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These are safer as prolonged use of steroids may produce open angle glaucoma by reducing outflow facility, cataract and secondary infection with bacteria or fungi. These agents should be administered with great caution under the supervision of haematologist or an oncologist as they have adverse side effects or kidney, liver and cause bone marrow depression. Recently azathioprine, mycophenolate, mofetil, tacrolimus are used in unresponsive or intolerant patients. Specific Treatment Specific treatment of the underlying disease should be added if the etiology is identified. Secondary glaucoma (hypertensive uveitis)?Drugs to lower intraocular pressure such as 0. Post-inflammatory glaucoma due to ring synechiae and iris bombe demand an iridectomy in all cases so that communication can be restored between anterior and posterior chambers. Surgical iridectomy should not be done during the acute phase of iritis (presence of kp). Complicated cataract requires lens extraction with guarded prognosis in a quiet eye under cover of steroids. The presence of fresh kp is considered a contraindication for intraocular surgery. Retinal detachment of exudative type usually settles itself if uveitis is treated aggressively. Secondary glaucoma?Timolol prednisolone, dexametha maleate, betaxolol eyedrops sone, betamethasone Tab acetazolamide, atropine and steroids 2. Annular (ring) synechiae and shade inflammatory drugs iris bombe?laser iridotomy 3. Anterior vitiritis?There is mild aqueous flare with occasional keratic precipitates. Peripheral retinal periphlebitis?It appears as isolated foci of inflammation or multifocal. Differential Diagnosis It includes toxoplasmosis, peripheral toxocariasis syphilis, sarcoidosis and multiple sclerosis. Approximately 80% cases do not need any treatment as it may resolve spontaneously. Corticosteroids and immunosuppressants may be given in chronic cases but the results are disappointing. Posterior sub-tenon injections of triamcinolone acetonide or methylprednisolone acetonide. As the outer layers of retina depend upon the choroid for nutrition, there is always associated inflammation of retina (chorio-retinitis). Non granulomatous choroiditis or exudative choroiditis is due to allergic reaction. There is diminution of vision due to retinal lesions and opacities in the vitreous (floaters). Micropsia?The objects appear smaller than they actually are due to separation of rods and cones. Macropsia?The objects appear larger than they actually are due to overcrowding of rods and cones. Positive scotoma?Patient complains of seeing a black spot in front of the eye corresponding to the retinal lesion. Negative scotoma?A black spot is present in the field of vision similar to the blind spot, corresponding to the retinal lesion. In early stage one or more yellowish areas with ill-defined edges are seen deep to retinal vessels. This appearance is due to infiltration of the choroid and presence of exudates which hide the choroidal vessels. In the healing stage?Yellow lesions become white due to fibrosis and the lesions are surrounded by black pigments. Clinical Types Choroiditis is usually classified according to number and site of lesions. Disseminated (diffuse) choroiditis?The lesions are seen scattered all over the fundus. Anterior choroiditis?The lesions are seen in the peripheral parts (near equator) of the fundus. Juxtapapillary choroiditis (of Jensen)?The lesions are present around the optic disc. Treatment It is usually unsatisfactory as great damage is usually done to the retina before the condition can be controlled, 1. Specific treatment is required for causative organism such as toxoplamosis, toxocariasis, tuberculosis, syphilis, etc. Anterior chamber may be deep or funnel-shapped due to the formation of occlusio-pupillae or ring synechiae. Keratic precipitates are scattered over a triangular area in the lower part of cornea. Mutton fat kp?Small kp coalesce together forming small plaques which gradually become translucent. Tractional retinal detachment?It may occur due to contraction of strands of fibrous tissue in the vitreous. Hypertensive iridocyclitic crisis of Posner and Schlossman may occur occasionally. Differential Diagnosis Hypertensive iridocyclitis should be differentiated from angle closure glaucoma. Primary angle closure glaucoma?As the treatment of angle closure glaucoma is exactly opposite of iridocyclitis, this condition should be diagnosed carefully. There is absence of keratic precipitate and aqueous flare in angle closure glaucoma. It occurs most commonly as an acute process 1-7 days following intraocular surgery such as cataract extraction and filtering operation. Chances of infection are much greater if there is associated vitreous loss as vitreous is a very good culture medium for organisms. Fungus?Aspergillus fumigatus, Candida albicans, Nocardia asteroides, Fusarium, etc. Perforation of suppurative corneal ulcer of Pseudomonas pyocyanea or fungal origin. There is absence of red fundus reflex and inability to visualize the fundus even with indirect ophthalmoscope. It affects the anterior vitreous and anterior uvea causing thick, organized hypopyon. Retained cortical lens material following lens extraction may be associated with severe anterior uveitis. Panophthalmitis?There is associated inflammation of extraocular tissues resulting in lid oedema, chemosis and painful limitation of movements of eyeball. Investigation Identification and culture and sensitivity of the causative organism from the aqueous and vitreous taps confirms the diagnosis. Broad-spectrum antibiotics which cover gram-positive and gram-negative organisms are given. Intravitreal?An aminoglycoside (gentamicin or amikacin) and vancomycin should be injected slowly into the midvitreous cavity using a 25-gauge needle. Corticosteroids are given topically, systemically and by periocular subconjunctival injections. It is indicated particularly in fungal endophthalmitis along with intravitreal and systemic amphotericin B. Preoperative prophylactic topical broad-spectrum antibiotics are instilled to decrease patients conjunctival bacterial flora. Exogenous?It is usually due to infected wound which may be accidental, operative or after corneal ulcer perforation. Endogenous?It is due to metastasis of the infected embolus in the retinal artery and choroidal vessels. Fundus examination?Media is hazy so the yellow oedematous retina is faintly visible or often invisible. Control the infection by administration of modern broad-spectrum antibiotics by all possible routes: i. Corticosteroids?Topical, subconjunctival injection and systemic administration of corticosteroids is essential. Atropine?Topical administration by drops or ointment and subconjunctival injection are given.

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As with any intervention, however, it is important to prescribe exercise in accordance. Clinicians disappointment, personal loss should be aware of this phenomenon and plan treatments accordingly, possibly starting with education and graded. Culturally competent exercise infexible about solutions, has unrealistic expectations for and activity prescription should consider both individual and others, and is very touchy? or reactive. Consider framing discharge as their positive assist the patient in obtaining more restful sleep and may achievement. Physiotherapy Alberta College + Association | Chronic Pain Management: A Toolkit for Physiotherapists 15 Strategies for the clinician to consider. Medications used in Management of Chronic Pain Optimal care includes awareness of the medications used in chronic pain management and their potential side efects. For example, inadequate sleep can afect QoL, and have a negative impact on mental health. Clinicians are encouraged to become familiar with the common medications used in chronic pain management, including their generic and branded names, their mechanism of action (in broad terms), usual dosing strategies, and potential side efects. These include common opioids, Clinician resources: pregabalin and gabapentin, tricyclics, and selective norepinephrine or serotonin reuptake inhibitors. Physiotherapists can use this information to implement the principles of chronic pain management in this. For example, it 73 reports evidence that aerobic exercise and strength training Seek input from these centers if transfer is not possible. Low back pain: guidelines for the clinical classifcation of predominant neuropathic, nociceptive, or central sensitization pain. Smart K, Blake C, Staines A & Doody C, Note: Sources are cited in order of frst appearance in the the Discriminative validity of nociceptive,? peripheral document. Open Access and Free Text articles are indicated as neuropathic,? and central sensitization? as mechanisms such. Physical functioning and opioid use in R, Recognition of central sensitization in patients with patients with neuropathic pain. Accessed December 15, Nijs J Clinical biopsychosocial physiotherapy assessment 2017. Weisgberg J, Personality and personality physiotherapy encounter: physiotherapists? accounts of back disorders in chronic pain, Curr Rev Pain 2000;4(1): 60-70. Clin Orthop Relat neuroscience approach to managing athletes with low back Res, 2011;469: 1859-1870. Diener I, Kargela M & Louw A, Listening is Therapy: Patient interviewing from a pain science 26. Core competencies for pain management: results of an interprofessional consensus 42. Darlow B, Dowell A, Baxter therapists? and patients? attitudes and beliefs regarding G, Mathieson F, Perry M& Dean S the Enduring Impact of chronic musculoskeletal pain are key to applying efective What Clinicians Say to People with Low Back Pain, Annals treatment, Man Ther. How does the self-reported clinical physical therapist led chronic pain self-management support management of patients with low back pain relate to the with pain science education and exercise in primary health attitudes and beliefs of health care practitioners? George S & Zeppieri G Physical Physiotherapists? pain beliefs and their infuence on the Therapy Utilization of Graded Exposure for Patients With management of patients with chronic low back pain Spine Low Back Pain Journal of Orthopaedic & Sports Physical (Phila Pa 1976). Galve-Villa M, Rittig-Rasmussen B, of pain on sleep in chronic nonmalignant pain of various Mikkelsen L, & Poulsen A. Pain Research & Management classifcation of pain for physical therapy management in : the Journal of the Canadian Pain Society, 18(4), 207?213. Pharmacoepidemiol & rehabilitation [0894-9115] yr: 2014 vol: 93 iss: 3 pg: 253-259 Drug Saf. Kemler M, de Vet H, Health-related quality of life in chronic refractory refex sympathetic 74. Galer B, Henderson J, Perander J Jensen M Course of symptoms and quality of life measurement in complex regional pain syndrome: A pilot survey, Journal of pain and symptom management [0885-3924] yr: 2000 vol: 20 iss: 4 pg: 286-292. Marinus J, Moseley L, Birklein F et al Clinical features and pathophysiology of complex regional pain syndrome the Lancet Neurology, Volume 10, Issue 7, 637 648. Lewis J & Schweinhardt P Perceptions of the painful body: the relationship between body perception disturbance, pain and tactile discrimination in complex regional pain syndrome. Validation of proposed diagnositc criteria (the Budapest Criteria) for complex regional pain syndrome. Their combined knowledge and clinical expertise were invaluable to the development, content and quality of this document. Physiotherapy Alberta would like to thank them for their ongoing commitment to the project. He obtained his PhD in 2011 in Rehabilitation Physiotherapy Alberta College+ Association Sciences at the University of Alberta with clinical and research interests in the feld of pain. He routinely teaches External review panel physical therapists and trainees in pain assessment and management and has over 50 peer reviewed publications the draft document was circulated to a review panel and presentations in the areas of pain assessment and the composed of researchers, educators and clinicians. Physiotherapy Alberta wishes to thank the following individuals for their contribution to this project. Their Alex Chisholm comments and recommendations were essential to the Alex is a clinical physiotherapist on the Burns Plastic team project outcome. Interdisciplinary Pain Management from the University of Clinician: chronic pain, functional rehabilitation, and exercise Alberta and is a Fellow of the Canadian Federation of Clinical management Hypnosis. Alex believes the physiotherapy profession blends Special interest in the management of temporomandibular science with the art of the therapeutic alliance? and that joint dysfunction, orofacial pain, neck disorders, and physiotherapists have a unique skill set with which to treat headache. Hand Therapy Clinic, Hamilton Health Sciences International associate editor, E-News for Somatosensory Rehabilitation Bostick 2017 Strategies for managing patients who demonstrate maladaptive patterns or behaviours. Brain and Spinal Cavernomas Helsinki Experience Juri Kivelev Academic dissertation To be presented for public discussion in the Lecture hall 1 of Toolo Hospital on December 10th, 2010 at 12 o?clock noon. Multiple cavernomas 83 Patients and symptoms 83 Radiology 84 Treatment 84 Outcome 86 Discussion 86 Publication 3. Spinal cavernomas 88 Patients and symptoms 88 Treatment 90 Outcome 91 Recovery from sensorimotor paresis 92 Recovery from pain 92 Recovery from bladder dysfunction 92 Discussion 93 Prognosis 94 Patients with sensorimotor deficits 94 Patients with pain 95 Patients with bladder dysfunction 95 Publication 4. Due to their rareness intraventricular, multiple, and spinal cavernomas remain poorly described in the literature. In addition, temporal lobe cavernomas were analyzed to better understand the prognostic factors determining a favorable postoperative outcome. Patients and methods Data on 383 consecutive patients with a total of 1101 brain and spinal cavernomas treated at Helsinki University Central Hospital from January 1, 1980 to December, 12 2009 were retrospectively analyzed. Most patients were primarily examined at the neurological department of the referring hospitals and thereafter sent to our neurosurgical center for further evaluation and treatment. The collection of the series began in 2006, and the patient database was continuously supplemented by new cavernoma patients recruited to the study. Results of their treatment were assessed at a median of two, eight, three, and six years, respectively. The study protocol was approved by joint Ethical Committee of Helsinki University. Results Inraventricular cavernomas (n=12) the median age of our patients on admission was 47 years (range 15 66 yrs). As a presenting symptom, 11 patients (92%) had an acute mild to severe headache accompanied by nausea and vomiting. Four patients (36%) had hydrocephalus on admission, but shunting was necessary in only one patient. Patients with fourth ventricle cavernomas had a worse outcome than those with lateral-ventricle lesions. The largest lesion (50mm) was a Zabramski type I frontal cavernoma that had radiologically presented as a rare cystic form. In the majority of cases, the removed cavernoma was the largest lesion, and usually with signs of recent bleeding. Spinal cavernomas (n=14) the median age at presentation was 45 years (range 20-57 yrs). In nine patients (63%), the cavernomas were intramedullary, while four patients (29%) had an extradural lesion and one had an intradural extramedullary cavernoma with an isolated intramedullary hemorrhage.


  • Rod myopathy
  • Sandrow Sullivan Steel syndrome
  • Lactic acidosis congenital infantile
  • Vasculitis, cutaneous necrotizing
  • Spinal bulbar motor neuropathy
  • Ichthyosis follicularis atrichia photophobia syndrome
  • Deafness craniofacial syndrome

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Alopecia X Alopecia X is a disease previously known as adrenal congenital hyperplasia, Cushing-like disease, dermatosis responsive to castration and adult-onset hyposomatotropism [127]. It is a condition associated with abnormalities on the hair cycle, affecting mainly the German Spitz breed. Affected animals display hairs in telogen phase what prevents new hair growth [128]. These animals are clinically healthy and show progressive hair loss, symmetric and non-pruritic, with variable degree of hyperpigmentation [129]. Histopathology findings are similar to those found in endocrinopathies, such as comedones, superficial and infundibu? Therapies with sex hormones, growth hormone, mitotane and castration usually do not pro? Seborrhea Seborrheic dermatitis is a skin keratinization disorder which can be primary or secondary. About 90% of the cases are secondary to an underlying disease [131,132] such as metabolic, hereditary or nutritional disorders [133] that causes excessive skin desquamation [131,132]. Seborrhea is classified in seborrhea sicca or oleosa according to hair and skin appearance [131,132]. In seborrhea sicca the coat is opaque and dry, containing aggregates of white to greyish scales, and in seborrhea oleosa there are adhesions of yellowish to brown lipid mate? Diagnosis is based in history, clinical signs, physical examination findings and complemen? Seborrhea treatment goals are scales and crusts removal and oil, pruritus and inflammation reduction [131,132]. Salicylic acid and sulfur shampoos are recommended and might have positive results in moderate cases. Secondary cases have an excellent prognosis when the underlying disease is eliminated, while primary keratiniza? Acne Acne is a common disorder in cats and it may result from an idiopathic keratinization defect or a secondary reaction pattern to another disorder [136]. The most common skin changes are found in the chin and lip margin, and they include comedones, crusts, papules, erythe? Usually this disorder courses with secondary bacterial pyoderma and in some cases, with M. Mild cases can be treated with anti-seborrheic shampoo; however, severe cases require association with systemic antimicrobial therapy or systemic corticoids 20 Insights from Veterinary Medicine [136]. Acral lick dermatitis Acral lick dermatitis is characterized by ulcerated, proliferative, firm and alopecic plaques, derived from compulsive licking of the distal portion of the limbs [141] (Figure 6). Diagnosis requires complete clinical evaluation (anamnesis, physical, neurological and der? Only after the elimination of possible organic causes for acral lick dermatitis, it can be con? In this case, the animal behavior should be evaluated, with the observation of its environmental and social stimuli and their motivational status. Vitamin A responsive dermatosis Vitamin A is essential to the maintenance of epithelial tissue integrity and is especially im? Lesions do not improve with anti-seborrheic therapy, but oral supplementation of vitamin A (retinol), at 10. Zinc responsive dermatosis Zinc is essential in the cellular metabolism and also in hair and skin health maintenance [144]. Zinc responsive dermatosis is an unusual disorder in dogs and it is characterized by scaling, focal erythema, crusts and alopecia, mainly over the head [146]. Affected animals have a diminished ability to absorb zinc from the intestinal tract, due to some subclinical disease or to genetic factors [144]. The diagnosis is based on history, clinical signs, characteristics lesions, breed, skin biopsy and response to zinc supplementation. Syndrome I control requires lifelong oral zinc supplementation with zinc methionine 1. Refractory cases to oral supplementation could receive intravenous administration of zinc sulfate at 10 to 15 mg/kg once a week, initially during four weeks and later each one, to six months [144]. Prognosis is good in most cases, although, lifelong supplementation may be required. External ear diseases the external ear is divided in three parts: inner, middle and outer ear. External or outer ear comprises the pinna, vertical canal and horizontal canal, formed by auricular and annular cartilages. The diameter of the external ear canal varies according to the age, breed and size of the animal and it is separated from the middle ear by the tympanum, a thin semitranspar? External ear diseases are particularly important in veterinary dermatology, since the outer ear is formed in the embryo life through a skin invagination, being susceptive to a number of dermatologic conditions [149]. Otitis externa is the most frequent disorder of the outer ear canal in dogs and cats, consisting in the inflam? In order to achieve the correct diagnosis and a successful therapy, it is essential to recognize and understand the primary predisposing and perpetuating causes. The most frequent trigger factors are parasitic infestation (Octodetes cynotis, Demodex canis, Sarcoptes scabiei, No? Factors that help to perpetuate otitis are bacterial infection (Staphylococcus pseudinterme? Worsening of symptoms can lead to head shake, ear pruritus, malodorous purulent or ceruminous dis? Diagnosis requires physical and dermatological examination, knowledge of the dermatolog? It is important to notice that a healthy ear canal might have small amounts of yellowish or brown cerumen [150]. Through otoscopy the clinician can access the presence of inflammation, exudate, hyperplasia, stenosis, foreign body, neoplasms and evaluate the tympanic membrane. Depending on the degree of pain, inflammation and stenosis, it might be necessary to use topical or systemic corticoids for two to three weeks before performing an otoscopic examination [156]. Cytological analysis is required for the diagnosis, and samples should be obtained from both pinna and the outer vertical and horizontal canal. A successful therapy is based on: removing or controlling the primary cause and predispos? It is also extremely important to instruct the owner about cleaning techniques and administration methods for topical medications [150]. Gram positive bacterial infections can be treated with topical steroidal antibiotics (fusidic acid) and topical fluoroquinolones (marbofloxacin and orbifloxacin). Aminoglycosides are contraindicated in cases of tympanic membrane rupture due to their ototoxicity [150]. Malassezia species are usually susceptible to azoles (clotrimazol and myconazol) and poly? Glucocorticoids efficiently control the inflammation and may prevent or reverse tissue hyperplasia and canal stenosis [154]. Therapy should be discontinued only when cytology is negative for microorganisms, if there is no ear canal edema and if the epi? Author details Elisa Bourguignon, Luciana Diegues Guimaraes, Tassia Sell Ferreira and1 2 3 Evandro Silva Favarato2 *Address all correspondence to: dermatovet@gmail. International Journal of Systematic and Evolutionary Microbiology 2005; 55(4) 1569?73. Topical Fusidic Acid/ Betamethasone-Containing Gel Compared to Systemic Therapy in the Treatment of Canine Acute Moist Dermatitis. Recommendations for the Management and Treatment of Dermatophytosis in Animal Shelters. Oral Itraconazole Versus Topical Bifonazole Treatment in Experimental Dermatophytosis. Comparative Study of Griseofulvin and Terbinafine Therapy in the Treatment of Canine and Feline Dermatophytosis. Population Sizes and Frequency of Malassezia pachydermatis at Skin and Mucosal Sites on Healthy Dogs.

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Facet joints are synovial joints with joint capsule, articular cartilage and synovium ! Osseous components include the superior articulating process from the caudal spinal segment and inferior articulating process from the rostral spinal segment ! Innervation from medial branch of the dorsal ramus of spinal nerve from the corresponding level and variably from a level above and below Medial branch of dorsal ramus Dorsal ramus of spinal nerve Presentation material is for education purposes only. Where equipment is available, pulsed radiofrequency ablation can be performed on medial branch of dorsal ramus Presentation material is for education purposes only. May require repeat series of injections for optimal effect Presentation material is for education purposes only. For therapeutic block of spinal nerve causing radicular pain following successful diagnosis Presentation material is for education purposes only. Nerve root exit the neural foramen in the lumbar region inferior to adjacent pedicle ! Postganglionic portion of lumbar exiting nerve root tracks anteroinferiorly under the mid transverse process the level below Procedure (Lumbar Postganglionic) ! Superior aspect of mid transverse process is targeted inferior to level of desired nerve root ! For periganglionic block (transforaminal epidural injection), neural foramen is targeted ! Confirm placement of needle by nerve root with contrast, frequently contrast will extend into epidural space ! For therapeutic block, mixture of Marcaine and Kenalog is injected Presentation material is for education purposes only. Steroid effects may gradually take effect after 1-2 day delay Presentation material is for education purposes only. Image-guided spine procedures can help delay or avoid more invasive surgical procedures ! Many patients have improvement in quality of life Presentation material is for education purposes only. Emotional currently that the pain is regulated by examples of these effects shall include stress may be a precipitating factor, as more complex mechanisms. Original International Association for the Study of Pain (Orlando) diagnostic criteria for complex regional pain syndrome 1) the presence of an initiating noxious event or a cause of immobilization 2) Continuing pain, allodynia, or hyperalgesia with which the pain is dispropor tionate to any inciting event 3) Evidence at some time of edema, changes in skin blood fow, or abnormal sudomotor activity in the region of pain 4) this diagnosis is excluded by the existence of conditions that would otherwise account for the degree of pain and dysfunction release of the infammatory neuropep dorsal horn of the spinal cord, enhances Figure 2. Indeed, several studies confirmed Neurophysiological studies have shown There is enough experimental evidences that this mechanism is involved in the that central disinhibition is a key cha of these changes. Once referred to as causal and blood fow of your affected and related to the affective painperception. Dissimilar results ing a central origin for this ailment and nary catheterization using a transra can indicate complex regional pain syn a potential treatment interest involving dial approach has become a common drome. Activ the phyiopathology remains still contro active substance injected into one ity in right pre-frontal and posterior versial and speculative. These tests look for distur diversion, selective attention to pain) not typically affect the direct neural cir bances in your sympathetic nervous and probably subserve attentional cuit between sensory and motor cortex system. Clinical diagnostic criteria for complex regional pain syndrome In some people, signs and symptoms 1) Continuing pain, which is disproportionate to any inciting event of complex regional pain syndrome go 2) Must report at least one symptom in three of the four following categories away on their own. In others, signs and Sensory: Reports of hyperalgesia and/or allodynia Vasomotor: Reports of tem symptoms may persist for months to years. Treatment is likely to be most ef perature asymmetry and/or skin color changes and/or skin color asymmetry Su fective when started early in the course domotor/Edema: Reports of edema and/or sweating changes and/or sweating of the illness. Also known as refex sym lodynia (to light touch and/or deep somatic pressure and/or joint movement) Va pathetic dystrophy syndrome, this somotor: Evidence of temperature asymmetry and/or skin color changes and/ type occurs after an illness or in or asymmetry Sudomotor/Edema: Evidence of edema and/or sweating changes jury that didn?t directly damage the and/or sweating asymmetry Motor/Trophic: Evidence of decreased range of mo nerves in your affected limb. About tion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic chang 90 percent of people with complex regional pain syndrome have type es (hair, nail, skin) 1. Your doc abnormalities whose signifcance re and opioids) are mainly dependent on tor may suggest medications to main obscure but which are localized effcacy originate in other common con prevent or stall bone loss, such as in thalamus and anterior cingulate ditions of neuropathic pain22. Imaging studies of al early as possible, may potentially but the limited data available do not lodynia should be encouraged in order to prevent progression of symptoms40. If the affected area is Treatment approach sants, such as amitriptyline, and cool, applying heat may offer relief anticonvulsants, such as gabapen in 4 to six weeks. The combination Prompt diagnosis and early treatment tin (Gralise, Neurontin), are used of all local terapies seems to be is required to avoid secondary physi to treat pain that originates from useful in sciatic causalgia after ac 63 Revista Chilena de Neurocirugia 43: 2017 etabular fracture56. Various topi with inoperable angina (that is, re cal treatments are available that fractory angina pectoris) resulted in may reduce hypersensitivity, such signifcant decreases in chest pain as capsaicin cream (Capsin, Cap and hospital admissions as well as sagel, Zostrix) or lidocaine patches increased exercise duration, with (Lidoderm, others). Gentle, guided dures that were performed for pain exercising of the affected limbs may control only. Chronic pain in reducing the chronic neuropathic is sometimes eased by applying pain of (faliled Back Pain Surgery Figure 3. More cation, and restore a psychological of neuropathic pain or subgroups over, there is evidence to demon sense of well-being9. Temporary implant of the sive neuropathy is currently treated Preoperative evoked potencial (sen StimRouter device resulted in both by direct stimulation of the nerve9. His continuous infusions of local an ment fails to give signifcant pain re stimulation parameters were less esthetic and morphin the epidural lief and 32-38% of treated patients than 1 mampere, < 1 volt, pulse catheter (ropivacaine 0. It serted electrodes along the spinal controlled trial showed a lifetime may be of beneft for subset(s) of cord. Careful patient selection, accurate target localization, and identifcation with intraoperative neurophysiological Figure 4 b. Electrodes were implanted in the somatosensory thalamus and the periventricular gray region. The best long-term results were at tained in patients with chronic low back and leg pain, for example, in so-called failed-back surgery syn drome. Disappointing results were documented in patients with central pain syndromes, such as pain due to spinal cord injury and poststroke pain44. The nerveperipheral nerve stimulation via a necessary to ensure patient safe effects of spinal cord stimulation quadripolar lead in the right carpal tun ty15,57. Benzodiazepines and high Living with a chronic, painful condition behavioral psychologist or other pro doses of baclofen may be benefcial in can be challenging, especially when fessional may be able to help them put the treatment of dystonia and spasms as is often the case with complex re things in perspective. Also, and family don?t believe you could be skills, such as relaxation or meditation no controlled studies exist on the use feeling as much pain as you describe. One study reported about complex regional pain syndrome where they can share experiences and on the benefcial effects of intrathecal with those close to you to help them un feelings with other people, is a good ap baclofen therapy in a small number of derstand what you?re experiencing. Long-term outcomes during treatment of chronic pain with intrathecal clonidine or clonidine/ opioid combinations. Clinical manifestations of refex sympathetic dystrophy and sympathetically maintained pain. Electrical stimulation and the treatment of complex regional pain syndromes of the upper extremity. Diffuse complex regional pain syndrome in an adolescent: a novel treatment approach. Prospective clinical study of a new implantable peripheral nerve stimulation device to treat chronic pain. Validation of proposed diagnostic criteria (the Budapest Criteria) for complex regional pain syn drome. Usefulness of thermography in diagnosis of complex regional pain syndrome type I after transradial coronary intervention. Motor cortex stimulation for phantom limb pain: comprehensive therapy with spinal cord and thalamic stimulation. Continuous Thoracic Sympathetic Ganglion Block in Complex Regional Pain Syndrome Patients with Spinal Cord Stimulation Implantation. Can the outcome of spinal cord stimulation in chronic complex regional pain syndrome type I patients be predicted by catastrophizing thoughts? Somatosensory conficts in complex regional pain syndrome type 1 and fbromyalgia syndrome. Spinal Cord Stimulation for the Treatment of Upper and Lower Extremity Neuropathic Pain due to Lyme Disease. Pain and reducedmobility in complex regional pain syndrome I: outcome of a prospec tive randomised controlled clinical trial of adjuvant physical therapy versus occupational therapy. Spinal cord stimulation for chronic pain of neuropathic or ischaemic 67 Revista Chilena de Neurocirugia 43: 2017 origin: systematic review and economic evaluation. Predictive value of somatosensory evoked potentials for long-lasting pain relief after spinal cord stimulation: practical use for patient selection.

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The examiner observes and measures when the lower back loses contact with the tabletop due to anterior pelvic tilt. The patient is instructed to extend at the lumbar spine and raise the chest of the table to approximately 30? and hold the position. Lateral Abdominals the patient is positioned in sidelying with hips in neutral, knees fexed to 90, and resting the upper body on the elbow. The patient is asked to lift the pelvis of the table and to straighten the curve of the spine without rolling forward or backward. The position is held and timed until the patient can no longer maintain the position. Transversus Abdominis the patient is positioned in prone over a pressure biofeedback unit that is infated to 70 mmHg. The patient is instructed to draw in the abdominal wall for 10 seconds without inducing pelvic motion while breathing normally. Hip Abductors the patient is positioned in sidelying with both legs fully extended, in neutral rotation and a relaxed arm position, with the top upper extremity resting on the ribcage and hand on abdomen. Hip Extensors the patient is positioned in supine with knees fexed to 90? and the soles of the feet on the table. The patient is instructed to raise the pelvis of the table to a point where the shoulders, hips, and knees are in a straight line. Nature of variable Continuous, ordinal Units of measurement Seconds to hold position, muscle performance assessment, change in mmHg using a pressure biofeedback device Measurement properties the double-leg lowering assessment for trunk fexor strength has demonstrated discriminative properties in identifying patients with chronic low back pain. For trunk fexion, test variations include bent double leg lowering and sit-up tasks. For trunk extension, numerous variations have been described, including the Sorensen test and prone double straight leg raise. The hip measured is placed in 0? of abduction, and the contralateral hip is placed in about 30? of abduction. The reference knee is fexed to 90, and the leg is passively moved to produce hip rotation. Manual stabilization is applied to the pelvis to prevent pelvic movement and also at the tibiofemoral joint to prevent motion (rotation or abduction/adduction), which could be construed as hip rotation. The motion is stopped when the extremity achieves its end of passive joint range of motion or when pelvic movement is necessary for additional movement of the leg. The inclinometer is aligned along the shaft of the tibia, just proximal to the medial malleolus, for both medial and lateral rotation range-of-motion measurements. Hip Flexion With the patient supine, the examiner passively fexes the hip to 90? and zeroes an inclinometer at the apex of the knee. One limb is held in this position, maintaining the knee and hip in fexion, the pelvis in approximately 10? of posterior tilt, and the lumbar region fush against the tabletop, while the ipsilateral thigh and leg are lowered toward the table in a manner to keep the hip in 0? of hip abduction and adduction. The patient is instructed to relax and allow gravity to lower the leg and thigh toward the foor. The angle of the femur of this lowered leg to the line of the trunk (and tabletop) is measured. The amount of knee fexion is also monitored to assess the relative fexibility of the rectus femoris muscle. Instrument variations Alternate positions for the testing of hip internal rotation, external rotation, fexion, and extension have been described in both short sitting and supine, with the hip and knee in 90? of fexion for the rotation measures. A variety and (2) During the past month, have you often been both of methods to screen for psychological disorders have been ered by little interest or pleasure in doing things? Answering yes? to 1 or both beliefs and pain catastrophizing, and screening for psycho questions should raise suspicion of depressive symptoms. Efective screening for depression involves more than just generating a clinical impression that the patient is depressed. Pain catastrophizing is a negative belief that the experienced Separate studies involving spine surgeons131 and physical pain will inevitably result in the worst possible outcome. Psychosocial subscale scores (ranging from 0 to 5) are determined by summing items related to bothersomeness, fear, catastrophizing, anxiety, and depression (ie, items 1, 4, 7, 8, 9). Instead, these guidelines focus on randomized, fcacy of mobilization/manipulation in isolation rather than controlled trials and/or systematic reviews that have tested in combination with active therapies. Recent research has these interventions in environments that would match physi demonstrated that spinal manipulative therapy is efective cal therapy application. In keeping with the overall theme of for subgroups of patients and as a component of a compre these guidelines, we are focusing on the peer-reviewed litera hensive treatment plan, rather than in isolation. Flynn et al99 conducted an initial derivation study of patients most likely to beneft It is believed that early physical therapy intervention can from a general lumbopelvic thrust manipulation. Five vari help reduce the risk of conversion of patients with acute ables were determined to be predictors of rapid treatment low back pain to patients with chronic symptoms. A study success, defned as a 50% or greater reduction in Oswes by Linton et al200 demonstrated that early active physical try Disability Index scores within 2 visits. These predictors therapy intervention for patients with the frst episode of included: acute musculoskeletal pain signifcantly decreased the inci dence of chronic pain. Only 2% of patients who received early inter vention went on to develop chronic symptoms, compared to the presence of 4 or more predictors increased the probabil 15% of the delayed treatment group. Patients meeting the rule who re ceived manipulation had greater reductions in disability the order of the interventions presented in this section is than all other subjects. These results remained signifcant at based upon categories and intervention strategies presented 6-month follow-up. A pragmatic rule has also been published in the Recommended Low Back Pain Impairment/Function to predict dramatic improvement based on only 2 factors: based Classifcation Criteria with Recommended Interven tions table. Aure and colleagues13 demonstrated lation and exercise demonstrated less risk of worsening dis superior reductions in pain and disability in patients with ability than those who received only exercise. Reductions in disability were signifcantly high this rule has been further examined by Cleland et er for the manipulation group at discharge and 12 months. The 2 groups re Whitman et al316,317 demonstrated that, for patients ceiving thrust manipulation fared signifcantly better than a with clinical and imaging fndings consistent with I group receiving nonthrust mobilization at 1 week, 4 weeks, lumbar central spinal stenosis, a comprehensive and 6 months. In the randomized control tri outcomes are dependent on utilization of a thrust al, 58 patients were randomized to receive a comprehensive I manipulation, as those who received nonthrust manual therapy approach, abdominal retraining, and body techniques did not have dramatic improvement. This had weight?supported treadmill training compared to lumbar previously been established by Hancock et al140 in a second fexion exercises and traditional treadmill training. The fndings of the Cleland et al66 and outcomes favored the experimental group, although these Hancock et al140 papers demonstrate that rapid improve diferences were not statistically signifcant. Manual therapy ments associated with patients ftting the clinical prediction was delivered in a pragmatic impairment-based approach; rule are specifc to patients receiving thrust manipulation. Seventy-four percent of patients with hypomo eral, or combined central and lateral lumbar spinal bility who received manipulation were deemed successful as stenosis. Patients were treated with lumbar thrust manipula compared to 26% of patients with hypermobility who were tion, nerve mobilization procedures, and exercise. These fndings may suggest that improvement in disability, as measured by the Roland-Morris assessment of hypomobility, in the absence of contraindica Disability Questionnaire, was 5. Beyond the success associated with the use of thrust Reiman et al,252 in a recent systematic review, recommended manipulation in patients with acute low back pain manual therapy techniques including thrust and nonthrust I who ft the clinical prediction rule, there is evidence mobilization/manipulation to the lumbopelvic region for pa for the use of thrust manipulation in other patients experi tients with lumbar spinal stenosis. However, as they may alter the loads placed on the lumbar facets and there was insufcient evidence to fnd motor control exercises posterior spinal ligaments. Variables that signifcantly predicted lative procedures to reduce pain and disability in a 50% improvement in disability from low back pain at 4 A patients with mobility defcits and acute low back weeks in a multivariate analysis were retained for the clinical and back-related buttock or thigh pain. In addition, these exercises are com monly prescribed for patients who have received the medical Costa et al70 used a placebo-controlled randomized diagnosis of spinal instability. Interventions consisted of either specifc motor-control treatment of nonspecifc low back pain, Hayden exercises directed to the multifdus and transversus abdomi I and colleagues147 examined the literature on exer nis or nontherapeutic modalities. Short-term outcomes dem cise therapy for patients with acute (11 randomized clinical onstrated small but signifcant improvements in favor of the trials), subacute (6 randomized clinical trials), and chronic motor control group for both patient activity tolerance and (43 randomized clinical trials) low back pain and reported global impression of recovery. The exercise interventions that exercise therapy was efective in decreasing pain in the failed to reduce pain greater than nontherapeutic modalities chronic population, graded activity improved absenteeism over the same period. The larger criticism that the Cochrane Rasmussen-Barr et al250 that compared a graded I reviewers found with the current literature was that the out exercise program that emphasized stabilization ex come tools were heterogeneous and the reporting was poor ercises to a general walking program in the treatment of low and inconsistent, with the possibility of publication bias. At both the 12-month journal of orthopaedic & sports physical therapy | volume 42 | number 4 | april 2012 | a33 Low Back Pain: Clinical Practice Guidelines and the 36-month follow-up, the stabilization group out Yilmaz and colleagues326 investigated the efcacy of performed the walking group, with 55% of the stabilization a dynamic lumbar stabilization exercise program I group and only 26% of the walking group meeting the pre in patients with a recent lumbar microdiscectomy. This research demonstrates the results of their randomized trial indicated that lumbar that a graded exercise intervention emphasizing stabilizing spinal stabilization exercises under the direction of a physi exercises seems to improve perceived disability and health cal therapist were superior to performing a general exercise parameters at short and long terms in patients with recur program independently at home and to a control group of rent low back pain. This study had a small sample size with 14 subjects in each group and did not de Choi and colleagues53 performed a review of ran scribe any loss to follow-up. Specifc types of exercise were not assessed in greater improvement in distance walked compared to educa dividually.

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Neonatal Care Protocol for Hospital Physicians 519 Chapter 44: Neonatal Procedures > Cleanse the cord and surrounding area with an antiseptic solution. Avoid tincture of iodine because of the potential effect on the neonatal thyroid; other iodine containing products. Low positioning is associated with more episodes of vasospasm of the lower extremities. It is also associated with a lower incidence of blanching and cyanosis of the extremities. Neonatal Care Protocol for Hospital Physicians 520 Chapter 44: Neonatal Procedures Figure (44-10): Localization of umbilical artery catheter > If the catheter tip is above required position, measure distance between actual and appropriate position on the radiograph and withdraw equal length of catheter. Never advance it once in situ, because this will introduce a length of contaminated catheter into the vessel. Figure (44-11): Umbilical artery catheter insertion A) Cutting the umbilical cord leaving a 1 cm stump, B) gently dilate the umbilical artery with a forceps, C) Catheter is inserted into the umbilical artery. Neonatal Care Protocol for Hospital Physicians 521 Chapter 44: Neonatal Procedures Figure (44-12): the umbilical artery catheter can be placed in one of two positions. The low catheter is placed below the level of L3 (between L3 and L4) to avoid the renal and mesenteric vessels. The graph is used as a guide to help determine the catheter length for each position. Figure (44-13): Securing the catheter to the abdominal wall using (bridge method) of taping Neonatal Care Protocol for Hospital Physicians 522 Chapter 44: Neonatal Procedures Catheter care? Indications of catheter removal: > the infant improves, so that continuous monitoring and frequent blood drawing is no longer necessary. If the catheter is placed for an exchange transfusion, it should be advanced only as far as it is necessary to establish good blood flow (usually 2-5 cm). This should be suspected if a resistance is met and the catheter can not be advanced to the desired distance, or if a Neonatal Care Protocol for Hospital Physicians 523 Chapter 44: Neonatal Procedures bobbing motion of the catheter is detected. Several options are available to correct this: > Try injecting flush as you advance the catheter. Figure (44-14): the umbilical venous catheter is placed above the level of the diaphragm. Infection: the risk of infection can be minimized by following strict aseptic technique, and not advancing the catheter after positioning. Do not use topical antibiotic ointment or creams on umbilical catheter insertion sites because of the potential to promote fungal infections and antimicrobial resistance. Neonatal Care Protocol for Hospital Physicians 526 Chapter 44: Neonatal Procedures Exchange Transfusion Exchange Transfusion Techniques Two techniques of exchange transfusion are used: ? Pull-push, or intermittent, method involves drawing an aliquot of infants? blood and then replacing it with an aliquot of donor blood. This method provides a more consistent arterial blood pressure and may be tolerated better in small, sick, or hydropic infants. Hyperbilirubinemia, of any etiology, when phototherapy fails to prevent rise in bilirubin to toxic levels (Refer to Chapter 21). A nasogastric tube should be passed to evacuate the stomach and should be left in place to prevent regurgitation and aspiration of gastric juices. This can be accomplished by hanging it upside down for approximately 20-30 minutes; this is followed by checking the hematocrit level (Hct should be between 45-55%). Neonatal Care Protocol for Hospital Physicians 528 Chapter 44: Neonatal Procedures? C, either by placing the tubing in a blood warmer with a precise thermostatic control or by immersing the tubing in a warm water bath of 37-38? If it is not possible to place the catheter at the level of the diaphragm, the catheter can be inserted only as far as required to permit free blood exchange (2-5 cm). In this case, avoid infusing drugs such as calcium to prevent potential liver damage. This usually is 5 ml for infants <1,500 gm, 10 ml for infants 1,500-2,500 gm, 15 ml for infants 2,500-3,500 gm, and 20 ml for infants >3,500 gm (smaller aliquots and a slower rate place less stress on the cardiovascular system). Whether withdrawing or infusing, the same amount of blood should always be handled. The stopcock is then closed to the donor bag and opened to the infant (Figure 44-16) and (Figure 44-17). When injecting the donor blood into the infant, the syringe must be held upright so that air bubbles rise to the top and are not injected into the infant. Neonatal Care Protocol for Hospital Physicians 529 Chapter 44: Neonatal Procedures? The assistant should record the amount of blood removed and infused on the Exchange Transfusion Flow Sheet (Table 44-1). Once the procedure has begun, it is important to have a third person available to record the blood removed and infused and to maintain a running total so that at the end of the procedure the total amounts are equal (Figure 44-18) and (Figure 44-19). The blood bag should be gently agitated every 10-15 minutes to prevent red cell sedimentation. This procedure is continued until the desired volume of donor blood has been infused. Periodically change the 50-60 ml syringe with a new one and gently flush the catheter with 1-2 ml of heparinized (5 unit/ml) saline to prevent clot formation. B) Removal system: 1) Blood is withdrawn from infant 2) Blood is discarded into collection bag 3) Periodically flush the catheter with 1-2 ml of heparinized saline. Once the calcium has been administered, the catheter should be flushed and the exchange transfusion continued. Bleeding: check platelet count before aspiration; if low, the procedure should not be performed. An intubated, critically ill infant must be placed in the lateral decubitus position. The assistant should hold the infant firmly at the shoulders and buttocks so that the lower part of the spine is curved. Advance the needle slowly in the direction towards the umbilicus, withdrawing the stylet frequently to check for the appearance of spinal fluid. Neonatal Care Protocol for Hospital Physicians 537 Chapter 44: Neonatal Procedures? Figure (44-21): Positioning the infant for lumbar puncture, and landmarks used for lumbar puncture, the iliac crest marks the approximate level of L4. Neonatal Care Protocol for Hospital Physicians 538 Chapter 44: Neonatal Procedures Blood and Blood Products Transfusion Indications Red blood cell transfusion (Refer to Chapter 34) Fresh frozen plasma transfusion? An otherwise stable healthy term infant with a platelet count as low as 20,000 30,000/? Infants receive type specific or group O platelets in plasma compatible with the infant. Neonatal Care Protocol for Hospital Physicians 539 Chapter 44: Neonatal Procedures? Consent from the parents must be obtained after explaining the reason for the transfusion. Mechanical pumps must not be used under any circumstances for the transfusion of red blood cells. Temporarily discontinue transfusion to deliver glucose if the blood sugar falls below 45 mg/dl. The blood glucose should be checked for rebound hypoglycemia 30 minutes to 1 hr after transfusion. Neonatal Care Protocol for Hospital Physicians 540 Chapter 44: Neonatal Procedures? There is a special consideration regarding the transfusion of donor blood to neonates. Irradiated blood should be considered in the following populations: > Neonates with a birth weight <1,200 gm > Neonates with a known immunodeficiency syndrome > Neonates receiving blood from direct donor relatives Transfusion Time? This timeframe begins when the blood is released from the blood bank refrigerator. The Neonatal Care Protocol for Hospital Physicians 542 Chapter 44: Neonatal Procedures risk of hemolysis and bacterial contamination of blood increases with prolonged handling at room temperature.

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Regulation of caspase-9 activity by differential binding to the apoptosome complex. The neurotoxic effects of amitriptyline are mediated by apoptosis and are effectively blocked by inhibition of caspase activity. Despite differences in cytosolic calcium regulation, lidocaine toxicity is similar in adult and neonatal rat dorsal root ganglia in vitro. Neurotoxicity induced by bupivacaine via T-type calcium channels in sh-sy5y cells. Intrathecal lidocaine neurotoxicity: Combination with bupivacaine and ropivacaine and effect of nerve growth factor. Neuroprotection by cord blood stem cells against glutamate-induced apoptosis is mediated by Akt pathway. Dexamethasone attenuated bupivacaine-induced neuron injury in vitro through a threonine-serine protein kinase B-dependent mechanism. Lithium attenuates bupivacaine-induced neurotoxicity in vitro through phosphatidylinositol-3-kinase/threonine-serine protein kinase B and extracellular signal-regulated kinase-dependent mechanisms. Differential activation of mapk in injured and uninjured drg neurons following chronic constriction injury of the sciatic nerve in rats. Inhibitors of p38 mitogen-activated protein kinase promote neuronal survival in vitro. Anderson, personal In 1940, Lichtenstein, an authoritative neu communication 1984). Interestingly, there is no ropathologist, was first to propose that tether word that has the same definition and connota ing of the spinal cord may cause paraplegia tion as English tether in any other language. The and herniation of the brain stem and cerebel delay in recognizing this syndrome may be due in lum through the foramen magnum. These symp evolved slowly but with increasing interest toms subsided after sectioning of a thickened among clinicians and pathologists. A suggestion filum terminale,13 which indicated that the 1 2 Tethered Cord Syndrome in Children and Adults neurological lesion was in the lumbosacral cord. It is clear that the lum electrophysiological impairments and recover bosacral neurological symptomatology in these ies were recorded before and after cord unteth patients is not caused by caudal traction effects ering, respectively. Based on the pathophysio increasingly appeared in the neurosurgical logical analysis on caudal spinal cord anom literature. Expanding the stretch-induced disorder from They include an inelastic filum terminale, cau tethered spinal cord to tethered cord syndrome, dal lipoma or lipomyelomeningocele, or sacral Yamada et al included patients with neural myelomeningocele. After surgical untethering, 1 Introduction to the Tethered Cord Syndrome 3 category 1 patients can expect excellent outcome (Chapter 20), and for conservative and operative with pain relief and neurological improvement. No surgical treatment is include the following: indicated for category 3 patients. This method relieved ering procedures spinal cord tension by shortening the length of 27. What is the true tethered cord spinal cord during normal and abnormal develop syndrome? The relationship of siology of tethered cord syndrome and similar com Arnold-Chiari and Dandy-Walker malformations. Spinal cord transection for ered spinal cord: its protean manifestations, diagnosis definitive untethering of repetitive tethered cord. Vertebral tethered cord syndrome and other dysraphic syn column subtraction osteotomy for recurrent teth dromes. During surgery, the level of the Based on the neurological signs and symp caudal end of the spinal cord was determined by toms localized in the lumbosacral cord and the exit of the lowest coccygeal nerve root, and consistent imaging and operative findings, its location was expressed in relation to the Hoffman et al adopted the term tethered spinal lumbar and sacral vertebral bodies. Despite these recent reliable end of the spinal cord, particularly when it is findings, it is still widely believed that an elon located at the L3 vertebral level. Further, this logic extends to such an in diameter),2 which is too small to be identified assumption as the patients without two as a landmark of the caudal end of the spinal 198 Tethered Cord Syndrome in Children and Adults cord. Commonly, the caudal end at the L3 verte much as the lumbar cord segments do, and bra is not included in the group of low-lying cord explain widely spread lumbosacral cord dys before surgery. In some cases, fat tissue that extends from the filum into the conus makes the defini Conclusion tion of the conus?filum junction impossible by imaging studies. The elongation of and musculoskeletal abnormalities that indicate the spinal cord usually occurs in lumbosacral or strongly suggest a stretch-induced lum segments, and the conus diameter is often bosacral functional lesion make imaging studies greater than the normally located conus (S2?4 useful. Pediatr Neurosurg 2004;40: Association of Neurological Surgeons; 1996: 139?165 51?57, discussion 58 2. Occult tethered cord syndrome: the case J Spinal Disord 2000;13: 319?323 for surgery. Normal diameter of drome: new classification correlated with sympto filum terminale in children: in vivo measurement. The teth Neurosurg 1986;1: 45?79 ered spinal cord: its protean manifestations, diagno 14. Symptomatic pro Pathophysiology of tethered cord syndrome and simi tocols for adult tethered cord syndrome. Pathophysiology of Adult tethered cord syndrome: relative to spinal cord tethered cord syndrome: correlation with sympto length and filum thickness. J Neurosurg 1987;66: 116?123 urodynamic outcome after division of the filum ter 20. J Urol 1990;144(2 Pt 2): 426?428, discussion syndrome: a survey of practice patterns. We are committed to promoting best practice by reducing delays and avoidable disability, including preventing paralysis, from adversely affecting the quality of life for people with metastatic spinal cord compression. Pain -pain in the middle (thoracic) or upper (cervical) spine -progressive or severe unremitting lower (lumbar) spinal pain -spinal pain aggravated by straining (for example, at stool, or when coughing or sneezing) -localised spinal tenderness -nocturnal spinal pain preventing sleep 2. Consider referral for specialist pain care including invasive procedures (such as epidural or intrathecal analgesia) and neurosurgical interventions for patients with intractable pain from spinal metastases. If >3 days, see table weaning regime Dexamethasone Reduction Following Radiotherapy or Surgery Follow weaning regime from table below. Observe for worsening pain or neurological status return to dose that previously maintained clinical situation. For all Radiotherapy regimes & surgery dose reduce regime is the same st (16mg until 1 intervention) Day Dexamethasone daily 18 1 2 (2 days) 16mg 3 4 (2 days) 8mg 5 6 (2 days) 4mg 7 8 (2 days) 2mg Aim to discontinue within a week post treatment, unless the patient previously taking long term steroids. Other Considerations the dose of dexamethasone may have to be higher in patients receiving phenytoin or carbamazepine (see Guidelines on Antiepileptics and Corticosteroids) Network Guidelines. Health professionals? assessment of constipation often differs from that of the patient, therefore when reaching a diagnosis of constipation, the views of the patient should be sought and whether they believe themselves to be constipated. Offer a bladder & bowel management programme Assess & Document Assess bladder and bowel function at presentation and start a care plan Monitor and document daily 20 Bladder If at any stage the patient has a palpable bladder / not passed urine > 4 hrs bladder scan Manage bladder dysfunction by a urinary catheter on free drainage If long-term catheterisation is required, consider intermittent catheterisation or suprapubic catheters Bowel Laxative choice for opioid induced and non-opioid induced constipation Rectal Interventions the choice of rectal intervention should be based on the results of a digital rectal examination 21 A rectal intervention should be given on alternate days combined with an alternate day stimulant or oral laxative i. These include hypoventilation, hypotension, bradycardia, and autonomic dysreflexia especially in the acute phase of paralysis or with high spinal cord lesions. Cervical spine collars and spinal bracing significantly reduce spinal motion, stabilise the spine, protect spinal cord and may reduce spinal pain. The impaired spinal cord is vulnerable to changes in vascular perfusion pressure; sitting prematurely may provoke hypotension, loss of cord perfusion, and irretrievably 30 permanent loss of neurological function. Referral to Physiotherapy < 24 hrs, Occupational Therapy < 48 hrs of diagnosis the aim of rehabilitation is: ? To understand the level/s of compression and potential implications If the patient is medically unstable, distressed, symptomatic. Assessments (if Including: patient on bed Assessment of feeding on ward and provision of rest) hospital feeding aids if available. Advise if assistance is required or food choices that could be made to enhance independence. Please note some sections will apply across the treatment pathway (for example psychological care) 1. Aspen / Miami J) If problems exist with collar fit and comfort, orthotics should be contacted for specialist assessment and collar. Avoid overstretching of the wrist and finger flexors in C6/7 tetraplegics who require a 35 tenodesis grip No neck exercises / movements 5. Prevention of contractures and/or spasticity control Prevention of contractures and/or spasticity control may include: Corrective positioning and splinting Physiotherapy stretching and exercises Muscle relaxants 8. Pressure ulcer prevention & skin care To be considered during all therapeutic activities Day 1: 10.

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Seamanship: Rope, knots Bends, Hitches and splices, Anchors, cables and mooring -. Observations of storms, formation of storms and method of locating the eye of the storms and method of escaping from the center of the storms as per buys ballet law. Leveling definitions, methods of leveling, leveling instruments, terms and abbreviations, types of spirit leveling. Contour surveying definition, instruments required, contour interval, characteristics of contour, contouring methods and uses of contour. Area calculation of plane surface of regular and irregular shape as applied to measurement of land. Design and construction of farm and Hatchery Structures: Soil Soil and its properties; classification of soil; soil sampling methods; three phase system of soil, definitions of soil properties and permeability of soil. Pumps purpose of pumping, types, selection of pump, total head, and horse power calculation. Effluent Treatment Plant: Concept of reservoir, Bio-ponds, Effluent treatment plan design. Fisheries Extension Methods: Individual, Group and Mass contact methods and their effectiveness, factors influencing their selection and use. Extension program planning and Evaluation: Steps and importance; Participatory planning process. Social groups meaning, elements and classification need for formation and motivation in group formation. Rural social concepts culture, customs, traditions and their role in fisheries extension. Value system meaning, Village institutions meaning, types and their role in Fisheries development. Leadership meaning of leader and leadership, classification of leaders, methods of selection and training, qualities and roles of leaders and use of local leaders in fisheries development. Educational Psychology: Introduction, psychological basis for human behavior, educational psychology; meaning, principles, scope and its importance in fisheries extension. Psychological traits Intelligence, personality, perception, meaning, types, factors affecting, role and importance in fisheries extension. Motivation; meaning, classification of needs, techniques of motivation and importance of motivation in fisheries extension. Teaching Learning process; concepts like teaching, learning, learning experience, learning situation, steps in teaching, principles of teaching and their implications in learning. Study of social issues / problems through participatory and rapid rural appraisal techniques. Everett Rogers, and Floyd Shoemaker, Communication of Innovation a Cross Cultural Approach, New York Free Press. Kaushik and Aparna, 2004 Course compendium for the Refresher course on communication and Reporting skills p. Organizational set up of fisheries administration at the Central and State levels. Functions and powers of functionaries of department of fisheries, corporations and co operatives. Role of central and state government in the regulatory activities of aquaculture and fisheries. Fisheries Legislation: Overview of fisheries and aquaculture legislations in India. Laws relating to conservation and management of fishery resources in marine and inland sectors. Brackish water aquaculture Act, Marine Fisheries Policy, Laws relating to Fish products and marketing. International law of the Seas and International commissions on fisheries and their impact. Disaster Management in Fisheries: Basic concepts: Hazard, risk, vulnerability, disaster, capacity building. Types of natural and manmade hazards in fisheries and aquaculture cyclones, floods, droughts, tsunami, El-nino, algal blooms, avalanches, pollution, habitat destruction, over fishing, introduction of exotic species, landslides, epidemics, loss of bio-diversity etc. Pre-disaster: prevention, preparedness and mitigation; different ways of detecting and predicting disasters; early warning, communication and dissemination, community based disaster preparedness, structural and non structural mitigation measures. During disaster: response and recovery systems at national, state and local, coordination between different agencies, international best practices. Post disaster: Methods for assessment of initial and long term damages, reconstruction and rehabilitation. Agencies involved in monitoring and early warnings at district, state, national and global levels. Handbook on Fisheries and Aquaculture, Indian Council of Agricultural Research, New Delhi. Diagrammatic and graphical representation of data: Bar diagrams, pie diagrams, histogram, frequency polygon, frequency curve and Ogives. Probability: Definition of probability, mutually exclusive and independent events, conditional probability. Concepts of theoretical distribution: Binomial distribution equation and properties of binomial distribution and problems there on. Poisson distribution equation and properties of Poisson distribution and problems there on. Normal Distribution equation and properties of normal distribution and problems there on. Test of Hypothesis: Basic concepts of sampling distribution, standard error and central limit theorem. Introduction to statistical inference, general principals of testing of hypothesis and types of errors. Chi-square distribution: Definition, conditions and uses of Chi-square in fisheries sector. Correlation and Regression: Bivariate data, scatter diagram, simple linear correlation, measures and properties, Problems on simple correlation. Application of statistics in fisheries: Length and weight relationship in fishes using regression. Estimation of population mean, population total using simple random sample and stratified random sample. Estimation of Population mean, Population total using simple and stratified sampling. Features of machine language, assembly language, high-level language and their advantages and disadvantages. Audio visual equipments: Planning, preparation, presentation of posters, charts, overhead transparencies and slides. Resource, scarcity, farm-firm relationships production Contribution of fisheries sector to the economic development of the country. Elasticity price, income, cross, application of elasticity in fisheries managerial decision. Law of diminishing marginal return, returns to scale, economies of scale and scope, revenue, profit maximization, measurement of technological change. Role of fisheries in economic development: International trade import and export policy. Structure, functions, status and problems of fisheries co-operatives management in relation to resources, production and marketing. Micro-credit, indigenous and institutional finance, structure of institutional finance in fisheries, returns, risk bearing ability and recovery in fisheries sector. Marketing: Introduction to marketing management, Marketing concepts: Market structure, functions and types,Marketing channels and supply chain, marketing margins, marketing environment, marketing strategies, product development and product mix, consumer behavior and marketing research. Fish markets and marketing in India, demand and supply of fish, market structure and price formation in marine and inland fish markets;Cold storage and other marketing infrastructure in India;Sea food export; case study on product and market diversification export and import policies (fisheries). Introduction to fish business management Concept of management, management process (planning, organising, staffing, leading and controlling), Organizational behaviour, human resource planning, new dimensions in fish business environment and policies. Overview of Indian social, political and economic systems and their decision making by individual entrepreneurs. The following selections from the text book are to be covered during the semester 1. Introduction to spoken English Improving Voice and speech Phonetic symbols Orthography Ortheopy Vowels and consonants Spoken English Practice by Using Audio Visual aids. Verbal ability Words often confused Words frequently misspells Antonyms Synonyms Homonyms Homo Phones Phrasal verbs Redundant Words and Phrases Idiomatic Languages Exercises.

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The centralisation phenomenon has been shown to be associated with a good prognosis; i. Studies have shown that patients with sciatica and suspected disc herni ation who have centralised will have better outcomes than non-centralisers (Albert et al. However, these studies have included patients with short duration of pain, which makes it dif? Kinesiophobia and fear of movement Fear of movement and kinesiophobia are two concepts, which are frequently used synonymously in the literature. Pain-related fear is a broad, general term that incorporates all kinds of fear related to pain (Crombez et al. In the most extreme situation of fear of move ment, the term kinesiophobia? can be used, according to Kori et al. The cognitive-behavioural fear-avoidance model (Figure 4) is often used when describing the different paths a patient with chronic pain can follow 16 Aspects of evaluations for patients with lumbar disc herniation! Figure 4: A cognitive-behavioural model of fear of movement/(re)injury by Vlaeyen et al. The model suggests two responses to pain after an injury; catastrophising, with fear of fear of movement/(re)injury and avoidance followed by disability and consequently a vicious circle, or non catastropising and confrontation, which are assumed to lead to recovery 4. Originally, the fear-avoidance model was used on patients with chronic low back pain (Boersma and Linton, 2006; Picavet et al. Kinesiophobia is thought to play a negative role in the out come of rehabilitation for patients with low back pain and a high prevalence of kinesiophobia has been observed among patients with persistent low back pain (Lundberg et al. During the last decade the number of studies concerning the fear-avoidance model have increased sub stantially (Vlaeyen and Linton, 2012). The model and conception of fear of movement have spread and have been used for patients with cervical radicu lopathy (Dedering and Borjesson, 2012), upper extremity disability (Das De et al. Many lumbar disc herniations heal spontaneously, but many patients have to endure a long period of pain and symptoms. However, there is little evidence to support the effect of physiotherapy treatment methods. In or der to account for the complexity of pain, symptoms, impaired function and disability these patients present, it seems necessary to design a structured physiotherapy treatment model. The treatment should aim for a reduction in the patients? pain and disability and also to empower the patients and in crease their self-ef? A more detailed description of patients? experience of health a couple of years after structured physiotherapy treatment or surgery is, however, lacking. A qualitative interview study with open-ended questions to patients with lumbar herniation could yield in-depth responses about their experiences, perceptions, opinions, feelings and knowledge. An evaluation of the centralisation phenomenon in relation to a structured physiotherapy treat ment model for patients with lumbar disc herniation therefore appeared to be justi? Fear of movement is thought to play a negative role in the outcome of rehabilitation for patients with low back pain and a high prevalence of kinesiophobia has been observed among patients with persistent low back pain (Lundberg et al. Study I All 97 patients between 18 and 65 years of age who had undergone stan dardised open discectomy in 2004 and 2005 at Sodra Alvsborg Hospital (Sweden) were invited to participate in the study. If no response was received after two mailed reminders, the patients were reminded by telephone. Eighteen of the 80 patients were initially randomised to physiotherapy, 17 patients were randomised to surgery and 45 patients did not accept randomisation. A decision was therefore made solely to present a cohort of 45 patients treated accord ing to the structured physiotherapy treatment protocol. Before the struc tured physiotherapy treatment began, four patients recovered to the extent that they could no longer be accepted as surgical candidates and they were therefore excluded from the studies. Independent examiners, who were not involved in the treatment, dis tributed the questionnaires before treatment and at the three-, 12 and 24 month follow-ups. Earlier quantitative studies show no differences between surgery and non-surgical treatments after one and two years (Jacobs et al. A decision was therefore made to in clude both patients who were treated with surgery and patients who were treated with structured physiotherapy, as these patients could be regarded as a homogeneous group. Two years after treatment, the patients answered questionnaires, which revealed that three patients experienced kinesiopho bia, 13 patients had no leg pain and likewise 13 patients reported no back pain. Treatment methods Surgical treatment was performed on all the patients in Study I. The post-surgery rehabilitation included early active rehabilitation according to Kjellby-Wendt and Styf (1998). The sur gical treatment is expected to reduce leg pain and thereafter the post-surgery rehabilitation aims to restore function, such as strength and? The aim of the protocol was to minimise pain and it was conducted with the emphasis on self-management and the empowerment of the patient. However, in patients with lumbar disc herniation, it is often movements in other directions that reduce pain, so-called lateral procedures such as side glide(Figure 8) and rotation in? The patients were instructed to perform exercises several times a day with the aim of reducing the leg pain. The fact that the patients were aware of the effect of different postures and mechanical loads and were able to adjust posture and loads from symptomatic responses was just as important as the exercises. This meant that the patients could decide whether to continue with the exercise or interrupt it until the next meeting with the physiotherapist. Sometimes, it may be necessary to introduce manual techniques performed by the physio therapist in order to produce a reduction in pain. Most patients will then be able to continue with their home exercises several times a day (McKenzie and May, 2003). The aim with the collaboration is to encourage empowerment and give the patients tools to treat themselves. The purpose of graded trunk stabilisation exercises was to improve muscle control. Initially, the stabilisation exercises were home based and performed without any equip ment. Phase 3 Stabilisation training with equipment at the physiotherapy department, weeks 4-9 the training was then scheduled at the physiotherapy department three times a week (Figure 6). In the training, dumbbells, expanders and weight 28 Treatment methods Figure 10: Training program. The low-load muscular endurance exercises were gradually increased in intensity on an individual basis with respect to the patients? reported leg pain and the observed movement con trol and quality. A schedule was used to record the progress in the number of exercises and weights throughout the training period. During the last weeks, the pa tients were encouraged to continue exercising on their own at a gym or to perform some other type of physical training of their own choice. Follow-up visit Four weeks after the completion of the nine-week physiotherapy treatment period, the patients attended a follow-up visit to the physiotherapist. Evaluation methods In this thesis, there are three types of evaluation methods; questionnaires, interviews and assessments of the centralisation phenomenon. Questionnaires All the patients presented in this thesis answered questionnaires, which have been found to be reliable and valid. The questionnaires included descriptive data including age, gender and duration of pain before treatment. Patients in Study I also answered questions about their history of previous disc her niation surgery. The total score is expressed as a percentage, where 0% represents no dis ability. Good reliability and validity have been reported (Fairbank and Pynsent, 2000; Gronblad et al. Each item has a 4-point Likert scale with scoring alternatives ranging from strongly dis agree? to strongly agree. A total sum is calculated after inversion of the individual scores for items 4, 8, 12 and 16. Each category is scored on an 8-point Likert scale whereby the patients estimate how long they believe they would be able to endure the activity, from less than 2 minutes to more than 45 minutes. The total score range is 8-64, with higher scores indicating more positive beliefs.

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Ray B, entering the lens at an increased angle of incidence, is lost through the edge of the lens. A curved lens will exhibit both retardation angle of incidence further, Ray C shows total internal refec and refraction (Fig. The angle of the angle by which the rays are deviated within incidence may increase to the point where the light the glass or other transparent medium is the angle emerges parallel to the surface of the lens beyond of refraction and the ratio of the sine values of the this angle of incidence total internal reflection will angles of incidence (i) and refraction (r) gives a fig occur, and no light will pass through (Fig. The distance glass has a range of values depending on the type, between the optical center of the lens and the princi mostly averaging 1. A lens has an additional Usually, light passing from one medium into pair of points, one either side of the lens, called con another of higher density is refracted towards the jugate foci, and an object placed at one will form a 28 Light microscopy 3 Screen White Object light Real image a Blue R ed Fig. The con adding more lens components, the more expensive jugate foci vary in position as the object is moved apochromat. This apochromatic types are usually overcorrected for is the real image and is formed by the objective lens of longitudinal chromatic aberration and must be the microscope (Fig. Spherical aberration is caused when light rays entering a curved lens at its periphery are refracted Image quality more than those rays entering the center of the lens and are not brought to a common focus (Fig. White light is composed of all the visible spec these faults are corrected by making lenses of differ tral colors and on passing through a simple lens, ent glass components. The latter operate via a transformer and can be adjusted to the intensity required. Condensers Light from the source is directed into the first major optical component, the substage condenser either directly, or via a mirror or prism. B Condensers in microscopes are capable of verti cal adjustment to allow for the varying heights or Objective thickness of the slides and once the correct position A A has been established it should not be moved, as any alteration will change the light intensity and impair the resolution. The screws allow centering Object of the light path which should be routinely checked stage before using the instrument. The diameter of the light beam can be controlled via the aperture dia phragm of the condenser. Adjustment of the iris diaphragm will alter the size and volume of the cone of light focused on the Condenser object. If the diaphragm is closed too much, there is Aperture increased contrast and the image becomes refrac diaphragm tile. Leaving the diaphragm wide open will cause the image to suffer from glare due to extraneous light interference. The correct setting for the diaphragm is when the numerical aperture of the condenser Fig. This is achieved by removing the eye the iris diaphragm should not be closed to piece, viewing the substage iris diaphragm in the reduce the intensity of the light, either use filters or back focal plane of the objective, and closing it down alter the rheostat setting of the lamp transformer. With experience In condensers fitted with a swing-out top lens, the correct setting can be estimated from the image this is turned into the light path when the higher quality. This focuses the light 30 Light microscopy 3 into a field more suited to the smaller diameter of possible from the object, forming a high-quality the objective front lens. This Object stage is expressed as a value calculated by a mathemati this sits above the condenser and supports the glass cal formula. It is perpendicular to the optical path with an index of the medium between the lens and objective, aperture for the light. The stage moves in two direc and the sine of the angle between the optical axis of tions and Vernier scales enable the operator to return the lens and the outermost ray of light which can to an exact location on the specimen. Resolution is the smallest distance between two Objectives dots or lines which can be seen as separate entities the type and quality of the objective has the great and is dependent on the wavelength of the light est influence on the performance of the microscope. The resolving power There may be from 5 to 15 lens elements within the of the objective is its ability to resolve the detail objective depending on the image ratio, type and which can be measured, i. The main task of the objective is tive increases, the resolving power increases but to collect and unite the maximum amount of light working distance, flatness of field and focal length decrease. Achromatic objectives are the most widely used for routine purposes; the more highly corrected apochromats, often incorporating fluorite glass, are used for more critical work, and plan-apo chromats, which have a field of view which is almost perfectly flat, are recommended for photomicrogra phy and cytology screening. Objectives are designed for use with a coverglass protecting the object and a value giving the correct coverglass thickness, usually 0. Apochromats between 40: 1 and 63: 1 require the coverslip thickness to be precise and some are mounted in a correction mount which can be adjusted to suit the thickness of the coverglass used. The body tube and eyepiece Achromatic Apochromatic the image from the objective is formed in the body Fig. The body tube can raphy and more specialized microscopes where an be monocular, binocular or combined with photo image of the light source is focused by the lamp graphic imaging tubes. The image Using the microscope of the field or lamp diaphragm is focused in the object plane and the illumination is even (Fig. The microscope should remain clean and well the illumination must be centered with respect to maintained. Dust, finger prints and other materials, the optical axis of the microscope to prevent poor. Only appropri ate oils should be used on the stage to allow free Occasionally it is preferable, or essential, that movement of the object in two dimensions. Only appropriate cleaning refractive indices close to that of the medium in cloths for the lenses should be used, cleaning any which they are suspended and are difficult to see oil immersion lens after each use. The light source by bright field techniques because of their lack of should be appropriate for the microscope and cen contrast. Dark field microscopy overcomes this by tered if necessary by adjusting the condenser posi preventing direct light from entering the front of tion. The filters used will depend on the type of the objective and the only light gathered is that microscopy. Coarse and fine focusing are achieved reflected, or diffracted by structures within the by moving the top tube and condenser lenses specimen (Fig. This causes the specimen to towards or away from the section on the slide appear as a bright image on a dark background, being careful not to crush the object lens into the the contrast being reversed and increased. When not in use the microscope should field microscopy permits the detection of particles be covered. Many small structures are more easily visualized by dark field techniques, In a standard microscope with an optical tube length although the resolution may be inferior to bright of 160mm, total magnification is the product of the field microscopy. It is particularly useful for spi magnification values of the objective and eyepiece. Thin slides and coverglasses should be possible for a total magnification of 500x being seen used and the preparation must be free of hairs, dirt, by the observer. Illumination Phase contrast microscopy There have been varying approaches to maximize Unstained and living biological specimens have little the illumination within the microscope. Phase contrast overcomes these 32 Light microscopy 3 Diaphragm Object plane Source Condenser Objective Eyepiece a Aperture Object Back focal diaphragm plane plane Collector Source Condenser Objective Eyepiece Field b diaphragm Fig. Objective problems by using controlled illumination with the Direct rays full aperture of the condenser and therefore improv ing resolution. To achieve phase contrast, a microscope requires Specimen modification of the objectives and condenser, the specimen to retard light by between 1? Usually the microscope condenser carries a series of annular diaphragms made of opaque glass with a clear narrow ring which produce a controlled hol low cone of light. A positive phase plate consists of a clear objective: only scattered rays from the edges of structures glass disc with a circular trough etched in it to half within the specimen form the image (dashed lines). The light passing through the Polarized light microscopy 33 E annulus and objective phase plate will require cen D tering. When the hollow cone of direct light from the annulus enters the specimen, some of the cone will pass through unaltered, whilst some rays will C be retarded or diffracted by approximately? The majority of the direct light will pass through the trough in the phase plate, whilst the diffracted rays pass through the thicker clear glass and are further retarded. This is a quick and efficient way of examining unstained paraffin wax, resin and frozen sections, as well as studying living cells and their behavior. B Interference microscopy In phase contrast microscopy the specimen retards some of the light rays with respect to those passing through the surrounding medium. The resulting interference of these rays provides image contrast A but with an artifact called the phase halo.


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