pooled venous Requires the placement of central venous line with a special oxygen levels probe. Other bedside assays Although there are many potential pitfalls in their application and interpretation, bedside assays may be extremely helpful. A variety of toxicological tests are now available, and, in the appropriate circumstances, bedside screening assays for various bioterrorism agents.

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Clinical indices were Changes in homocysteine levels following assessed and the results showed that the balneotherapy (Leibetseder 2004) number of active joints was reduced as were the number of tender points best buy for evista. A significant Researchers observed that plasma homocysteine improvement was found in dolorimetric (tHcy) is a risk factor for cardiovascular disease 60 mg evista amex, and threshold readings after the treatment period in that it has been associated with anti-oxidative status purchase 60mg evista with amex. The conclusion was that balneotherapy Forty patients with degenerative osteoarthrosis were appears to produce a statistically significant buy 60mg evista amex, randomized into a treatment group receiving station- substantial improvement in the number of ary spa therapy plus daily sulfur baths (sulfur group) active joints and tender points in both male and a control group receiving spa therapy alone and female patients. The results support the findings of previous investigations that therapeutic sulfur baths • Evcik et al (2002) report a Turkish study in have clear effects on biochemical parameters: in par- which 42 primary fibromyalgia patients, ticular, that they positively influence plasma tHcy. Group 1 (n = 22) received 20 Although most balneotherapy trials involving rheu- minutes of bathing once a day, five times per matic conditions such as fibromyalgia report positive week. Patients participated in the study for 3 findings, many studies have been assessed as being weeks (total of 15 sessions). Patients ‘positive findings’ should be interpreted with caution were evaluated by the number of tender (Verhagen et al 2003). All participants differences in the number of tender points, stayed for 10 days at a Dead Sea spa. However, program incorporating manual lymph drainage, there was no statistical difference in Beck’s exercise therapy, massages, psychological counseling, Depression Index scores compared to the relaxation training, carbon dioxide baths and mud control group (p >0. This study the greatest short-term improvements found for shows that balneotherapy is effective and may mood-related aspects of quality of life, the most lasting be an alternative method in treating improvements found for physical complaints (e. Older patients, non-obese patients, – in which the patient floats in warm water patients with a greater lymphedema and patients sourced from hot springs (35°C) while having with an active coping style showed slightly greater the moves and stretches of Zen Shiatsu applied improvements. The combination of inpatient rehabilitation with spa therapy provides a promising approach for breast cancer rehabilitation (Van Tubergen et al 2006). Spa therapy As spa therapy is typically practiced in a health Spa therapy and depression resort, it is sometimes called health resort medicine. Spa therapy combines hydrotherapy, balneotherapy, There is a modest degree of support for the value of patient education, nutrition and physical therapy as spa therapy in the treatment of moderate depression. In combination, spa therapy The majority of spas do not accept individuals with has been shown to be clinically beneficial for a variety serious behavioral problems or those who are at risk of common health conditions. Thus, this form of therapeutic intervention et al 2002) show that spa therapy is cost-effective as has only limited evidence of value in these conditions compared to standard treatment alone, for example in due to the lack of research (Dubois 1973, Dubois & treatment of osteoarthritis of the knee. While spas may not accept serious behavioral problems, it is important to consider chronic pain or other medical conditions as Spa therapy and fibromyalgia causes for depression or thoughts of suicide. The In a Turkish study (Cimbiz et al 2005), 470 patients evaluation of the depressed patient and determina- with fibromyalgia and other conditions received spa tion of a positive treatment outcome is based on the therapy twice a day (with underwater exercise in the cause of depression. Given that chronic pain and other spa pool), 20 minutes total duration per day in the first medical conditions may seriously affect the activities week and 30 minutes for the following weeks. Results of daily living, it is plausible that hydrotherapy, bal- showed a significant decrease in pain and high blood neotherapy or spa therapy may improve these medical pressure without hemodynamic risk. Thirty-seven patients (14 men and 23 women) women, aged 32–82 years, who participated in the suffering from chronic pain participated in the study. Quality They were randomly assigned to either a control 530 Naturopathic Physical Medicine group (17 participants) or an experimental group (20 ment are T5–T8 and T11–L2. The overarch- indicated that the most severe perceived pain inten- ing goal of the treatment system is to ‘improve the sity was significantly reduced, whereas low perceived quality of the circulating blood’. In the words of the developer of constitutional Current (2006) calls for continued and expanded hydrotherapy, Dr O. Carroll: research are occurring at an international level by the Health must at all times come from and be maintained Cochrane Library and the International Society of by digested foods. Naturopathic Physicians understand Medical Hydrology and Climatology (Bender 2006). These necessary naturopathic approaches, will continue to clarify the elements can come only from digested foods. After possibilities of hydrotherapy application in a wide a food is digested, it goes through a process of variety of conditions. Remember this process begins first with the Naturopathic applications and the role digestion of food, and no drug yet offered can rectify of constitutional hydrotherapy damage done by failure of digestion. Unique The strategy of application within the constitutional naturopathic approaches have also been developed. Dr Carroll developed a flexible is determined by the pathology and the physical clinical system that combined Kneipp hydrotherapy effects of the modality chosen. Relative to the terminology of his respiratory tree affected is a very common modifica- day, as described in Chapter 3, Dr Carroll would have tion. Or, in the case of osteoarthritis of the knee, a been considered not in the nature curist camp but in standard constitutional treatment with the addition of the physiotherapist camp of the naturopathic profes- 10 minutes of constant low voltage alternating current sion due to his wide inclusion of electrotherapy to the limb affected is a very common modification modalities. Dr Carroll also incorporated irisdiagnosis, heart The standard treatment is a tonification of the organ- tone diagnosis, food intolerance evaluation and ism and as such represents the basic treatment of the physiomedicalist botanical prescriptions, and used system. The approach is constitutional in nature, treat- the Schuessler Biochemic minerals in a systematic ing the whole organism to enhance general adaptation approach to naturopathic clinical practice. As men- mechanisms particularly relevant to circulatory distri- tioned above, Dr Carroll was trained by Dr Ledoux of bution and metabolic function. Dr developed during the 1920s, which was a particularly Carroll was encouraged to move to the American fruitful period for the profession. While he the whole-body constitutional approach that utilized was unable to do that, he did operate a very busy and physical medicine for a wide variety of complaints well-known clinic until his death in 1962. It was during The standard constitutional hydrotherapy treatment this period that the general naturopathic tonic treat- combines a modified Kneipp torso pack with the ment was originally developed, as well as the basic spondylotherapy methods of Dr Abrams (see Chapter spinal and abdominal treatments of neuromuscular 12). Chapter 11 • Naturopathic Hydrotherapy 531 Constitutional hydrotherapy treatments are still replaces the two Turkish towels previously widely taught, applied and researched because of applied. Slide two 4-inch electrode pads tional hydrotherapy represents the clinical evolution underneath the patient, one from each side, so of an eclectic, flexible, constitutional and uniquely that each is on one side of the spine with the naturopathic approach to comprehensive physiother- upper edge of the electrode approximately apy treatment for a general clinical setting. Replace the hot towel with one Turkish towel well wrung from cold water from the Standard constitutional hydrotherapy faucet (40–55°F/4–12°C; note this does not include iced or especially cold water) and As previously discussed in the naturopathic applica- folded in half. Again cover the patient with the dard treatment’, the representative treatment and cor- blanket. Place the low volt alternating current sine Indications wave unit within reach of the patient and instruct the patient to adjust the intensity. The The standard constitutional treatment is designed to current output should be on the surge tonify digestion, enhance appropriate immune func- (massage) setting with a low duty cycle of tion, improve intestinal flora balance and gently 6–10 cycles each minute. Modifications of the physiotherapy adjusted by the patient, and the following modalities allow for a flexible application to a large levels are noted in this order: variety of clinical conditions such as inflammatory bowel disease, asthma, upper respiratory infection, a. The patient will feel a gentle contraction dysfunction, cancer, musculoskeletal injury and/or somewhere in the abdomen, usually under disease, metabolic diseases as well as cardiac condi- the costal margin on the right, but not tions (Blake 2006b, Boyle & Saine 1988e, Scott 1992). The patient will feel strong contractions of Methodology the muscles of the upper back. This is Patient supine, undressed from the waist up, covered unnecessary and counterproductive. Two Turkish towels, each folded in half, well minutes of total treatment time have elapsed), wrung from hot water (130–140°F/54–60°C; check the center of the towel over the solar note the relatively high temperature of the plexus to see if the patient has warmed the compress) are applied covering chest and towel to at least body temperature. If the patient has not, the towel as needed so that they do not lie then cover the patient again with the blanket, beyond the anterior axillary line. Ask the patient to arch the back or lift the is used to separate the patient and the shoulder in order to move the sine wave pads blanket, as is common for sanitation reasons, from the upper back to the abdomen. One an impermeable barrier (such as a thin rubber pad is placed on the back and will be centered mat) should be placed over wet towels so as over the spine at the thoracolumbar junction, to avoid wetting the cotton sheet and thus the top edge at approximately the 11th fundamentally changing the treatment thoracic vertebra. At the 5-minute mark one Turkish towel, the epigastric region (directly superior to the folded in half, well wrung from hot water, umbilicus on adults). Instruct the patient to adjust the sine wave have been described in the literature (Blake 2006b, intensity until a gentle contraction at one or Watrous 1996). The sine wave output remains on the surge (massage) cycle at the Alternatives same low duty cycle. At the 10-minute mark (approx 25 minutes Standard constitutional hydrotherapy is a broadly total), remove the sine wave pads. Ask the applicable modality for a wide variety of clinical com- patient to turn over onto the abdomen. Internal medi- the back: cations do not supply the same physiological responses 10. Place two Turkish towels (the same as though, and application of constitutional hydrother- previously used), freshly well wrung from apy in combination with internal medications will hot water, each folded in half, on the patient’s have additive effect. The lateral towel edges are folded up so as not to lie beyond There have been a number of preliminary investiga- the posterior axillary line. At the 5-minute mark (approx 30 minutes has been conducted at the National College of Natu- total), replace the two towels with one fresh ropathic Medicine to investigate the blood count towel wrung from hot water.

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