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This tendon can usually be palpated if the examiner inserts a finger just lateral to the more prominent lacertus fibrosus. It is this insertion into the radius that allows the biceps to func tion as a powerful supinator of the forearm. It is not distinctly visible, but it contributes to the appar ent bulk of the biceps. More rarely, rupture of the biceps muscle can also lead to severe deformity of the mally visible. Lateral to the tendon, the musculo biceps tendon serve as helpful anatomic landmarks for cutaneous nerve emerges from beneath the biceps mus other structures of the anterior elbow that are not nor cle and continues distally as the lateral cutaneous nerve of the forearm. The proximal portions of the fore arm muscles form the inverted triangular depression known as the cubital fossa (antecubital fossa). The lat eral border of the antecubital fossa is formed by a bulky group of three muscles that originates from the lateral humerus above the elbow: the brachioradialis, the exten sor carpi radialis longus, and the extensor carpi radialis brevis. The bra chioradialis, which arises from the lateral border of the humerus and inserts near the radial styloid, is the only one of these three that is visible anteriorly when the fore arm is fully supinated, and it forms the lateral border of the forearm in this position (. The muscles that originate from the medial epicondyle are sometimes known as the flexor-pronator group because they consist of the pronator teres and the principal flexors of the wrist and fingers. The pronator teres is the most centrally sit uated of these muscles, and it forms the lateral border of the antecubital fossa. The bellies of the wrist flexors (flexor carpi radialis, palmaris longus, and flexor carpi ulnaris) are located medial to the pronator teres. Because the finger flexors are located deep to these four muscles, they add to the bulk of the anterior forearm but do not directly influence its contour. Distally, the forearm muscles taper to tendons, which are discussed in Chapter 4, Hand and Wrist. Anterior aspect of the elbow during resisted flexion (arrow indicates lacertus fibrosus). A, brachio radialis; B, pronator teres; C, flexor carpi radialis; D palmaris longus; B, flexor carpi ulnaris. A, olecranon process; H, medial epicondyle; C, lateral epicondyle; D, triceps brachii; E, brachioradialis; F. The posterior aspect of the elbow is domi nated by three bony prominences: the olecranon process and the medial and lateral epicondyles (. When the elbow is fully extended, the tip of the olecranon moves prox imally, so that the three landmarks lie along a straight line. The relationship of these three bony landmarks to one another can be used to assist in the clinical diagnosis of frac tures and dislocations about the elbow. In the presence of a dislocation of the elbow, the relationship of the two epi condyles to each other remains normal but their relation ship to the olecranon changes. In the case of a posterior elbow dislocation, the most common type, the olecranon moves posteriorly with respect to the epicondyles and becomes more prominent. When a supracondylar fracture of the humerus occurs, the normal relationship of these three bony landmarks is maintained but the entire triangle is translated or angulated with respect to the humerus, most commonly Figure 3-6. If one of the humeral epicondyles is fractured and displaced or a comminuted supracondylar or intracondylar fracture is present, the normal relationship muscle, these three constitute the lateral border of the pos of the two epicondyles to each other is disrupted. The central portion of the pos terior forearm is occupied by the extensor digitorum Olecranon Bursa. The redundancy of the skin overlying communis and extensor carpi uinaris, which originate the olecranon process facilitates the extreme amount of from a common tendon at the lateral cpicondyle and flexion possible at the elbow. The group of three muscles, which originates in the midfore olecranon bursa lies between the tip of the olecranon and arm, emerges between the extensor digitorum communis the overlying skin, facilitating the large amount of sliding motion that takes place between the skin and the bone. Trauma, inflammation, or infection can cause this bursa to fill with blood, synovial fluid, or pus, respectively. The presence of fluid causes the bursa to swell to the size of a Ping-Pong ball or even larger and bulge outward (. In the presence of sterile inflammation, the skin overlying the bursa may be slightly warm; in the presence of infection, the skin is normally hot and erythematous. The tip of the elbow and adjacent subcutaneous bor der of the proximal ulna is the most common site for for mation of rheumatoid nodules (. When present, these rubbery nodules satisfy one of the criteria for the diagnosis of rheumatoid arthritis. The muscular anatomy of the dis tal portion of the upper arm is dominated by the triceps brachii, the principal extensor of the elbow. The principal insertion of the triceps is into the proximal olecranon, although it also flares into an aponeurosis that covers the small anconeus muscle and blends into the fascia of the posterior forearm. A bulge on the lateral aspect of the pos terior elbow marks the proximal portions of the radially innervated brachioradialis and extensor carpi radialis longus muscles, which originate on the epicondylar ridge above the elbow and course distally to their insertions at Figure 3-7. Together with the extensor carpi radialis brevis S, Sledge C: Textbook of Rheumatology, 2nd ed. A, brachioradialis; B, extensor carpi radialis longus; C, extensor carpi radialis brevis; D, extensor digitorum communis; E, extensor carpi ulnaris; F, outcropping muscles of the thumb; G, subcutaneous border of the ulna. The tip Owing to the way these muscles emerge obliquely between of the olecranon is a subcutaneous prominence that the other two extensor muscle groups, they are sometimes should be visible in virtually all individuals. In leaner patients, the epicondylar ridge of the distal humerus is visible in con Ulna. The muscular contours of the posterior forearm tinuity with the lateral epicondyle. The radial head, how are completed by the ulnar portion of the flexor muscle ever, is not normally visible because it is covered by the mass, which bulges out sufficiently to constitute the extensor muscle mass. The subcutaneous border When an olecranon fracture occurs, the pull of the of the ulna is often visible as a linear furrow extending triceps muscle usually causes the proximal fragment of distally from the olecranon. The subcutaneous examined before much swelling has set in, this displace border of the ulna constitutes the dividing line between ment is detectable as a disruption in the normal trian the extensor and the flexor compartments of the forearm. There is relatively little soft tissue overly distal aspect of the upper arm to the medial epicondyie. This soft spot is also generally considered the triceps, and anterior to it lie the biceps and brachialis easiest point at which to aspirate or inject the elbow joint. Distention or fullness at the site of the normal soft spot suggests the presence of intraarticular fluid. The ulnar nerve is best identified from the causes of such a distention include hemarthrosis due to medial aspect. It courses through the posterior compart an intraarticular fracture; synovitis due to arthritis, ment of the upper arm just posterior to the intermuscu osteochondritis dissecans, or loose bodies; or infection. The ulnar nerve is virtually subcuta of the olecranon process and the prominence of the neous as it passes through the groove between the medial media] epicondyie (. The medial epicondyie epicondyie and the olecranon; this groove is often called serves as the origin of the flexor-pronator muscle group. In lean individuals, the ulnar nerve A linear soft tissue ridge may be seen leading down the may actually be visible in the cubital tunnel as a linear Figure 3-10. A, olecranon process; B, medial epicondyle; C, biceps brachii; D, intermuscular septum; E, triceps; F, cubital tunnel. If ulnar neuropathy is suspected, ligament the examiner should inspect this area very closely as the Abnormal laxity to valgus stress test patient maximally flexes and extends the elbow several (complete injuries) times. In some patients, neuropathy is secondary to Pain elicited by the milking maneuver (partial instability of the ulnar nerve in the cubital tunnel, and the injuries) nerve can be seen to pop back and forth across the medial Associated ulnar nerve irritation at the cubital tunnel possible epicondyle as the elbow flexes and extends. The forearms are fully supinated so that the palms face forward and the elbows are fully extended. The shoulders are adducted so that the erable variation in the carrying angle among individuals, upper arms lie comfortably against the side of the chest. Interestingly, the extended; instead, the forearm and hand angle away from ulnar-humeral articulation is so engineered that the car the body. This normal valgus angulation at the elbow is rying angle disappears when the elbow is flexed, and the referred to as the carrying angle. In the case of a growth disturbance, the magnitude of the deformity increases until skeletal growth is completed.

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By using precise anatomical terminology, including anatomical position, regional terms, directional terms, body planes, and body cavities, we can eliminate ambiguity and increase precision. The root of a term often refers to an organ, tissue, or condition, whereas the prefix or suffix often describes the root. Anatomical Position Anatomists have standardized the position of the body when it is referenced using descriptive terms to increase precision in language. The upper limbs are held out to each side, and the palms of the hands face forward (see Figures 1. Using this standard position helps reduce confusion and increase precision while describing parts of the human body. It does not matter how the body being described is oriented (ex: a doctor describing their patient who is sitting on an exam table), the terms are used as if that person is in anatomical position. Prone describes a face-down orientation, and supine describes a face up orientation. These terms are sometimes used in describing the position of the body during specific physical examinations or surgical procedures and you may hear the terms used to describe the position of the cadavers used in this course. While you are not expected to learn these terms at this point in the course (you will not find them in the Module 1 Need to Know), you will see these terms throughout the semester as they often form the basis for many of the structures you will learn later. The human body is shown in anatomical position in an (a) anterior view and a (b) posterior view. Directional Terms A set of specific directional anatomical terms appear throughout this and most other anatomy textbooks ure 1. These terms are essential for describing the relative locations of different body structures. Learning these terms now is critical to avoid confusion when you are studying or describing the locations of particular body parts in this course and in any future study of the human body. Superior and cranial can often be used interchangeably though cranial is used to specifically refer to a structure near or toward the head. Inferior and caudal can often be used interchangeably though caudal is used to specifically refer to a structure near or toward the tail (in humans, the coccyx, or lowest part of the spinal column). Paired directional terms are shown as applied to the human body in anatomical position. Body Sections & Planes A section is a two-dimensional surface of a three-dimensional structure that has been cut. Body sections and scans can be correctly interpreted, however, only if the viewer understands the plane along which the section was made. If this vertical plane runs directly down the middle of the body, it is called the midsagittal or median plane. If it divides the body into unequal right and left sides, it is called a parasagittal plane. The three planes most commonly used in anatomical and medical imaging are the sagittal, frontal, and transverse planes. Body Cavities the body maintains its internal organization by means of membranes, sheaths, and other structures that separate compartments. The dorsal (posterior) cavity and the ventral (anterior) cavity are the largest body compartments ure 1. These cavities contain delicate internal organs, and the ventral cavity allows for significant changes in the size and shape of the organs as they perform their functions. The lungs, heart, stomach, and intestines, for example, can change their shape considerably during expansion or contraction without distorting other tissues or disrupting the activity of nearby organs since they are found in cavities. The ventral cavity includes the thoracic and abdominopelvic cavities and their subdivisions. In the dorsal cavity, the cranial cavity houses the brain, and the vertebral (spinal) cavity encloses the spinal cord. Just as the brain and spinal cord make up a continuous, uninterrupted structure, the cranial and spinal cavities that house them are also continuous. The brain and spinal cord are protected by the bones of the skull and vertebral column and by cerebrospinal fluid, a colorless fluid produced by the brain, which cushions the brain and spinal cord within the dorsal cavity. The ventral cavity has two main subdivisions: the thoracic cavity and the abdominopelvic cavity. The thoracic cavity is the more superior subdivision of the anterior cavity, and it is enclosed by the rib cage. The thoracic cavity contains the lungs (each found in a pleural cavity) and the heart (found in a pericardial cavity). The diaphragm forms the floor of the thoracic cavity and separates it from the more inferior abdominopelvic cavity. Although no membrane physically divides the abdominopelvic cavity, it can be useful to distinguish between the abdominal cavity, the division that primarily houses the digestive organs, and the pelvic cavity, the division that primarily houses the organs of reproduction. There are (a) nine abdominal regions and (b) four abdominal quadrants in the peritoneal cavity. The more detailed regional approach subdivides the cavity with one horizontal line immediately inferior to the ribs and one immediately superior to the pelvis, and two vertical lines drawn as if dropped from the midpoint of each clavicle (collarbone). Complete the table below by sorting the given organizational levels of the human body from smallest to largest and then providing a one-sentence definition of each level. Tissue; organelle; atom; organ; organ system; cell; organism; molecule Smallest Definition Largest 2. Summarize the major similarity for what defines tissues, organs, and organ systems in one phrase. Lying face-up on the ground with their head, back, hands, and feet on the floor with both knees bent 2. In a seated position on the floor with their legs straight and arms folded across their chest 3. Standing and facing you with their legs crossed and hands in their pocket Check Your Understanding 3. Use all of the directional terms provided in the table below in an accurate context by illustrating the terms on a skeleton or torso model. You cannot use the examples provided in the background information and must come up with different examples.

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Do not turn the individual onto a body surface that is damaged or still reddened from a previous episode of pressure loading, especially if the area of redness does not blanch. Use devices to enable the individual to assist or independently position, lift and transfer (example trapeze, bed rails). When the individual is positioned in the supine position, the head of the bed should be fat (Diagram A). Individuals positioned in the lateral side lying position should be positioned at no greater than 30 degrees. Individuals should be positioned in a wheelchair or other suitable chair for meals and activities. If this is not possible, frst raise the knee gatch to prevent sliding and then the head of the bed. When the body heat cannot dissipate, it will increase the risk of skin maceration and may impede healing. Repositioning for the Treatment of Pressure Ulcers 57 Repositioning the Seated Individual 105. Only sit someone with a pressure ulcer if the pressure to the area can be ofoaded or minimized in a seated position. If clients are not independent in repositioning, a caregiver should assist with repositioning. The client may also beneft from a tilt wheelchair where they can be assisted to change their tilted position every 15 minutes. If there is no evidence of further tissue damage and the ulcer is showing signs of healing, the sitting time can be gradually increased. Refer to the Glossary for selected terms and defnitions associated with support surfaces. When pressure ulcers deteriorate or fail to heal, the professional should consider replacing the existing support surface with one that will improve pressure redistribution and microclimate (heat and moisture control) for the individual. Preventive interventions and local wound care should also be intensifed as needed. A signifcant increase in risk status may also prompt re-evaluation of the individual and the support surface. Do not base the selec tion of a support surface solely on the perceived level of risk for pressure ulcer development or the category/stage of any existing pressure ulcers. Use a mattress that minimizes peak pressures over bony prominences or intermittent removal of pressure. Risks increase if the mattress edges compress and bed rails are in use (Health Canada, 2008). The original bed settings need to be resumed immediately after these activities are completed. If plastic-backed incontinence products must be used, allow product to remain open or place them loosely against the skin to promote as much air fow as possible. The seating components need to address a number of performance goals in addition to pressure redistribution. It is critical that the therapist prescribing seating components for individuals with neuromusculoskeletal conditions have expertise in the area. Determine the efects of postural stability and asymmetries on pressure distribution by completing a comprehensive seating assessment. Determine the exact location of the pressure ulcer before making a cushion or back rest recommendation. Pressure mapping is an additional tool that can be used to supplement information gathered during this evaluation. Ensure that the heels are free of the surface of the bed for individuals at high risk of developing heel pressure ulcers. They should elevate the heel completely (ofoad them) in such a way as to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon. Once a device is applied it is important to check for proper foot position on a regular basis and conduct a thorough skin assessment if any issues with positioning are found. Consider the need to change support surfaces for individuals with poor local and systemic oxygenation and perfusion to improve pressure redistribution, reduce shear, control microclimate and utilize additional features. Consider the need to change support surfaces for individuals who cannot be turned for medical reasons such as spinal instability and hemodynamic instability. Consider alternative methods, other than lateral rotation, of pressure redistribu tion in individuals with sacral or buttock pressure ulcers. Inspect the pressure ulcer and the peri-ulcer skin for shear injury with every dressing change. Shear injury may appear as deterioration of the ulcer edge, undermining, and/or as increasing infammation of peri-ulcer skin or the ulcer. In all cases, the risks and benefts of continued lateral rotation should be weighed in individuals with existing pressure ulcers. Individuals with Neurological Conditions Individuals with neurological conditions such as spinal cord injuries, multiple sclerosis, amyotrophic lateral sclerosis require the use of a wheelchair. Maintaining the ability to sit in their wheelchair, despite the presence of a pressure ulcer on a sitting surface, would be a high priority to allow the individual to continue to participate in daily activities. In addition to the following recommendation, all general treatment recommendations should be followed. Consult a therapist who has expertise in treating individuals with neurological conditions for a comprehensive seating assessment and evaluation of all positioning and support surfaces required over a 24-hour period. The treatments dis cussed in this section have been studied specifcally in individuals with pressure ulcers) Several forms of energy have been studied in the management of pressure ulcers. Biophysical agents can be used to deliver specifc treatment substances to the wound bed. Use of biophysical agents should be directed by and under the supervision/management of a skilled licensed professional who has been educated and trained in safe and efective methods of choosing the appropriate patient candidate and the method of application and monitoring the positive and untoward efects. Ultraviolet light may be considered as an adjunctive therapy; but should not be used instead of other recommended therapies to reduce bacterial burden (see infection section). Biophysical Agents in Pressure Ulcer Management 67 Acoustic Energy (Ultrasound) 120. Studies on other types of chronic wounds report mixed results and some adverse efects. High frequency ultrasound may be considered as an adjunctive therapy and should not be used instead of other recommended therapies to reduce bacterial burden (see Infection section). If pain is anticipated or reported, consider placing a non-adherent interface dressing on the wound bed, lowering the level of pressure, and/or changing the type of pressure (continuous or intermittent). Consider a course of pulsatile lavage with suction for wound cleansing and debride ment).

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Most commonly, the head of the ulna subluxes dorsally in relation to the radius when the forearm is in the pronated position. The test for instability in the distal radioulnar joint is sometimes called the piano Figure 4-86. This maneuver may be called the distal different from the visible jumping or clunking sensation radioulnar joint compression test. The wrist is then loaded by this reduction maneuver is the first part of the shuck compressing the hand proximally against the forearm, test, as described previously. While maintaining the basi and the wrist is moved repeatedly back and forth from lar joint in reduction, the examiner loads the basilar radial deviation to ulnar deviation (. This portion of the examination is known as the this test is similar to the midcarpal instability test, the grind test. The examiner places the lighted end of a penlight flashlight against the cutaneous surface next to the mass. If the mass is indeed a ganglion, the light should be seen to pass through it, changing the glow of the light from a round to a dumbbell-shaped globe. This demon strates that the mass is indeed a cyst filled with fluid, and thus it is almost certainly a ganglion. If, on the other hand, the mass does not transmit the light, it is probably Figure 4-89. The most basic test for evaluating the circulation to the fingers is to assess the capillary refill. The examiner first tenosynovitis of the first dorsal compartment, which con notes the color of the nailbed of the finger to be evalu tains the abductor pollicis longus and extensor pollicis ated. If reperfusion occurs more slowly than this, circu artery while maintaining compression on the artery that lation to the finger is compromised. Again, the time required for other digits allows the examiner to determine whether perfusion to return to the hand is noted. In about 80% the problem is confined to one particular finger or affects of normal individuals, the ulnar artery predominates the entire hand. This informa longed after the release of either artery, the examiner tion is important to know before performing a procedure should conclude that perfusion from that artery is that might injure one of the arteries, such as inserting an reduced. The examiner locates the normal resting color of the finger in question and has radial and ulnar pulses as described in the Palpation section the patient exsanguinate it by flexing the finger tightly. Immediately releases compression from one of the digital arteries and after opening, the hand should appear blanched because the observes the time required for normal color to return to examiner is occluding inflow from both arteries (. The examiner then quickly releases compression hand, the procedure is then repeated for the other digi from one of the arteries and observes the color of the hand tal artery so that the relative contributions of the two (. Ulnar sided wrist pain has multiple causes and is the diagnosis and treatment of six hundred filty-four hands. You must examine all of the radial sided wrist bones from the radius to the first metacarpal. Performing the Finkelstein test by having the patient make a fist around their thumb will cause pain in many normal individuals. Basilar joint arthritis occurs in 18% of women over 50 years of age and 5% of men. Martell he pelvis is a complex bony structure that is formed in the supine position, the panniculus tends to shift supe by the joining of seven individual components. The most prominent feature of the pelvis is the pubis fuse together to become a pelvic, or innominate, arching superior margin of the ilium, known as the iliac bone. The iliac crest is visible in many patients and pal riorly at the pubic symphysis and join the sacrum poste pable in most, in obese patients, it lies immediately riorly at the sacroiliac joints to form a closed ring. The pelvis provides a foundation for that traverses the anterior pelvis and inserts just lateral to the spine and upper body and the point of origin or the pubic symphysis on a small prominence of the pubis insertion for many muscles of the thorax, the hip, and the known as the pubic tubercle. The obliquely across the anterior thigh to insert on the proxi great depth of the acetabulum combines with the strong mal medial tibia as the outer layer of the pes anserinus. This is the site at which the nerve may a tremendous variety of positions in space. Distal to the be compressed by tight clothing, leading to the uncom hip, the femoral shaft undergirds the muscles of the thigh, fortable condition known as meralgia paresthetica. In others, the femoral artery should be pal pable just medial to the midpoint of the inguinal liga Surface Anatomy ment. The femoral nerve is just lateral to the artery, and the fcmoral vein is just medial to it. In the presence of obesity, femoral triangle, which may be visible, include the the pendulous abdominal fat, or panniculus, tends to inguinal ligament superiorly, the sartorius muscle later obscure these landmarks. The disruption of the two inserts into the fascia lata, or enveloping fascia, of the lat halves of the pelvis may occur as a result of high velocity eral thigh. Pelvic disruption is often associated with fractures individuals, forming the lateral contour of the proximal of the pubic ramus or dissociation of the pubic symphysis. This small bony promi marks of the pelvis can be used to identify the location of nence is not normally visible because it is obscured by the hip joint. The contours of the pubic bone are not nor ogy of the hip joint, such as osteoarthritis, usually is local mally visible. The upper portion of the pubis is known as ized to this site and often is described by the patient as the superior pubic ramus. The quadriceps muscle group constitutes the the superior pubic ramus, and the pyramidalis and rectus primary bulk of the anterior thigh (. A, rectus femoris; B, vastus medialis; C, vastus lateralis; D, iliotibial tract; E, adductor loDgus; F gracilis; G, sartorius. It should lie just distal to the midpoint through the patellar tendon, into the tibial tubercle. The vastus to the vicinity of the greater trochanter usually arises intermedins is located deep to the rectus femoris and is from trochanteric bursitis or gluteus medius tendinitis, not separately visible. The lateral border of the thigh again dominated by the curve of the iliac crest (. The sacroiliac joint is not nor originates from the pubis and inserts on the linea aspera mally visible, although it can be palpated as a longitudi of the femur. The runs the length of the medial thigh until it inserts as a other landmarks of the posterior hip and pelvis are narrow tendon on the tibia as part of the pes anserinus. Viewed from the lateral position, the into both the fascia lata and the linea aspera of the poste most prominent landmark of the pelvis is the arching rior femur. The position of the lar depression between the two great prominences created pelvis is traditionally judged by the orientation of by the gluteus maximus muscles. Its infe From the lateral perspective, the examiner is looking rior contour, the ischial tuberosity, constitutes the inferi directly at the prominence created by the principal ormost portion of the pelvis. The gluteus normally visible, but it is palpable in the inferior medial medius arises from the superior portion of most of the buttock deep to the gluteus maximus. Anterior gin for the hamstrings, the principal flexors of the knee, to the gluteus medius, the tensor fascia lata arises from and a portion of the adductor magnus. Posterior to the gluteus medius, the bulky gluteus max muscles of the posterior hip, their position can be esti imus muscle arises from the posterior ilium and adjacent mated through knowledge of their relationship to the sacrum. The belly of the gluteus maximus constitutes the greater trochanter, whose prominence can usually be familiar rounded contour of the buttock. A group of four short external rotators arises from the pelvis and inserts in Thigh. Distal to the pelvic area, the vastus lateralis and a relatively small area on the superior portion of the greater the biceps femoris muscles constitute the anterior and trochanter. From superior to inferior they are the piri the posterior contours of the thigh, respectively (. The greater trochanter can be a source of posterior hip pain, and the piriformis is projects laterally to provide increased leverage for the glu thought to sometimes compress the sciatic nerve, which teus medius and the gluteus minimus muscles that insert emerges from beneath it. These critical muscles not only abduct the femur muscles, the obturator externus and the quadratus but also, more importantly, prevent drooping of the femoris, insert further distally on the posterior margin of pelvis when the opposite limb is lifted from the ground the greater trochanter. These folds, which are formed as the gluteus maxinuis sively from the ischial tuberosity. The semimembranosus inserts into the posterior aspect of the proximal femur, are courses distally to its own complex insertion on the pos normally symmetric. The semitendi arthritis with hip joint subluxation or congenital hip dys nosus is superficial and lateral to the bulk of the plasia, cause the gluteal folds to appear asymmetric. The lateral margin of the posterior thigh is defined don that curves around the medial tibia to insert anteriorly by the iliotibial tract (.

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Include the attachments at the at risk for serious shoulder, along the scapula, into the cervical and thoracic spine bruising resulting regions. You are soften resolve after several ing related structures in order to work into the primary trigger sessions. Warm this an indicator of cancer entire area by repeating the same steps you performed on the unaf recurrence or other fected side before you begin the actual trigger point work. Include the attachments at the can cause extremely shoulder, along the scapula, into the cervical and thoracic spine uncomfortable regions. Using gentle palpation and digital kneading, ask the client to help identify the exact location of the offending trigger point. Sometimes, I draw a circle around the nodule with a nonpermanent marker in order to save time and to be able to return to the exact spot again as the protocol demands. With your full open hand, grasp as much tissue around the trigger point and including the trigger point region. Hold this position, just grasp ing the superior trapezius in a medium-pressure grasp for a few seconds. Feel as if you are actually lifting the trapezius off the bone but not yanking it. Return the tis sue to its normal position, stroke it for a few seconds, and repeat. This action is similar to that of kneading bread, rhythmically, with both hands working toward the center Contraindications of the trigger point. These compressions should not cause pain, although redness, or heat is they might cause mild discomfort. This may be a position in which he on the body) and stretches his head to the side and forces the shoulder down. Ask refer the client to a him to move the shoulder just an inch or two to relieve the worst physician. Effeurage, petrissage, kneading, plucking, hacking, medium heat to the region is to-deep (nonpainful) pressure at a brisk pace. Include the attachments at the is secondary to an shoulder, along the scapula, into the cervical and thoracic spine overstretch injury, regions. Assign ample homework including stretches, stress management, and the application of hot packs. This painful and radiating problem will consistently recur unless the client realizes that he must manage both his stress level and his muscles. Place your right hand on your head, almost over to the top of your left ear, and gently press your head down to the right shoulder. While 95% of whiplash injuries involve superfcial damage to muscle and tendons only, treatment confusion exists because so many neck, shoulder, and back structures can be affected long after the initial injury. For example, compensatory trigger points can lead to muscular dys function and pain that can linger for months or years. The short-term prognosis is usually good, and most people recover within several weeks. About 40% of patients may experi ence symptoms after 3 months; 18% may still suffer after 2 years. However, a previous whiplash injury can double the risk of developing severe symptoms from a second whiplash incident. It is densely packed with arteries, veins, lymphatic vessels, muscles, tendons, and ligaments, most of which intricately work to keep the brain alive, the body moving, and the immune system responsive. Although most whiplash injuries affecting soft tissue (muscles, tendons, ligaments) are transient, No Massage Immediately the lingering chronic pain and emotional stress refect the profound fear surround After Whiplash ing injury to this area. The sooner after doctor, and my neck is killing the incident symptoms manifest, the more serious the injury. Neck immobilization, usually by the ftting of a neck brace, has been the traditional whiplash treatment. New think ing includes the understanding that artifcial and lengthy immobilization of already injured (immobilized) tissue can promote further damage and prolong rehabilita tion. Health care practitioners now suggest early and gentle neck movement, lim ited physical activity, and rest following an accident or neck injury. If a neck brace is prescribed, it should be worn intermittently and for short periods. Massage Prevention includes wearing a seat belt, using proper headgear when doing Therapist high-impact sports, and not shaking a child in a way that could injure the neck. The answers to the following questions will help determine safe that prolonged immobility treatment. If the acute pain and spasms have quieted, if the incident occurred at least 3 days ago, and if the client is taking neither narcotics nor muscle relaxants, the therapist can proceed with assessment and then treatment. The neck and shoulder structures should be palpated for hypertonicity and trig Thinking ger points. If the therapist is qualifed, palpa It Through tion of every spinous process, from the cervical to the lumbar spine, will determine tenderness or rotation, as well as hypertonicity in the surrounding muscles. Chapter 44 Whiplash 335 Cervical Strain 5 Days After Step-by-Step Protocol for a Motor Vehicle Collision Thinking It Through Technique Duration (cont. Leave in place 5 minutes the job when he was hit while you perform general relaxation techniques anywhere else by another vehicle from in the body other than the neck and shoulders. Palpate the entire area listed previously for 2 minutes taut muscle bands and trigger points.

Syndromes

  • Lethargy
  • Signs of dehydration
  • Avoid knowingly spreading disease.
  • Night sweats
  • Hernias: umbilical hernia, inguinal hernia
  • Try to go to bed at the same time every night and wake at the same time each morning.

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Interstitial cells produce spermatozoa and secrete nutrients to developing spermatozoa within the testes. The tubes of women and the deferens of men transport gametes. A exists when one or both of the testicular veins draining blood from the testes are swollen, resulting in poor testicular circulation. The is a thin remnant of mucous membrane that may partially cover the vaginal orifice. Ejaculated spermatozoa can live up to days, whereas an ovulated egg can survive only about hours. Mitotic divisions of a zygote are referred to as. An occurs when a blastocyst implants at a site other than the uterine cavity. Epididymis (j) transports semen Answers and Explanations for Review Exercises Multiple Choice 1. The ovaries no longer respond, however; thus, no follicles develop, and little or no estrogen and progesterone are produced. False; parasympathetic impulses cause marked vasodilation of the arterioles, which increase blood flow into the penis, causing an erection. False; spermatozoa mix with additives from the accessory reproductive glands in the ejaculatory ducts. False; secretions from the vestibular glands moisten and lubricate the vaginal orifice during sexual arousal. False; interstitial cells secrete testosterone; the sustentacular cells provide nutrients to the spermatozoa. False; the secretory phase is from the time of ovulation until the start of the menstrual phase. Professor, Division of Anatomy, Professor Emeritus in Division of Anatomy, Department of Surgery, Faculty of Department of Surgery Medicine Former Chair of Anatomy and Associate Department of Physical Therapy, Dean for Basic Medical Sciences Department of Occupational Therapy Faculty of Medicine, University of Toronto Division of Biomedical Communications, Toronto, Ontario, Canada Institute of Medical Science Graduate Department of Rehabilitation Arthur F. Science, Graduate Department of Dentistry Professor, Department of Cell and University of Toronto Developmental Biology Toronto, Ontario, Canada Adjunct Professor, Department of Orthopaedics and Rehabilitation Director, Structure, Function and Development and Anatomical Donations Program Vanderbilt University School of Medicine Adjunct Professor for Anatomy Belmont University School of Physical Therapy Nashville, Tennessee, U. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U. The publishers have made every effort to trace the copyright holders for borrowed material. If they have inadvertently overlooked any, they will be pleased to make the necessary arrangements at the first opportunity. In loving memory of Marion, My best friend, wife, colleague, mother of our five children and grandmother of our nine grandchildren for her love, unconditional support, and understanding. Moore has been the recipient of many prestigious awards Honored Member Award, 1994). He has received the highest awards for excel was inducted as a Fellow of the American Association of lence in human anatomy education at the medical, dental, Anatomists. Although the factual basis of anatomy is remark tion that is typically the sole focus in anatomy texts. This per able among basic sciences for its longevity and consistency, spective is important to most health professionals, including this book has evolved markedly since its inception. This is the growing number of physical and occupational therapy a reflection of changes in the clinical application of anatomy, students using this book. Surface anat ways, and improvements in graphic and publication tech omy and medical imaging, formerly presented separately, are nology that enable superior demonstration of this informa now integrated into the chapter, presented at the time each tion. The sixth edition has been thor relationship to physical examination and diagnosis. Both nat oughly reviewed by students, anatomists, and clinicians for ural views of unobstructed surface anatomy and illustrations accuracy and relevance and revised with significant new superimposing anatomical structures on surface anatomy changes and updates. Clinically Oriented Anatomy has been widely acclaimed for Case studies, accompanied by clinico-anatomical the relevance of its clinical correlations. The extensive art program anatomy they will need to know in the twenty-first century, initiated in the fourth edition has been extended and revised. These summaries provide a convenient the official English-equivalent terms are used throughout means of ongoing review and underscore the big picture the book, when new terms are introduced, the Latin form, point of view. The roots and derivations of terms are provided A more realistic approach to the musculoskeletal system to help students understand meaning and increase reten emphasizes the action and use of muscles and muscle groups tion. These blue boxes feature anatomical variations that may be encoun Students and faculty have told us what they want and expect from Clinically Oriented Anatomy, and we listened: tered in the dissection lab or in practice, emphasiz ing the clinical importance of awareness of such variations. These blue boxes emphasize pre laboratory guides become exclusively instructional, and natal developmental factors that affect postnatal multiauthored lecture notes develop inconsistencies in anatomy and anatomical phenomena specifically comprehension, fact, and format. Health professional students have tures and observations that play a role in physical more diverse backgrounds and experiences than ever diagnosis are targeted in these blue boxes. Curricular constraints often result in unjustified assumptions concerning the prerequisite information Surgical procedures icon. These blue boxes necessary for many students to understand the presented address such topics as the anatomical basis of material. The Introduction includes efficient summaries surgical procedures, such as the planning of inci of functional systemic anatomy. Many orientation in boldface type, so that the main entries can be easily figures have been added, along with arrows to indicate the located. Boldface type is also used to introduce clinical locations of the inset figures (areas shown in close-up terms in the clinical correlation (blue) boxes. Almost all illustrations have indicates anatomical terms important to the topic and been completely relabeled, moving the viewpoint out of region of study or labeled in an illustration that is being the legend and next to each part of every illustration. We have tried to present the material in an interesting way so that it can be easily integrated with what Anne M. Agur will be taught in more detail in other disciplines such as phys University of Toronto ical diagnosis, medical rehabilitation, and surgery.

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I po b ff a pt b me qui mi ma qua pa ul us ful t b ur ph mb w upun ur f bun p s a f un pi b ur f. Ea F igur e a n d a ur icula in ha a M n c, eym uth, w k b z w m pa k w ui ub M a in et deta il fti i me ur pa b I pl w ma pl Fi ur 1) ho t gr a h: ur tes y f R m er ica eym uth, M a 1 3 N a a A ug upun ur ut s k pr ma pr f w pe k w b f, me c pr ud mus b xe n f ma pa c ul pe z ma Va us me us upun ur n. W k pi p o f p o f t n us n ui n mo I f us ful us mi ut k F igur e t b pe pe ul k que b mo ffic ul r f qui mo pr ma; w pa f n mo mf b F igur e 1 N B pa m un b mbul pl i G V2 6 pa w A ur ul upun ur w ut z s w up w k fun t Un St b Fo C o w mi ut w ut pa N mt z w b e upun ur que. Ph U o ou u the u u r ow r mb mo b un f mi 2 B k p ffic ul me uppl W pa t ps ut w b k mus ul A tu t: G 6 G V2 6 l f mi jun o f uppe w w f t f m p (Fi ur 6 a c G V2 6 po po f pa w e xt me xh us k b us i ma ua. I f mo pa i pr me j t ug upe pi f b pr f upun ur b b w r me b l b Fi ur 8 e b k upt k b (Fi ur 8 a b a z pi m. L b f un b s umbb w r a c e a us pa un G f pr H b a w b w e xe G V2 0 b e b pl t mi n f o f b ps f t umb mi l w ug t upe pi f N us po ul n b w ul s mul pe s If k p pa w m w w mi b k L pl f 1 5 b 0 mi ut mo t m. The textbook content was produced by OpenStax and is licensed under a Creative Commons Attribution 4. Our free textbooks are developed and peer-reviewed by educators to ensure they are readable, accurate, and meet the scope and sequence requirements of modern college courses. Through our partnerships with companies and foundations committed to reducing costs for students, OpenStax is working to improve access to higher education for all. As a leading research university with a distinctive commitment to undergraduate education, Rice University aspires to path-breaking research, unsurpassed teaching, and contributions to the betterment of our world. It seeks to fulfill this mission by cultivating a diverse community of learning and discovery that produces leaders across the spectrum of human endeavor. Foundation Support OpenStax is grateful for the tremendous support of our sponsors. Without their strong engagement, the goal of free access to high quality textbooks would remain just a dream. The William and Flora Hewlett Foundation has been making grants since 1967 to help solve social and environmental problems at home and around the world. The Foundation concentrates its resources on activities in education, the environment, global development and population, performing arts, and philanthropy, and makes grants to support disadvantaged communities in the San Francisco Bay Area. Guided by the belief that every life has equal value, the Bill & Melinda Gates Foundation works to help all people lead healthy, productive lives. 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About OpenStax OpenStax is a nonprofit organization committed to improving student access to quality learning materials. Unlike traditional textbooks, OpenStax resources live online and are owned by the community of educators using them. Through partnerships with companies and foundations committed to reducing costs for students, we are working to improve access to higher education for all. OpenStax is an initiative of Rice University and is made possible through the generous support of several philanthropic foundations. About Concept Coach Thanks to a generous courseware grant, OpenStax is developing a new, free tool to increase reading comprehension. As students read, they will be asked questions to reinforce their understanding of the content. Students will find Concept Coach questions at the end of most non-introductory sections of the web view version of the book, accessible here: cnx. Customization OpenStax learning resources are conceived and written with flexibility in mind so that they can be customized for each course. Our textbooks provide a solid foundation on which instructors can build their own texts. Instructors can select the sections that are most relevant to their curricula and create a textbook that speaks directly to the needs of their students. Instructors are encouraged to expand on existing examples in the text by adding unique context via geographically localized applications and topical connections. Anatomy and Physiology can be easily customized using our online platform openstaxcollege. Simply select the content most relevant to your syllabus and create a textbook that addresses the needs of your class. This customization feature will ensure that your textbook reflects the goals of your course. Cost Our textbooks are available for free online, and in low-cost print and tablet editions. About Anatomy and Physiology Anatomy and Physiology is designed for the two-semester anatomy and physiology course taken by life science and allied health students. It supports effective teaching and learning, and prepares students for further learning and future careers. The text focuses on the most important concepts and aims to minimize distracting students with more minor details. The development choices for this textbook were made with the guidance of hundreds of faculty who are deeply involved in teaching this course. These choices led to innovations in art, terminology, career orientation, practical applications, and multimedia-based learning, all with a goal of increasing relevance to students. We strove to make the discipline meaningful and memorable to students, so that they can draw from it a working knowledge that will enrich their future studies. Coverage and Scope the units of our Anatomy and Physiology textbook adhere to the scope and sequence followed by most two semester courses nationwide. This unit is the first to walk students through specific systems of the body, and as it does so, it maintains a focus on homeostasis as well as those diseases and conditions that can disrupt it.

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The panel In Press (3/18/96) finalized the revisions within a few weeks after the National Institutes of Health conference. Most Americans have little or no physical relevant to the consensus questions during a 2-day activity in their daily lives, and accumulating evi public session; (2) questions and statements from dence indicates that physical inactivity is a major conference attendees during open discussion peri risk factor for cardiovascular disease. However, ods that are part of the public session; and (3) closed moderate levels of physical activity confer signifi deliberations by the panel during the remainder of cant health benefits. In addition, 27 Despite this decline, coronary heart disease remains experts in cardiology, psychology, epidemiology, the leading cause of death and stroke the third exercise physiology, geriatrics, nutrition, pediatrics, leading cause of death. Lifestyle improvements by public health, and sports medicine presented data to the American public and better control of the risk the panel and a conference audience of 600. Medline and an extensive bibliography of references Coronary heart disease and stroke have many was provided to the panel and the conference audi causes. Experts prepared abstracts with relevant cita high blood pressure, blood lipid levels, obesity, dia tions from the literature. The panel, answering pre ing, high blood pressure, and high blood cholesterol, defined questions, developed their conclusions obesity and physical inactivity in the United States based on the scientific evidence presented in open have not improved. The panel com technologies have contributed greatly to lessening posed a draft statement that was read in its entirety physical activity at work and home. These community-level factors also need to be better Physical activity in this statement is defined as understood. Institute on Aging, National Institute of Arthritis and Physical inactivity characterizes most Ameri Musculoskeletal and Skin Diseases, National Insti cans. Exertion has been systematically engineered tute of Diabetes and Digestive and Kidney Diseases, out of most occupations and lifestyles. About 50 percent of high school students reported the conference brought together specialists in they are not enrolled in physical education classes. After a day risk factors, including high blood pressure, blood and a half of presentations and audience discussion, lipid levels, insulin resistance, and obesity. The type, an independent, non-Federal consensus panel frequency, and intensity of physical activity that are weighed the scientific evidence and developed a needed to accomplish these goals remain poorly draft statement that addressed the following five defined and controversial. What Is the Health Burden of a Sedentary fluence the adoption of this behavior at the individual Lifestyle on the Population National surveillance programs have adhere to a physically active lifestyle need to be documented that about one in four adults (more 42 Historical Background, Terminology, Evolution of Recommendations, and Measurement women than men) currently have sedentary lifestyles that the addition of physical activity to dietary en with no leisure time physical activity. An additional ergy restriction can increase and help to maintain one-third of adults are insufficiently active to achieve loss of body weight and body fat mass. The prevalence of inactivity varies by Middle-aged and older men and women who gender, age, ethnicity, health status, and geographic engage in regular physical activity have significantly region but is common to all demographic groups. Children become far less active as they move Most studies of endurance exercise training of through adolescence. Obesity is increasing among individuals with normal blood pressure and those children, at least in part related to physical inactivity. Insulin sensitivity is have a high risk of becoming obese adults, and obesity also improved with endurance exercise. Regular endurance exercise lowers the risk participation in vigorous physical activity; by age 21 related to these factors. What Type, What Intensity, and What elderly suggests that the findings are similar in these Quantity of Physical Activity Are Important groups. The majority of Physical activity is directly related to physical benefits of physical activity can be gained by per fitness. The increase in mortality is not entirely ex prevent disease and promote health must, therefore, plained by the association with elevated blood pres be clearly communicated, and effective strategies sure, smoking, and blood lipid levels. Only a few studies activity or fitness and magnitude of cardiovascular have examined the relationship between physical benefit may extend across the full range of activity. A activity and body fat distribution, and these suggest moderate level of physical activity confers health an inverse relationship between levels of physical benefits. These mod achieve cardiovascular benefits, but low-intensity erate intensity activities are more likely to be or shorter duration activities should be performed continued than are high-intensity activities. We recommend that all children and adults activity, is a subset of activity that may encourage should set a long-term goal to accumulate at least 30 interest and allow for more vigorous activity. People minutes or more of moderate-intensity physical ac who perform more formal exercise. People who are currently sedentary or or tasks of daily living, also have similar cardiovascu minimally active should gradually build up to the lar and health benefits if performed at a level of recommended goal of 30 minutes of moderate activ moderate intensity (such as brisk walking, cycling, ity daily by adding a few minutes each day until swimming, home repair, and yardwork) with an reaching their personal goal to reduce the risk asso accumulated duration of at least 30 minutes per day. Older people or those ther increases in the intensity or amount of activity who have been deconditioned from recent inactivity produce further benefits in some, but not all, param or illness may particularly benefit from resistance eters of risk. High-intensity activity is also associated training due to improved ability in accomplishing with an increased risk of injury, discontinuation of tasks of daily living. Resistance training may contrib activity, or acute cardiac events during the activity. The risk of injury increases with increased the substantial benefits of short bouts (at least 10 intensity, frequency, and duration of activity and minutes) of moderate-level activity. Exercise-related the frequency, intensity, and duration of activ injuries can be reduced by moderating these param ity are interrelated. A more serious but rare complication of activ activity recommended for health depends on the ity is myocardial infarction or sudden cardiac death. Data are inadequate to determine In children and young adults, exertion-related whether stroke incidence is affected by physical deaths are uncommon and are generally related to activity or exercise training. It is functional capacity at baseline may be at somewhat recommended that patients with those conditions higher risk during exercise training. Because the risks of physical activity are very low Appropriately prescribed and conducted exer compared with the health benefits, most adults do cise training programs improve exercise tolerance not need medical consultation or pretesting before and physical fitness in patients with coronary heart starting a moderate-intensity physical activity pro disease. Patients with low basal over age 40 and women over age 50 with multiple levels of exercise capacity experience the most func cardiovascular risk factors who contemplate a pro tional benefits, even at relatively modest levels of gram of vigorous activity should have a medical physical activity. Patients with angina pectoris typi evaluation prior to initiating such a program. What Are the Benefits and Risks of ischemia, presumably as a result of decreased myo Different Types of Physical Activity for cardial oxygen demand and increased work capacity. Patients with congestive heart failure also appear People with Cardiovascular Disease In addition, more should be tailored to the needs of these patients and than 300, 000 patients per year are currently sub supervised closely in view of the marked predisposi jected to coronary artery bypass surgery and a similar tion of these patients to ischemic events and number to percutaneous transluminal coronary arrhythmias. Increased physical activity appears to Cardiac rehabilitation exercise training often benefit each of these groups. Benefits include reduc improves skeletal muscle strength and oxidative tion in cardiovascular mortality, reduction of symp capacity and, when combined with appropriate nu toms, improvement in exercise tolerance and tritional changes, may result in weight loss. In addi functional capacity, and improvement in psycho tion, such training generally results in improvement logical well-being and quality of life. However, cardiac programs significantly reduce overall mortality, as rehabilitation exercise training has less influence on well as death caused by myocardial infarction.

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Did the whole sample or a random selection of the sample receive Y Y Y Y Y Y Y Y verifcation using a reference standard of diagnosis Did patients receive the same reference standard regardless of the Y Y Y Y Y Y Y Y index test result Was the execution of the index test described in suffcient detail to Y U Y Y Y Y Y U permit replication of the test Was the execution of the reference standard described in suffcient Y Y Y Y Y Y Y U detail to permit its replication Were the index test results interpreted without knowledge of the results Y Y Y Y Y Y Y Y of the reference test Were the reference standard results interpreted without knowledge of Y U Y Y Y Y Y Y the results of the index test Were the same clinical data available when test results were Y Y Y Y Y Y Y Y interpreted as would be available when the test is used in practice Y Y Y Y Y Y Y Y Quality Summary Rating: N N N N N N N N Y = yes, N = no, U = unclear. Segmental instabil tests to diagnose lumbar segmental instability: a ity of the lumbar spine. A clinical predic clinical presentation and specifc stabilizing exer tion rule for classifying patients with low back pain cise management. Prelimi joint pain: a study in an Australian population nary development of a clinical prediction rule for with chronic low back pain. A study to investigate whether ability of physical examination items used for clas golfers with a history of low back pain show a sifcation of patients with low back pain. An epidemiological survey of the signs tive contributions of the disc and zygapophyseal and symptoms of ankylosing spondylitis. Clinical reliability of symptom-provoking active sidebend, features of patients with pain stemming from rotation and combined movement assessments of the lumbar zygapophysial joints. Mechanical diagnosis and therapy nostic performance of the medial hamstring refex for disorders of the low back. Philadelphia: Churchill Livingstone; lumbar fexion range of motion: intertester reli 2000:141-165. Preliminary formal medical education be used without loss of results of the use of a two-stage treadmill test as a quality Interrater reliability active rotation in standing: reliability of a simple of lumbar accessory motion mobility testing. The reli reliability and concurrent validity of measure ability of clinical examination measures used for ments used to quantify lumbar spine mobility: an patients with suspected lumbar segmental instabil analysis of an iphone application and gravity ity. Accuracy of the clinical manipulable lesions in patients with chronic low examination to predict radiographic instability of back pain. Clin nation of the reliability of a classifcation algo ical tests on impairment level related to low back rithm for subgrouping patients with low back pain. Lumbar segmental hypomobil rater reliability of the history and physical exami ity: criterion-related validity of clinical examina nation in patients with mechanical neck pain. Motion low back pain in older adults: prevalence, reliabil palpation fndings and self-reported low back pain ity, and validity of physical examination fndings. Palpa reliability and validity of motion assessments tory accuracy of lumbar spinous processes using during lumbar spine accessory motion testing. Intra-observer and inter-observer agreement of the evaluation of lumbar multifdus muscle func the manual examination of the lumbar spine in tion via palpation: reliability and validity of a new chronic low-back pain. Inter phy results in chronic low back pain, and the examiner reliability in physical examination of infuence of disability and distress on diagnostic patients with low back pain. An investigation observer repeatability of four clinical measurement of the reliability and validity of posteroanterior techniques. Reliability and diagnos Standardized physical examination protocol for tic validity of the slump knee bend neurodynamic low back disorders: feasibility of use and validity test for upper/mid lumbar nerve root compression: of symptoms and signs. The test of Lasegue: systematic review of the for suspected impaired motor control of the accuracy in diagnosing herniated discs. Physical examination for lumbar radicu reliability of physical examination tests that may lopathy due to disc herniation in patients with predict the outcome or suggest the need for lumbar low-back pain. Low back pain: sis of disc herniation in patients with monoradicu clinimetric properties of the Trendelenburg test, lar sciatica. The use of a classifcation rological signs and myelographic fndings in the approach to identify subgroups of patients with diagnosis of lumbar root compression. Comparative value of electromyo in a classifcation system for acute low back pain. The sensi drome: identifying and staging patients for tivity and specifcity of the slump and the straight conservative management. Reliability and mea tion of a clinical prediction rule in primary care to surement error of active knee extension range of identify patients with low back pain with a good motion in a modifed slump test position: a pilot prognosis following a brief spinal manipulation study. Clinically important preliminary clinical prediction rule for identifying changes in acute pain outcome measures: a valida a subgroup of patients with low back pain likely to tion study. The value adaptation, reliability and validity in two different of accurate clinical assessment in the surgical man populations. Distribu difference for pain and disability instruments in tion of referred pain from the lumbar zygapophy low back pain patients. Clinical Oswestry Disability Questionnaire and the Quebec examination of the sacroiliac joints: a prospective Back Pain Disability Scale. Reliability, validity diagnosis with a diagnosis established by a uni and responsiveness of the Fear-Avoidance Beliefs level lumbar spinal block procedure. Postoperative pain intensity assessment: a comparison of four scales in Chinese adults. Tuberculum of iliac crest Posterior sacral foramina Greater sciatic foramen Anterior superior iliac spine Sacrospinous lig. Lesser sciatic foramen Acetabular margin Ischial tuberosity Tendon of long head of biceps femoris m. Iliac fossa Outer lip Intermediate Iliac crest zone Tuberculum Inner lip Anterior sacroiliac lig. Sacral promontory Greater sciatic foramen Anterior superior iliac spine Sacrotuberous lig. Pecten pubis (pectineal line) Obturator foramen Pubic symphysis Inferior pubic ramus Anterior view Pubic tubercle Figure 5-6 Sacroiliac region ligaments. Recent research suggests that the sacroiliac joint can be a contributor to low back pain and disability and can certainly be a primary source of pain. The diagnostic properties for the aggravating and easing factors and patient-reported location of pain are below. They then prospectively tested the ability of the pain distribution patterns to diagnose the response to sacroiliac joint radiofrequency neurotomies in 160 patients with presumed sacroiliac joint pain. The pain distribution patterns with the best diagnostic utility are depicted, with colors representing pain intensity (scale, 1-5). Usefulness of pain distributionpatternassessmentindecision making for the patients with lumbar zygapophyseal and sacroiliac joint arthropathy. The researchers found no differences in the locations of pain distribution but did fnd differences in the pain intensity locations.

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The dose range for avoiding psy was most frequently used for sedation in the inten chomimetic side eects is 0. Lorazepam is a cost-effective drug that is lon be the analgesic of choice in patients with a history of ger acting and can have useful anxiolytic effects for bronchospasm to have the benet of bronchodilator prolonged treatment of anxiety; however, it can result activity without contributing to arrhythmias, if amino in oversedation. Where expensive analgesics Care Medicine Guidelines, lorazepam was the drug are not available, ketamine may have a slightly greater recommended for longer-term sedation. Overse avoid nerve damage, nerve stimulators or ultrasound dation may slow the weaning process or delay extuba guidance should be used, if the patient is sedated and tion, when the patient is otherwise ready, and so can paresthesias cannot be communicated. After several days of continuous ther bers should be noted before these procedures as re apy with propofol or benzodiazepines, withdrawal phe gional techniques are contraindicated in patients with nomena may be precipitated, and reduction in dose a bleeding tendency such as anticoagulation, coagu should be gradual to avoid them. If a continuous tech What adjuncts to pharmacological agents nique with an indwelling catheter is used, this should should be considered in the intensive care unit Although these drugs have no analgesic proper Adjustment of the lighting to provide night ties, they may reduce the dose of analgesia required. Feeling thirsty, hun playing the most common complaints and requests can gry, hot, or cold is a driving force that normally results be used. Awareness of all such details helps to reduce make pain considerably more tolerable, they will not unnecessary discomfort. Terefore, appropriate doses of analge Supportive modes of ventilation such as pres sics will still be required. Maintaining muscle activity will reduce respiratory an intravenous infusion of morphine at a rate of 10 mg muscle wasting. He starts struggling, and the ventilator alarm Other symptoms such as nausea, vomiting, keeps buzzing. He also becomes very tachycardic and itch, significant pyrexia, and cramps require their hypertensive, causing concern for the sta. He is started preferably breathing spontaneously to coordinate deep on regular nasogastric paracetamol, his sedation with breathing with sequential relaxation of muscle groups midazolam is increased, and his morphine dose is from head to toe. Music can be benecial, particularly raised to 15 mg per hour, after a bolus dose of 5 mg. Speaking to the patient by name, even though What should be considered for weaning and preparation for extubation It helps patients to ful weaning and extubation, from a pain control point reconnect with who they are and with their family. References Joe is reviewed next day; sedation and morphine are minimal, and he is wide awake and wants the endo [1] Cardno N, Kapur D. Patterns of prescribing and ad ministering drugs for agitation and pain in a surgical intensive care unit. Clinical practice guidelines for the use sustained those who are less well about some positive as use of sedatives and analgesics in the critically ill adult. Practice parameters for intrave nous analgesia and sedation for adult patients in the intensive care unit: Regarding pain: an executive summary. Sedative and analgesic practice in the intensive care unit: the results of a European survey. An educational journal aimed at providing practi Websites cal advice for those working in isolated or dicult environments. Detailed A selection of articles on acute pain topics drug information is not given. Laboratory and radiological testing are often the next place the clinician seeks reassurance, underlying the use of nerve although the lack of readily available diagnostic testing in blocks in pain management Fortunately, diagnostic nerve block requires The cornerstone of successful treatment of the patient limited resources, and when done properly, it can pro with pain is a correct diagnosis. As straightforward as vide the clinician with useful information to aid in in this statement is in theory, success may become dicult creasing the comfort level of the patient with a tentative to achieve in the individual patient. Our current understanding of neurophysiological, neuroanatomical, and behavioral components of pain is incomplete and imprecise; and What would be a roadmap for Tere is ongoing debate by pain management spe the appropriate use of diagnostic cialists as to whether pain is best treated as a symptom nerve blocks The uncertainty introduced by these factors can It must be said at the outset of this discussion, that even often make accurate diagnosis very problematic and the perfectly performed diagnostic nerve block is not limit the utility of neural blockade as a prognosticator without limitations. This material may be used for educational 293 and training purposes with proper citation of the source. Many patients rophysiological, and radiographic testing, should be have more than one type of pain. This be recognized that the clinical utility of the diagnostic often means that the clinician must tailor the type of nerve block can be aected by technical limitations. Furthermore, the tive to the expected pharmacological duration of the proximity of other neural structures to the nerve, gan agent being used to block the pain. If there is discor glion, or plexus being blocked may lead to the inadver dance between the duration of pain relief relative to tent and often unrecognized block of adjacent nerves, duration of the local anesthetic or opioid being used, invalidating the results that the clinician sees. Diagnostic and Prognostic Nerve Blocks 295 Finally, it must be remembered that the pain Neuroaxial diagnostic nerve blocks and anxiety caused by the diagnostic nerve block it Dierential spinal and epidural blocks have gained self may confuse the results of an otherwise technically a modicum of popularity as an aid in the diagnosis of perfect block. Popularized by Winnie [9], dierential spinal and that many pain patients may premedicate themselves epidural blocks have as their basis the varying sensitivity with alcohol or opioids because of the fear of procedur of sympathetic and somatic sensory and motor bers to al pain. Obviously, the use of sedation or these techniques are subject to some serious technical anxiolysis prior to the performance of diagnostic nerve diculties that limit the reliability of the information block will further cloud the very issues the nerve block obtained. Despite the many technical sensation of warmth associated with sympathetic block limitations these pioneers were faced with, these clini ade as well as the numbness and weakness that accom cians persevered.

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