أرشيفات التصنيف: Other

حقن الحساسية


حقن الحساسية

إذا كنت تعاني انت او اي شخص آخر تعرفه من الحساسية ، فلا شك انك تدرك مدى الشعور بعدم الراحة الذي تسببه الحساسية ، و الاعراض المزعجة الناتجة عنها مثل العطاس ، احتقان الانف ، السعال ، ضيق الصدر ، سماع صفير أثناء التنفس ، وهذه بعض اعراض حمى القش ( التهاب الانف التحسسي ، و الربو الشعبي .

إذا اصيب بعض مرضى الحساسية ، بلسع او قرص بعض الحشرات اللاذعة كالنمل او النحل فإن الامر لا يقتصر على الالم فقط بل من الممكن ان تحدث ردة فعل تحسسية خطيرة وقد تؤدي الى الموت اذا لم يتم علاج المريض فوراً .

إذا كنت مصاب بحساسية الانف او الربو الشعبي ، فإن اعراض الحساسية التي تعاني منها قد تكون رد فعل لبعض المواد الموجودة في الهواء والتي قد تستنشقها ، وهذه المواد تسمى مواد مثيرة للحساسية .


قد تتواجد المواد المثيرة للحساسية داخل المنزل او خارجه ، حيث تكون معرضاً طوال اليوم لمثيرات التحسس الموجودة داخل المنزل مثل : عثة الغبار ، مخلفات الصراصير ، شعر او وبر بعض الحيوانات ، وبعض الفطريات .

تتنوع مثيرات الحساسية الموجودة خارج المنزل حسب الموسم والمكان الذي تعيش فيه ، وهي تشمل حبوب لقاح الاشجار ، الحشائش ، الاعشاب ، بعض انواع الفطريات .

سيحدد طبيب الربو و الحساسية مثيرات التحسس التي قد تزيد من شدة اعراض الحساسية لديك ، وذلك عن طريق عمل اختبار الحساسية للجلد ، ثم سيصف لك العلاج ، ويقوم بتزويدك بالتعليمات الخاصة عن كيفية تفادي او تقليل تعرضك لمثيرات التحسس ، حيث يطلق على تجنب مثيرات التحسس بالسيطرة البيئية .

غير ان مثيرات التحسس مثل عثة الغبار ، و حبوب اللقاح يصعب تفاديها تماماً ، لذا فإنه قد تستمر في العطاس ، و السعال ، و صعوبة التنفس بالرغم من كل الاجراءات و الاحتياطات المأخوذة لتفادي مثيرات التحسس .

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All Stress management Techniques Here

All Stress management Techniques Here

This is a series of relaxation techniques that you can do almost any where and any time. They do not take very long to do. Do not force yourself to relax – just let it happen . . .

BREATHING:
2-Step breath – Fill the bottom of your lungs first, then add the top as you breathe through your nose. Breath out slowly. Feel the tension flowing out.

TENSE-RELAX MUSCLES:
Tighten the muscle that you want to relax. Focus on and feel the tension where you have tighthen. Now let the muscle become loose and limp. Feel the relaxation flow into the muscle.

BODY SCAN:
With your mind briefly scan every muscle in your body from the tips of your toes to the top of your head. If you sense a tight muscle, just let it become limp and relaxed.

LIMP RAG DOLL:
Do the 2-step breath two times.
With your mind imagine that you are a limp rag doll. Feel your mind and body become limp and relaxed.
*** You may use whatever image you like best **

MIND QUIETING:
To quiet your mind first, focus on your breathing. As you breathe in say slowly to yourself “I am” and as you breathe out, say slowly to yourself “calm.” When your mind feels calm you may focus only on your breathing, with no thoughts at all.

SHOULDERS, ARMS AND HANDS HEAVY AND WARM:
Put your mind into your shoulders, arms and hands – imagine and experience them becoming heavy, relaxed and warm.

10-Second Stress Busters

Whether we’re fretting over that pile of monthly bills or anticipating an exciting change like the birth of a new nephew, the million things we’ve got going on can leave us all feeling like big balls of stress—and that can wreak serious havoc on our health. But you don’t need to turn your life inside out to beat the effects of stress. These quick and easy natural solution can help you stay mellow in a crazy world.

Drink Tea
Black tea has been shown to have an effect on stress hormone levels in the body. Researchers in England have found that people who drink black tea de-stress more quickly than those drinking a fake tea substitute. Tea contains catechins, polyphenols, flavonoids and amino acids that affect your brain’s neurotransmitters and ultimately reduce blood levels of the stress hormone cortisol.

Go Nuts
Next time you feel a bit cracked up, forgo the junk food and snack on some nuts instead. Nuts are typically high in tryptophan and magnesium, two key nutrients that support serotonin production. And almonds are especially high in stress-busting B vitamins, zinc, vitamin E and antioxidants

Rub Your Ears
“According to Ayurveda, India’s 5,000-year-old ‘science of life,’ there are marma points—like acupuncture points—in the ears that correspond to the various parts of the body,” says Lissa Coffey, author/producer of the Dosha Yoga DVD. Simply rub the circumference of each ear—right hand on right ear and left hand on left ear—to instantly ease tension.

Take a Whiff
Aromatherapy has calming effects that can tame the tension in no time. Proven stress-reducing aromas include lavender, lemon balm, chamomile and geranium. Carol Duncan, a registered aromatherapist and owner of Massage Central says to place a few drops of essential oils on cotton balls and place them a few inches from fans or heater vents or underneath your car seat. “Each time air passes over the cotton ball, the essential oils are reintroduced to the area,” she explains.

Pop a Vitamin C Pill
Researchers at the University of Alabama say that vitamin C reduces the levels of stress hormones in the blood, which may alleviate the body’s response to stress. Studies suggest that 1,000 mg of vitamin C is most helpful.

Put on the Pressure
“Self-administer acupressure,” suggests Susan Lark MD, a leading authority on integrative medicine and women’s health. Put your left finger at the base of your skull, then move it down the width of one finger, and then move it to the left the width of one finger. Position your right finger in the same place on the right side. Press both points for one to three minutes. According to Dr. Lark, a second stress-busting point is located four finger-widths below your kneecap and one finger-width to the outside of your shin. (You should feel a slight indentation.)

Eat Berries
Blueberries, blackberries and other barriers contain some of nature’s most powerful antioxidants and are jam-packed with vitamin C, making them potent stress-busters. Stress causes the body to release free radicals—highly unstable oxygen molecules that can damage normal cells—and antioxidants help to neutralize those harmful molecules.

Strike a Yoga Pose
“When we get stressed, we tend to tense up and cave our chest in,” says Lissa. She recommends folding your hands as if in prayer behind your back, then pulling your shoulders back, tilting your head back andbreathing deeply

Stretch for Balance
Another move that Lissa suggests is to sit in a chair with your left foot on the floor. Put your right ankle on your left knee and lean forward with a stretch. Hold it as far as you can go, then bend forward a bit more. Repeat on the other side. “This opens up your hips and balances that tensed up muscle feeling,” she adds.

Reframe Your Thoughts
“Reframing simply means putting a different context around the situation,” says Jay Winner, M.D., author of Take the Stress Out of Your Life. For example, Winner suggests thinking of time spent in a long line as a break from a busy day—a chance to relax your mind or meet someone new like the person standing next to you. A positive spin can counteract the stress-induced physiological changes that wreak havoc on your body.

Crave Complex Carbs
Complex carbohydrates boost serotonin levels and keep a heightened sense of calm and relaxation for a longer period of time. Target carbs include whole-grain foods and cereals—such as whole-grain breads, oats and brown rice—as well as legumes such as peas, beans and lentils.

Take 10
Brian Jump, multi-day tour sales manager for Arizona Outback Adventures, breaks the tension of his long days by doing 10 jumping jacks, push-ups or anything that gets the blood flowing through the body. “This helps to release endorphins, which are a natural stress reliever,” he says.

Laugh Out Loud
According to a University of California, Irvine study, even the expectation of a laugh boosts stress-busting hormones and increases hormones that induce relaxation—an effect that can last for up to 24 hours. Read a comic strip, check out the joke of the day or make funny faces in the mirror until you bust out with a belly laugh.

Related Keyword terms:

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Infantile Scoliosis

Infantile Scoliosis


Author: Palaniappan Lakshmanan, MBBS, MS, AFRCS, FRCS (Tr & Orth), Specialist Registrar, Department of Trauma and Orthopedics, Wansbeck General Hospital, UK

Coauthor(s): Jeetender Pal Peehal, MBBS, MS, MRCS, Knee Research Fellow, Positional MRI Centre, Woodend Hospital, UK; Sashin Ahuja, MBBS, FRCS, MSc, MS, Consultant Spinal Surgeon, Department of Orthopedics, University Hospital Of Wales, Cardiff, UK

Introduction

The term scoliosis is derived from the Greek word skol, meaning “twists and turns” and refers to a sideward (right or left) curve in the spine. Scoliosis is not a simple curve to one side but, in fact, is a more complex, 3-dimensional deformity that often develops in childhood


Preoperative and postoperative radiographs show a....

Preoperative and postoperative radiographs show an increase in the space available for lung (SAL) after correction of scoliosis by VEPTR (vertical expandable prosthetic titanium rib

Preoperative and postoperative radiographs show a...

Preoperative and postoperative radiographs show an increase in the space available for lung (SAL) after correction of scoliosis by VEPTR (vertical expandable prosthetic titanium rib).

Recent studies

In a retrospective study of the treatment of patients with idiopathic infantile scoliosis, 31 consecutive patients (average age, 25 mo) with a primary diagnosis of idiopathic infantile scoliosis were reviewed. Treatment modalities included bracing, serial body casting, and vertical expandable prosthetic titanium rib (VEPTR). Of the 31 patients, 17 were treated with a brace, 9 of whom had curve progression and subsequently received other treatments. Of the 8 patients who responded to brace treatment, overall improvement was 51.2%. Patients who received body casts had a mean preoperative Cobb angle of 50.4º and had an average correction of 59.0%. Patients who were treated with VEPTR had a mean preoperative Cobb angle of 90º and had an average correction of 33.8%. The study results suggest that body casting is useful in cases of smaller, flexible spinal curves, and VEPTR is a viable alternative for larger curves.1

Another retrospective case series, of magnetic resonance imaging (MRI) findings in patients with presumed infantile idiopathic scoliosis, reviewed the medical records of 54 patients. MRI revealed a neural axis abnormality in 7 (13%) of 54 patients who underwent MRI. Of these 7 patients, 5 (71.4%) required neurosurgical intervention. Tethered cord requiring surgical release was identified in 3 patients, Chiari malformation requiring surgical decompression was found in 2 patients, and a small nonoperative syrinx was found in 2 patients. The authors concluded that on the basis of these findings, close observation may be a reasonable alternative to an immediate screening MRI in patients presenting with presumed infantile idiopathic scoliosis and a curve greater than 20º.2

A recent study reviewed the frequency of asymmetric lung perfusion and ventilation in children with congenital or infantile thoracic scoliosis before surgical treatment and the relationship between Cobb angle and asymmetry of lung function. The authors found that asymmetric ventilation and perfusion between the right and left lungs occurred in more than half of the children with severe congenital and infantile thoracic scoliosis, but the severity of lung function asymmetry did not relate to Cobb angle measurements. Asymmetry in lung function was influenced by deformity of the chest wall in multiple dimensions and could not be ascertained by chest radiographs alone.3

History of the Procedure

Probably the oldest mention of scoliosis is in ancient Hindu mythology (3500 to 1800 BC), in which Krishna corrects the hunchback of one of his followers. Hippocrates (460 to 377 BC) wrote about scoliosis and devices to correct it. The term infantile scoliosis was first used by Harrenstein in 1930 and by James in 1951 in describing the clinical entity idiopathic infantile scoliosis.4,5,6

Problem

The term infantile scoliosis is used specifically to describe scoliosis that occurs in children younger than 3 years. Other terms for scoliosis also depend on the age of onset, such as juvenile scoliosis, which occurs in children aged 4-9 years, and adolescent scoliosis, which occurs in those aged 10-18 years. These terms, however, are now being replaced by the broader terms early-onset scoliosis and late-onset scoliosis, depending on whether the scoliosis occurs before or after 5 years of age.

In 80% of cases of scoliosis, there is no obvious cause; this is termed idiopathic scoliosis. In the remaining 20% of cases, a definite cause can be found. These cases are divided into 2 types: nonstructural (functional) and structural scoliosis, which could be part of a well-recognized syndrome (syndromic scoliosis), congenital spinal column abnormalities (congenital scoliosis), neurologic disorders, and genetic conditions.

The syndromes that can produce congenital scoliosis are VATER syndrome (vertebral anomalies, anorectal anomalies, tracheo-esophageal fistula, and renal anomalies), VACTERL syndrome (vertebral anomalies, anorectal anomalies, tracheo-esophageal fistula, renal and vascular anomalies, and cardiac and limb defects), Jarcho-Levin syndrome, Klippel-Feil syndrome, Alagille syndrome, Wildervank syndrome, Goldenhar syndrome, Marfan syndrome, and MURCS association (M ü llerian, renal, cervicothoracic, and somite abnormalities).

The congenital anomalies of the vertebral spinal column include defects of segmentation (block vertebra, unilateral bar) and defects of formation (hemivertebra — fully segmented, semisegmented, incarcerated and nonsegmented, wedge vertebra). The neurologic deficits in congenital scoliosis may be secondary to the spinal deformity or may be associated with vertebral anomalies (spinal dysraphism — diastematomyelia, myelocele, myelomeningocele, meningocele). A higher incidence of idiopathic scoliosis has been reported in families of children with congenital scoliosis. Spondylocostal dysostosis (Jarcho-Levin syndrome) has a genetic etiology.7,8,9,10

Frequency

Infantile scoliosis is a rare condition, accounting for less than 1% of cases of idiopathic scoliosis in North America; in Europe, the rate is 4%.

Sex: Males account for 60% of the cases of early-onset scoliosis; 90% of the cases of early-onset scoliosis resolve spontaneously, but the other 10% of cases progress to a severe and disabling condition. Females constitute 90% of late-onset cases and need close monitoring to intervene at appropriate times.

Etiology

Although the exact cause of idiopathic infantile scoliosis is not known, hypotheses have been proposed on the basis of epidemiologic evidence7,8,9,11,12 :

* One theory holds that the mechanical factors during intrauterine life are responsible for the higher incidence of plagiocephaly, developmental dysplasia of the hip, and scoliosis on the same side of the body.

* A second hypothesis suggests multifactorial causes, including predisposing genetic factors that are either facilitated or inhibited by external factors such as defective motor development or collagen disorders, joint laxity, and nursing posture of the infant.

* Other associations include older mothers from poorer families, breech presentation, and premature and male low-birth-weight babies.

Pathophysiology

Most of the curves in the spine develop during the first year of life, and strong correlation has been found between the nursing posture of the infant and development of the curve. It is less common in the United States than in Europe, where babies are nursed in the supine position. Infants have a natural tendency to turn toward the right side, and because of plasticity of the infant’s axial skeleton, this can lead to development of plagiocephaly, bat ear on the right side, and curvature of the spine toward the left side.11

Presentation

Infantile scoliosis usually is detected during the first year of life either by the parents or by the pediatrician during routine examination of the infant. Usually, a single, long, thoracic curve to the left is present; less often, a thoracic and lumbar double curve is noted. A child who is diagnosed with scoliosis requires a thorough clinical and radiologic examination to exclude any congenital, muscular, or neurologic causes.

Indications

There are 3 management options for infantile scoliosis: observation, orthosis, and operative. The decision when to use each of these is based on the rib-vertebral angle difference (RVAD), established by Mehta in 1972 (see Image 1).13 The RVAD is a useful guide in distinguishing between resolving and progressive idiopathic infantile scoliosis

RVAD (rib-vertebral angle difference) measurement...

RVAD (rib-vertebral angle difference) measurement at apical vertebra: RVAD = b-a (concave – convex side).


The rib-vertebrae angle is measured by (1) drawing a line perpendicular to the middle of the upper or lower border of the apical vertebrae of the curve and then (2) measuring the angle this line makes with medial extension of another line drawn from the mid point of the head to the mid point of the neck of the rib, just medial to the beginning of the shaft of the rib. The difference between the right and the left side (concave and the convex side) is the RVAD.

The apical vertebra is the vertebra at the curve of the apex. If there are the same number of vertebrae between the superior and the inferior end vertebrae, there will be 2 apical vertebrae.

For scoliosis curves with an RVAD of less than 20°, observation every 4-6 months is sufficient. If the RVAD is more than 20° or if it is not flexible clinically (ie, curve cannot be corrected even slightly with different postures, especially lateral bending), then it is considered to be progressive until proven otherwise.

Management with orthosis is necessary when the curve is considered to be progressive or if a compensatory curve has developed. Various types of orthosis are available for children younger than 3 years. The most commonly used orthoses are the hinged Risser jacket; the plaster spinal jacket (Cotrel EDF [elongation, derotation, flexion] type) applied under anesthesia; the Milwaukee brace; and the Boston brace. The brace should be used for 23.5 hours a day and should be removed only for exercises and swimming. It needs to be used until skeletal maturity is attained, because curves usually do not progress after skeletal maturity; however, curves may progress in spite of using a brace.14,15

Spinal deformity in scoliosis progresses during periods of peak growth velocity. The first spinal growth peak occurs at 2 years of age, and the second peak occurs during the prepubescent period.

Operation is usually an option only for children in older age groups (ie, around age 10 years), and segmental posterior wiring to 2 L-rods without fusion is preferable until combined posterior and anterior fusion can be done. These procedures, however, have been associated with complications in 50% of patients.

Because of advances in instrumentation, pedicle screw instrumentation can be performed for children with further growth potential. In these patients, a growing rod is used, which is associated with fewer complications than surgical fixation using L-rods. The disadvantage associated with the growing rod is that every 6 months the posterior aspect has to be opened to lengthen the rod, which increases the risk of infection; however, if the curve is severe or increases despite the use of orthosis, a short anterior and posterior fusion is recommended to prevent crankshaft phenomenon.

Relevant Anatomy

The spine is made up of 33 individual vertebrae that form a column. The spine is divided into 5 regions, starting from the top:

* Cervical – 7 vertebrae

* Thoracic – 12 vertebrae

* Lumbar – 5 vertebrae

* Sacrum – 5 vertebrae

* Coccyx – 4 vertebrae

The sacrum and coccyx are fused in the adult. The spine provides a protective function for the spinal cord; bears and distributes the weight of the body; provides an area for attachment of ligaments and muscles; and is the site for production of red blood cells. Together, all the vertebrae form a flexible structure providing mobility for the body to bend forward or sideward.

Each vertebra has a cushionlike fibrous structure called a disk, which acts like a shock absorber during movements of the spine. The disk is made up of a soft, jellylike central nucleus pulposus surrounded by a ring of fibrous tissue called an anulus, which is actually a strong ligament between 2 adjacent vertebrae.

Developmentally, the spine of the fetus is C-shaped, with concavity in the front (kyphotic) of the thoracic region; this is called the primary curve. Two secondary curves develop after birth, with concavity occurring anteriorly (lordosis); one of the secondary curves develops in the cervical region as the infant starts to hold up the neck, and the second curve develops in the lumbar region when the child starts to walk. Normally, there are no sideward (scoliosis) curves, so that the spine looks straight when viewed from behind or from the front.

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DRINK WATER ON EMPTY STOMACH

DRINK WATER ON EMPTY STOMACH

It is popular in Japan today to drink water immediately after waking up
every morning. Furthermore, scientific tests have proven a its value.
For old and serious diseases as well as modern illnesses the water
treatment had been found successful by a Japanese medical society as a 100%
cure for the following diseases:

Headache, body ache, heart system, arthritis, fast heart beat,
epilepsy, excess fatness, bronchitis asthma, TB, meningitis, kidney and urine
diseases, vomiting, gastritis, diarrhea, piles, diabetes, constipation,
all eye diseases, womb, cancer and menstrual disorders, ear nose and
throat diseases.

METHOD OF TREATMENT

1. As you wake up in the morning before brushing teeth, drink 4 x 160ml
glasses of water

2. Brush and clean the mouth but do not eat or drink anything for 45
minute

3. After 45 minutes you may eat and drink as normal.

4. After 15 minutes of breakfast, lunch and dinner do not eat or drink
anything for 2 hours

5. Those who are old or sick and are unable to drink 4 glasses of water
at the beginning may commence by taking little water and gradually
increase it to 4 glasses per day.

6. The above method of treatment will cure diseases of the sick and
others can enjoy a healthy life.

The following list gives the number of days of treatment required to
cure/control/reduce main diseases:

1. High Blood Pressure – 30 days

2. Gastric – 10 days

3. Diabetes – 30 days

4. Constipation – 10 days

5. Cancer – 180 days

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Cervical Disc Disease: Treatment & Medication

Cervical Disc Disease: Treatment & Medication

Rehabilitation Program

Physical Therapy

For most cervical disc disorders, studies support conservative treatment, such as the McKenzie approach and cervicothoracic stabilization programs, combined with aerobic conditioning.

The McKenzie system identifies 3 mechanical syndromes, as follow, that cause pain and compromise function:

* The postural syndrome provokes pain when normal soft tissues are loaded statically at end ROM; pathology need not be present. Treatment aims to correct posture.

* The dysfunction syndrome produces pain when the patient, upon attempting full movement, mechanically deforms contracted scarred soft tissue. Consequently, therapy involves stretching and remodeling of such contracted tissue.

* The derangement syndrome produces intermittent pain when certain movements or postures occur. Specifically, pain may become centralized or peripheralized because of theoretical activity-dependent displacement of intradiscal material. Therapy attempts to correct derangement by promoting activity that centralizes pain.

The McKenzie theory recognizes that although patients may demonstrate similar signs and symptoms, one movement (eg, cervical extension) nevertheless may help some patients and aggravate symptoms in others. Indeed, McKenzie therapy does not use only extension-biased exercise. Consequently, treatment individualization and patient education play key roles.

Cervicothoracic stabilization limits pain, maximizes function, and prevents further injury. Such stabilization includes cervical spine flexibility, postural training, and strengthening. This program emphasizes patient responsibility through active participation.

Restoring flexibility prevents further repetitive microtrauma from poor movement patterning. Pain-free ROM is determined by placing the cervical spine in positions that produce and relieve symptoms. Initially, stabilization commences within established pain-free ROM and then progresses outside this ROM as pain diminishes. Soft tissue or joint restriction inhibiting ROM is treated quickly. Anterior and posterior neck muscles are stretched. Indeed, such spine and soft-tissue mobilization, passive ROM, self-stretching, and correct posturing collectively restore ROM.

Postural training commences with the patient, supervised by a therapist, in front of a mirror. The patient performs various transfer maneuvers while maintaining a neutral spine (ie, correct posturing), with feedback from the mirror and the therapist. Patient goals include maintenance of neutral spine and demonstrating correct posture during daily activities.

These proprioceptive skills, implemented during strengthening exercises, facilitate stable, safe, and pain-free cervical posture during strenuous activity. Indeed, cervicothoracic stabilization requires strengthening and coordination of neck, shoulder, and scapular muscles. Cervical muscles include extensors, flexors, rectus capitis anterior, rectus capitis lateralis, longissimus cervicis, and longissimus capitis. Primary thoracic stabilizers include abdominals, lumbar paraspinal extensors, and latissimus dorsi. Scapular muscles include the middle and lower trapezius, serratus anterior, and rhomboids. Chest muscles include the pectoralis major and minor. Successful stabilization also requires the training of the lumbar spine and lower extremities, which provide a foundation for the cervicothoracic spine.

Stabilization exercises proceed systematically from simple to complex. Isometric and isotonic resistive exercises employ elastic bands, weight machines, and free weights. Such conditioning distributes forces away from the cervical spine. Exercise repetition ultimately encodes an engram that commands immediate, automatic cervicothoracic stabilization during everyday activity.

Butler’s therapy techniques treat radicular symptoms by mobilizing the involved nerve. First, the therapist identifies “adverse neural tension,” defined as pathologic mechanical and physiologic responses elicited from a nerve when its stretch properties and ROM are evaluated. Specifically, the therapist performs neurodynamic testing to evaluate a nerve’s mechanical properties (eg, its mobilization around neighboring intervertebral discs) and physiological characteristics (eg, its response to ischemia, inflammation). Having tested the nerve in question, the therapist may institute treatment consisting initially of passive mobilization to provide CNS input without inciting a stress response and neurogenic massage to reduce perineural swelling. Later, the therapist progresses to active neuromobilization, because, according to Butler, recovering nervous tissue (like other connective tissue) requires movement to promote healing and restoration of optimum mechanical properties.

Butler admits that limited evidence suggests that neurodynamic mobilization improves clinical outcomes. However, he believes that optimizing tissue health and cardiovascular fitness, as well as minimizing negative beliefs and environmental factors, can be beneficial.

Functional restoration programs assist patients disabled by chronic cervical pain overcome obstacles to recovery. Such obstacles include deconditioning, secondary gain, poor motivation, and psychopathology. An occupational or physical therapist, athletic trainer, or nurse instructs the patient in cervical anatomy, biomechanics, pathology, and ergonomics. Patients employ preventive measures in order to prohibit further injury during all daily activities. These medically directed interdisciplinary programs have been successful at enabling workers’ compensation patients to return to work. Furthermore, Wright and colleagues reported lower rates of recurrent injury, new surgery, and need for health care services for patients with chronic cervical pain who successfully completed functional restoration.

Medical Issues/Complications

An intervertebral disc compressing the spinal cord can provoke myelopathy with associated weakness, hyperreflexia, and neurogenic bowel and bladder dysfunction. Radiculopathy can manifest significant upper limb weakness or numbness. Intractable axial or radicular pain may result from cervical disc disorders.

Surgical Intervention

Studies indicate that cervical HNP with radiculopathy can be managed conservatively. Surgery is warranted when neurogenic bowel or bladder dysfunction, deteriorating neurologic function, or intractable radicular or discogenic neck pain exists. Specifically, cervical spine surgical outcomes are most favorable for radicular pain, spinal instability, progressive myelopathy, or upper extremity weakness. The literature has demonstrated favorable cervical spine fusion outcomes for chronic discogenic axial neck pain when the presurgical evaluation incorporated provocative cervical discography. Provocative discography identified the painful segment(s) and confirmed adjacent pain-free levels. Fusion can increase intradiscal pressure and other stress at adjacent unfused levels, thereby accelerating postsurgical spinal degeneration.12,13,14

A 2009 study sought to determine which factors are predictive of patient outcome following anterior discectomy and fusion.15 Surgical outcomes that developed over a 2-year period were examined in patients who were treated for recalcitrant single-level subaxial radiculopathy or myelopathy. The study’s results indicated that important prognostic factors include whether or not a patient is gainfully employed, has normal sensory function prior to surgery, has higher preoperative disability scores, and is involved in spine-related litigation.

Consultations

* Consultation with an internal medicine specialist is indicated when neck pain suggests an underlying systemic illness (eg, malignancy, infection, metabolic bone disease).

* Consider consultation with a rheumatologist when neck pain suggests a rheumatologic condition (eg, polymyalgia rheumatica).

* Consultation with a surgeon for cervical disc disorders is warranted for resulting neurogenic bowel/bladder dysfunction, deteriorating neurologic status (eg, myelopathy), segmental instability, and/or intractable radicular or discogenic pain.

Other Treatment

* Physical modalities should be used to reduce pain only in the acute phase. Once past the acute phase, modalities are used sparingly on an as-needed basis.

o Superficial heat modalities relax muscle and relieve soft-tissue pain.

o Conversely, deep-heating modalities (eg, ultrasonography) should be avoided in acute cervical radiculopathy, because they augment inflammation and, consequently, exacerbate radicular pain and nerve root injury.

* Cervical traction may relieve radicular pain from nerve root compression. Traction does not improve soft-tissue injury pain. Hot packs, massage, and/or electrical stimulation should be applied prior to traction to relieve pain and relax muscles.

o Traction regimens include heavy weight-intermittent or light weight-continuous. The neck is flexed 15-20 º (ie, not extended) during traction. In the cervical spine, approximately 10 lb of force is necessary to counter gravity and 25 lb of force is necessary to achieve separation of the posterior vertebral segments.

o Light weight-continuous home traction is cost effective and provides the patient with more autonomy.

o Pneumatic traction devices afford greater patient comfort and, consequently, increased compliance.

* A soft cervical collar is recommended only for acute soft-tissue neck injuries and for short periods of time (ie, not to exceed 3-4 days’ continuous use). Risks include limiting cervical ROM and losing neck strength if the collar is worn continuously for longer periods.

o When worn for radiculopathy caused by foraminal stenosis, the wide part of the collar is placed posteriorly and the thin part is placed anteriorly to promote neck flexion, discourage extension, and open the intervertebral foramina.

o Collars can be worn during certain activities, such as sleeping or driving, for longer periods.

o Although not commonly used, a Philadelphia collar can be worn at night to position the neck rigidly in flexion, thereby maintaining open foramina.

* Spinal manipulation and mobilization may restore normal ROM and decrease pain; however, no clear therapeutic mechanism of action is known. Some believe that zygapophysial joint adjustment improves afferent signals from mechanoreceptors to peripheral and central nervous systems.

o Normalization of afferent impulses improves muscle tone, decreases muscle guarding, and promotes more effective local tissue metabolism. These physiologic modifications subsequently improve ROM and pain reduction.

o Studies document short-term improvement in the acutely injured patient and in those with cervicogenic headache and radiculopathy secondary to disc herniation.

o No evidence exists that manipulation confers long-term benefit, improves chronic conditions, or alters the natural course of the disorder.

* Cervical epidural, spinal nerve (or root), Z-joint, and sympathetic injections serve diagnostic and therapeutic roles. (See images below and Images 4-5.) These procedures can be instrumental in determining the anatomic pain generator (eg, nerve root, facet) and providing aggressive, conservative treatment

.

Right C7 cervical transforaminal epidural steroid injection demonstrating epidural and radicular spread of radiologic contrast dye

.

Cervical epidural steroid injection at the C7-T1 interlaminar space.

* Therapeutic cervical epidural injections treat radicular pain, although some literature has demonstrated reduced axial pain as well.

o An anesthetic and corticosteroid mixture may be injected into the epidural space (interlaminar) or along the nerve root (transforaminal) after precise radiologic, contrast-enhanced fluoroscopic localization.16

o The anesthetic can relieve sympathetically mediated pain.

o The corticosteroid provides long-term relief if pain results from an intense inflammatory component.

o Such injections provide a pain-free window of opportunity for more aggressive physical therapy.

* Diagnostic selective spinal nerve or ventral ramus blocks inject a small anesthetic volume extraforaminally at a single spinal segment level (eg, C5 versus C6); consequently, they are more precise than the “gun shot” interlaminar approach in identifying the symptomatic nerve.

o Precise symptomatic nerve identification permits the physician to design a more focused treatment protocol.

o Patients record pain changes in a pain diary following the injection, to confirm diagnostic accuracy.

o A double injection paradigm previously reported in the literature for facet injections can provide information to the physician for use in determining a diagnosis of radicular pain and to help confirm the symptomatic nerve level. This paradigm identifies patients who have tested false-positive or may have a tendency to respond to a placebo, by determining whether, on separate injection days, they received short-term relief with a short-acting anesthetic (eg, lidocaine) and long-term relief with a long-acting anesthetic (eg, bupivacaine).

* Adverse effects include those from anesthesia, corticosteroids, and radiologic contrast dye.

o Blood clotting parameters should be drawn prior to injection in patients with suspected bleeding diathesis. Indeed, spinal cord compression could result if bleeding occurs in the presence of relative spinal stenosis (ie, midsagittal diameter less than 12 mm) in which little room exists to accommodate an epidural hematoma.

o Nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, should be discontinued prior to the procedure in accordance with their half-life and hematologic profile.

o Other potential risks include seizure, vertebral artery spasm, infection, temporary quadriparesis from anesthetic, and respiratory arrest.

o One study, however, suggested that selective cervical nerve blocks carry low morbidity when performed under contrast-enhanced fluoroscopic guidance.

o In any event, proper patient monitoring and emergency equipment always should be present.

* Reports of serious CNS complications, including spinal cord injuries and strokes, following cervical transforaminal steroid injections have gained the attention of many practitioners. The mechanism of the injury is believed to be related to the introduction of particulate matter within the corticosteroid preparations, causing occlusion of a vessel.

o Hodges and colleagues described 2 case reports in which intrinsic spinal cord damage resulted from cervical epidural steroid injection despite fluoroscopic guidance; the patients, because of intravenous sedation, were unable to perceive and report pain and paresthesias from needle-induced spinal cord trauma during the procedure.17

o Furman et al demonstrated a relatively high incidence of entering the intravascular space with transforaminal epidural steroid injections.18 They also showed that attempting to use a flash of blood in the needle hub to predict intravascular compromise was 97% specific but only 45.9% sensitive. This article underscored the importance of using fluoroscopy and contrast dye to ensure proper placement of the therapeutic agents. Using a flash of blood in the hub without fluoroscopy cannot reliably predict intravascular compromise.

o Brouwers et al reported a fatal case of spinal cord infarction following a cervical transforaminal steroid injection.19

o Baker et al demonstrated that a radicular artery supplying the cervical spinal cord can be infiltrated by a transforaminal epidural steroid injection.20 In this report, prior to steroid injection for a left C6-C7, contrast was administered. Using digital subtraction technique, it was clear that a radicular artery filled with contrast; the procedure was aborted without adverse effects. This report revealed a potential access point for an injection-related spinal cord infarction.

o The potentially catastrophic complications that can follow a cervical transforaminal epidural steroid injection cannot be underestimated. While these procedures are perceived as posing less of a risk than surgery, they still carry substantial hazards. They should be performed by skilled practitioners and under fluoroscopic guidance. Baker et al further suggest the use of digital subtraction, because intravascular compromise may be missed on routine spot films.20

Medication

NSAIDs are first-line pharmacologic intervention for most cervical conditions. NSAIDs reduce pain at low doses and decrease inflammation at high doses. Patients require a therapeutic NSAID plasma level to achieve an anti-inflammatory effect. NSAIDs with once-a-day dosing improve compliance and increase the probability of achieving therapeutic levels. Controlling inflammation is paramount when treating cervical radiculopathy.

Aspirin rarely is recommended, because it binds irreversibly to cyclooxygenase (COX) and incites gastritis, requiring large doses to reach anti-inflammatory effect. Traditional NSAIDs provoke multiorgan toxicity, including peptic ulcer disease, renal insufficiency, and hepatic dysfunction. COX isomer type 2 (COX-2) NSAID inhibitors confer the same analgesic/anti-inflammatory benefits without multiorgan toxicity. All NSAIDs have a dose-related ceiling point for analgesia above which higher doses fail to provide additional pain relief. The same precautions should be observed with COX-2 NSAIDs, despite their reduced risk of organ toxicity.

Use muscle relaxants to potentiate the NSAID analgesic effect and not necessarily to control muscle spasm. Muscle relaxants primarily sedate by relaxing muscle with subsequent relaxation of the patient.

Oral corticosteroids treat inflammatory cervical radiculopathy. No documented case of avascular necrosis exists in the literature when the total prednisone dose or corticosteroid equivalent stayed under 550 mg. Some providers use a methylprednisolone dose pack (tapers from 24 to 0 mg over 7 days); however, concern exists regarding adequate dosing to treat radiculopathy. A prednisone dose schedule outlined below stays within the 550-mg limiting amount.

Tricyclic antidepressants (TCAs) decrease pain and reduce nonrestorative sleep. Side effects include dry mouth, constipation, and weight gain. Selective serotonin reuptake inhibitors (SSRIs), despite lacking side effects associated with TCAs, are inferior to TCAs in treating diabetic peripheral neuropathic pain, and their efficacy in relieving neck and back pain compared with that of other antidepressants remains unknown. Additional medications include membrane-stabilizing agents (eg, gabapentin, carbamazepine). Gabapentin has demonstrated efficacy in treating diabetic peripheral neuropathic pain. Other analgesics (acetaminophen, tramadol) provide pain relief without inflammation control.

Opioids may be prescribed orally, transdermally, rectally, or sublingually on a scheduled basis. Patients on opioids should sign a medication contract restricting them to a single physician and pharmacy, scheduled medication use, no unscheduled refills, and no sharing or selling medication. Patients with a previous history of alcoholism or other addiction who are prescribed opioids long term are at risk for dependence. Therefore, consider recommending cotreatment of these patients with a psychologist or other addiction specialist.

Lastly, many short-acting opioid preparations contain acetaminophen, which may be toxic in doses above 3 g per day. Consequently, patients should be counseled to avoid toxicity by avoiding other pharmaceuticals containing acetaminophen.

Corticosteroids

Used to treat inflammatory cervical radiculopathy. Have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body’s immune response to diverse stimuli.

Prednisone (Deltasone, Orasone Sterapred)

Decreases inflammation by inhibiting polymorphonuclear leukocyte and fibroblast migration, stabilizing lysosomes, and decreasing capillary permeability.

Methylprednisolone dose pack (Solu-Medrol, Medrol, Depo-Medrol)

Decreases inflammation by inhibiting polymorphonuclear leukocyte and fibroblast migration, stabilizing lysosomes, and decreasing capillary permeability.

Anticonvulsants

Use of certain anti-epileptic drugs, such as the GABA analogue Neurontin (gabapentin), has proven helpful in some cases of neuropathic pain. Have central and peripheral anticholinergic effects, as well as sedative effects, and block the active reuptake of norepinephrine and serotonin. The multifactorial mechanism of analgesia could include improved sleep, altered perception of pain, and increase in pain threshold.

Gabapentin (Neurontin)

Has anticonvulsant properties and antineuralgic effects; however, exact mechanism of action is unknown. Structurally related to GABA but does not interact with GABA receptors.

Carbamazepine (Tegretol)

May reduce polysynaptic responses and block posttetanic potentiation. Inhibits nerve impulses by decreasing influx of sodium ions into cell membrane.

Analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort and have sedating properties, which are beneficial for patients who experience pain.

Acetaminophen (Tylenol, Feverall, Aspirin Free Anacin)

DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.

Tramadol (Ultram)

Inhibits ascending pain pathways, altering perception of and response to pain. Inhibits also reuptake of norepinephrine and serotonin.

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Target hemoglobin levels in the correction of anemia of chronic illness in patients with chronic kidney and cardiovascular disease


Anemia of Chronic Disease and Renal Failure: Follow-up

Follow-up

Complications

Hypoxia

Hypoxia is the most potent stimulus to the production of erythropoietin by the kidneys. In the healthy individual, erythropoietin exerts its effects in the bone marrow to help in the production of RBCs, thereby improving oxygen concentration in the blood, relieving the hypoxia.

Another complication that commonly occurs in those with chronic kidney disease is that of secondary hyperparathyroidism and the development of renal osteodystrophy. In these patients, the bone marrow tends to be fibrotic and, hence, less responsive to the effects of erythropoietin.

Cardiorenal anemia syndrome

Silverberg described the “cardiorenal syndrome,” which refers to a vicious cycle, whereby decreased kidney function, as seen in chronic kidney disease, leads to decreased erythropoietin production and, thence, anemia.14

Anemia, if severe, leads to a compensatory LVH. Such compensatory LVH eventually leads to precipitation of congestive heart failure (CHF), which causes a decline in blood perfusion to the kidneys, resulting in further kidney damage. Levin et al estimated that for every 1-g decrease in hemoglobin concentration, there is an increased 6% risk of LVH in patients with chronic kidney disease.15 Foley et al estimated that such a 1-g decrease in hemoglobin concentration also translated into a 42% increase in left ventricular dilatation in patients with stage 5 chronic kidney disease.16

Cardiovascular disease

As an individual ages, the risk of death from cardiovascular disease also increases. The impact of anemia in cardiovascular disease and chronic kidney disease in this elderly population cannot be understated. Cardiovascular disease remains the most common cause of mortality in this patient population, much higher than in the general population.17 Anemia has been shown to be an independent risk factor for increased cardiovascular morbidity and mortality.

The Dialysis Outcomes Practice Pattern Study (DOPPS) involved several countries and showed that as hemoglobin concentrations decreased to <11 g/dL, there was a corresponding increase in the rates of hospitalization and mortality in patients with chronic kidney disease.18 Ofsthun et al analyzed the databases from Fresenius Medical Care of North America (FMCNA) (selection restricted to patients in the census for 6 consecutive months from July 1, 1998, through June 30, 2000) and showed that the longer it took for these patients with stage 5 chronic kidney resolve their hemoglobin concentrations from <11 g/dL, the more dramatic an increase in their mortality hazard ratio.19 The investigators further added that lower hemoglobin concentrations clearly correlated positively with adverse events in these patients.

In summary, one can derive that if hemoglobin levels are maintained at the recommended target goals, these translate into decreased LVH, decreased hospitalizations related to cardiovascular disease, and decreased mortality from cardiovascular disease. Aside from these findings, however, higher quality of life (QOL) scores are also obtained: less easy fatigability and fatigue symptoms, improved physical well-being and exercise tolerance, and improved functional well-being.

The next question is what are the appropriate target levels for the correction of anemia? Certainly, this issue has received much recognition as of late, in connection with recently published literature in which it was demonstrated that targeting higher hemoglobin levels may relate positively with higher rates of death and cardiovascular disease death, as well as positively with an increased risk of death, overall. Two of the trials relating to patients with cardiovascular disease will be discussed here.

Two landmark trials tried to address the controversial issue of the upper limit to target hemoglobin concentration, namely, the Cardiovascular Risk Reduction by Early Anemia Treatment with Epoetin Beta (CREATE)20 and the Correction of Hemoglobin and Outcomes in Renal Insufficiency (CHOIR)21 studies. As a result of the CREATE and CHOIR studies, in March 2007, the US Food and Drug Administration (FDA) issued a black box warning to the labeling of epoetin alfa (Procrit) and darbepoetin alfa (Aranesp) to emphasize that use of these ESAs may increase the risk of serious cardiovascular events and death when they are dosed to achieve a target hemoglobin of >12 g/dL.

This warning was again updated in November 2007, at which time, the FDA stated that “ESAs should be used to maintain a hemoglobin level between 10 g/dL to 12 g/dL. Maintaining higher hemoglobin levels in patients with chronic kidney failure increases the risk for death and for serious cardiovascular reactions such as stroke, heart attack or heart failure.”22

The FDA further recommends that hemoglobin be measured twice per week for 2-6 weeks after a dose adjustment, the purpose of which is to ascertain that the hemoglobin has had enough time to stabilize in response to the dose adjustment. Moreover, the FDA recommends withholding the dose of the ESA if the hemoglobin is >12 g/dL or increases by 1 g/dL over a 2-week period. The latter recommendation is in stark contrast to what has been done in most clinical practices until recently.

With these latest developments, the current clinical management of anemia in chronic kidney disease will certainly be significantly affected.

Likewise, the 2007 NKF update of the target hemoglobin recommendation stated that, although the lower limit of the target hemoglobin range remains 11 g/dL, the target range is 11–12 g/dL, and patients who have already or are currently receiving an ESA should maintain a hemoglobin target of less than or 13 g/dL

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New studies on MRI and Rotator Cuff Injury

New studies on MRI and Rotator Cuff Injury

Author: Michael Tuite, MD,, Director, Musculoskeletal Division, University of Wisconsin Hospital and Medical School

Coauthor(s): Matthew F Sanford, MD, Fellow in Musculoskeletal Radiology, Department of Radiology, University of Wisconsin Medical School

Introduction

Background

Shoulder pain is a common complaint by patients during physician visits, and it can be due to a variety of causes. The major cause of shoulder pain in patients older than 40 years is rotator cuff impingement and tears. With the development of new arthroscopic techniques for treating rotator cuff disorders, magnetic resonance imaging (MRI) has played an increasingly important role as a noninvasive test for determining which patients may benefit from surgery

Related Keyword terms:

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