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Smaller adhd medications 6 year old 2.5 ml xalatan overnight delivery, round medications vaginal dryness order xalatan once a day, discrete treatment ind purchase xalatan without a prescription, pigm ented lesions in any species should be considered m etastatic lesions o f a m elano sarcoma medicine xanax purchase xalatan no prescription. Diffuse brow n discoloration (brow n atrophy) throughout the heart in extrem ely old anim als is suggestive o f w ear-and-tear pigm entation (lipofuscin). In any one animal, these may be only one band at either side, or several incom pletely across, attached to the septal wall in this location. If the band extends across the entire wall they usually result in a com plete subaortic stenotic ring, w hich is usually fatal early in life. Ventricular Endocardial Plaques Lim ited alm ost entirely to the left ventricular endocardium are a few to m any (dozens) o f discrete opaque, white, discoid, 5 -1 0 m m plaques o f endothelial proliferation histologically. Their cause is unknow n, but one suggestion is that they are the result o f constant friction effected during systole betw een the septal endocardium and the opposing wall endocardium. Strongylus vulsaris Scarring In the horse, 1-2 cm verm iform plaques, and irregular verm iform m asses on the intim a o f the aortic arch and/or the aortic valve cusps, as well as in the cavity o f the aortic valve cusps them selves (sinuses o f Valsalva) may be single or m ultiple (2-6). When sectioned histologically, they are often m ineralized and pieces o f the causative agent, im m ature Strongylus vul garis, may be found. Elsew here in the heart, irregular pale scars o f con nective tissue m ay be found if the animal is aged, attesting to the chronici ty o f the lesions in the aorta. In young anim als, viable or at least recently living larvae m ay be found anywhere in the entire aorta, from the cranial or caudal m esenteric arteries back to the arch o f the aorta, even right into the ventricular endo cardium. This indicates larval m igrations from the bowel, along with m in imal to m arked thickening and throm bosis with larvae in the lumen, called verm inous endarteritis. Aortic Valve Friction Lesions In the horse, aortic valve friction rubs are a very com m on le sion on the aortic valve cusps near the free edges and are found as paired 2 -3 m m nodules o f scar tissue. They occur about equally distant from the valve attachm ent site and are apparently caused at the sites o f the valves rubbing together at closure. These are to be differentiated from nodules o f Arantius, which are single nodules in the center o f each aortic cusp edge that are norm al structures the kissing lesion, while com m only m istaken for strongyle larval granulom as, are not related to parasites. Pericardial Fibrovascular Proliferation Red, soft, fibrillar, highly vascular tissue in strands and plaques, at tached to the tissues o f the base o f the heart and nearby m ajor vessels w ithin the pericardial sac, are very com m on in the horse and cow and are called fibrovascular proliferations. The cause is suspected to be m in imal friction reaction, as alm ost no inflam m atory cells are present histo logically. M ost cases are not clinically important, but some m ay becom e m ore extensive and even be a source o f severe hem orrhage pericardially, w ith fatal tam ponade resulting. A trial Diverticuli M ultiple (5-20) pale to red, round, 1-5 m m blebs o f atrial tis sue, lined up along the free edges o f both left and right atria are called atrial diverticuli and are com m on findings in the horse and ox. They consist o f thin w alls o f atrial m uscle and connective tissue filled w ith blood in the red ones, and clotted blood in the paler ones. They m ay be found collapsed and slightly inverted w hen the blood pressure drops at death. In a recent retro spective study, 19 o f 21 cases in dogs that had these atherom atous deposits in their vessels also had diabetes m ellitus. This lesion m ay be found in ju st about any species w ith diabetes and is very com m on in man. They are opaque, pale, white plaques or strands o f very thin (less than 1 m m) tissue on the intim a o f the arch o f the aorta, but also the tho racic aorta. Grossly, the m aterial can be elevated by knife point and peeled o ff w ith no underlying lesion to be noted. This is not fatty m aterial o f any type, and is considered only an aging change in older dogs. Pvogranulom atous M yocarditis and Pericarditis M ultiple, various-sized areas o f purulent inflam m ation may be found in and around the heart and inside the pericardium. Some m ay have pus, and there m ay even be some with m ultiple, fibrinous adhesions o f the heart to the sac. M any granulom as m ay also be found scat tered in the m uscle throughout the heart, from the purulent thrombi on or near the aortic cusps and adjacent coronary arteries. In any species, m any different agents are potentially capable o f causing these septic em boli to the m yocardium. W P 1636, 1645, 1719 Ox/Cow: Such lesions are com m on with traum atic pericarditis. Dog: the fungal agent Aspergillus terreus is a com m on cause o f this entity in G erm an shepherd dogs, specifically. H em orrhages o f the H eart Small (pinpoint) to larger (ecchym otic, or even diffuse, hem or rhages scattered on the epicardium, endocardium, or even w ithin the heart m uscle, are usually only an artifact seen w ith dying, probably in part from term inal anoxia. Pools o f blood m ay suggest a bleeding problem in any species, but again caution is advised in their inter pretation. In a busy necropsy room over the years, m aybe only one or two cases o f significance have been seen. W P 1631 Pig: Streaked hem orrhages and pale heart m uscles together m ay be helpful in the diagnosis o f m ulberry heart disease associated with vitam in E/Se responsive disease. Thebesian V essel-R elated Scarring Thebesian vessel-related scarring occurs com m only in the horse only, and is characterized by: 1. The pathogenesis o f these Thebesian lesions have been suggested asso ciated w ith its name, that the right atrium has no m ajor nutrient artery, only the tiny vessels, the Thebesian arterioles, com ing from the lumen directly. These tiny vessels m ay not be able to supply enough oxygen and nutrition under certain cardiac m uscle conditions such as a heavy workload, and the fibers degenerate and are replaced by fat or connec tive tissue. The use o f Klotz solution is recom m ended for short-term storage for dem onstration purposes. Chloral hydrate is a controlled substance, expensive, and harder to obtain, so citric acid may be used (less satis factorily) instead. Too m uch form alin will darken and stiffen the tis sues one is trying to save for demonstration. L Latin derivation G r G reek derivation -an L-without, not arthro Gr-joint ab L-from -ase L-enzym e acro G r-extrem ity auto G r-self ad L-to bi L-two adeno Gr-gland bio Gr-life adipo L-fat blast Gr-germ, bud ala-i L-wing bothri Gr-pit alb-i L-white brachi Gr-arm -algia Gr-pain brady G r-slow am bi L-both brevis L-short amphi Gr-both caec L-blind amyl L-starch capit L-head an G r-without, not card Gr-heart ana Gr-up cata Gr-down ankylo Gr-bent cer G r-hom ante L-before cervix L-neck anti Gr-against chlor Gr-green aqua L-w ater choan Gr-fimnel archi Gr-first chrom G r-color 224 chyl Gr-juice dys Gr-bad, ill chym Gr-juice ectasis Gr-dilated clast Gr-to break ecto gr-outside coel Gr-hollow ella,us L-dim inutive collum L-neck -em ia Gr-blood conch Gr-a shell endo Gr-within com L-hom ento Gr-within cortico L-bark enero Gr-intestine cruci L-cross erythro Gr-red crypt Gr-hidden ex L-out cten Gr-comb extra L-beyond cyan Gr-dark blue fenestra L-window cyn Gr-dog fer L-to carry, bear cyt Gr-cell, hollow flav L-yellow de L-down, from fiig(s) L-flee dent L-tooth gamo Gr-m arriage derma Gr-skin gastro Gr-stom ach di Gr-double -gen Gr-to produce dia Gr-through -glia L-glue diplo Gr-double glossi Gr-tongue dis L-down, from glyco Gr-sweet, sugar duo L-two gnath Gr-jaw dura L-hard -gogue Gr-leading duct L-convey gon Gr-angle-seed 225 graph Gr-to write lepto Gr-thin haem o Gr-blood leuco Gr-white hemi G r-half lemma Gr-skin hepta G r-liver lingua L-tongue hetero Gr-different lipo Gr-fat hex Gr-six lith Gr-stone hippo Gr-horse -logy Gr-discourse histo Gr-tissue -lysis Gr-divide, destroy homo Gr-sam e macro Gr-large horm Gr-to excite m acula L-spot hyalo Gr-glassy, clear mal L-bad, ill hydro G r-water m ast Gr-breast hym en G r-m em brane medi L-m iddle hypo G r-under m ega Gr-large in L-not, w ithout m es Gr-m iddle in-en L-into m eta Gr-change, beyond inter L-between -m eter L-m easure intra L-within m icro Gr-small iso Gr-equal mono Gr-single -itis L-inflam m ation m orph Gr-form lact L-milk m orti L-death lacun L-pit, lake myi Gr-fly lamin L-layer, plate myo Gr-m uscle leio Gr-sm ooth m yelo Gr-m arrow 226 myxo Gr-m ucus, slime opisth Gr-behind necro Gr-dead or-, os L-m outh nemo Gr-thread orchi Gr-testicle neo Gr-new ortho Gr-straight nephro Gr-kidney -ose L-sugar neuro Gr-nerve ossi L-bone nid L-nest osteo Gr-bone nigr L-black osti L-door noct Gr-night ot(o) G r-ear noto Gr-back oxy Gr-sharp nucleus L-nut pachy Gr-thick nud L-naked palaeo Gr-ancient nyssus Gr-to prick pan Gr-all oct L-eight par L-to beget odont Gr-tooth para Gr-beside oid Gr-like pariet L-wall olig Gr-few ped L-foot -om a Gr-tum or penta Gr-five -om m a Gr-eye peri Gr-around ophalo Gr-navel petro Gr-stone oneh Gr-barb phago Gr-to eat 00 Gr-egg phil Gr-loving opercul L-a cover phlebo Gr-vein ophthalm Gr-eye phon Gr-voice, sound 227 phot Gr-light ptero Gr-wing phyll G r-leaf ptyi Gr-saliva phyto Gr-plant pulic L-flea pia L-tender pulm o L-lung plasm Gr-form ed pupa L-baby platy Gr-flat pyl Gr-gate pleo Gr-m ore pyo Gr-pus pleuro Gr-side pyn L-pear pneum on Gr-lung quadr L-four pneum o G r-air rachi Gr-spine pod(i-o) Gr-foot ram(i) L-branch p iy Gr-m any re L-again pons L-bridge rect L-straight porta L-gate ren-(i) L-kidney post L-after ret-(a-i) L-net pre L-before rhabdo Gr-a rod pro Gr-before rheo Gr-to flow proct Gr-anus rhino Gr-nose proto Gr-first rhizo Gr-root psalter Gr-book rhyncho Gr-snout pseudo Gr-false rostri L-beak psor Gr-itch rum in L-throat psych Gr-breath, soul sagitta L-arrow psyll Gr-flea salpi Gr-trum pet 228 sarco Gr-flesh squam L-scale sapro Gr-putrid stat Gr-standing scalar L-ladder stell L-star schizo Gr-cleft steno G r-narrow sclera Gr-hard stereo Gr-solid scoli Gr-bend sterco Gr-dung, feces -scope Gr-see stetho G r-breast scut L-a shield stigmo Gr-point seb L-tallow stoma Gr-mouth sect L-to cut strati Gr-layered sella L-saddle strepto G r-tum ed semi L -half stria L-furrow ed sept L-a wall strongylo Gr-round septic L-putrid stylo L-colum n serra L-a saw sub L-under seti L-bristle super L-over sialo Gr-saliva supra L-above siphon Gr-tube sym G r-together siphuncal L-sm all tube syn G r-together soma Gr-body syringo Gr-pipe somn L-sleep tachy Gr-rapid sperm Gr-seed tact L-touch spheno Gr-wedge taen Gr-ribbon splanchno G r-viscera ov(i) L-egg 229 tapet L-carpet trop G r-tum ing tel Gr-far, end trophy G r-nutrition tenui L-thin trypano Gr-an auger terato G r-m onster tum or L-sw elling tetra G r-four tunic L-a garm ent thalam G r-cham ber tym pano Gr-a drum theco Gr-case, covering tyro Gr-cheese theli Gr-nipple ultra L-beyond therio Gr-beast unci L-hook therm o Gr-heat -uncula L-little throm b Gr-clot unguli L -hoof thyro Gr-door, shield uni L-one thysan Gr-fringe uro Gr-urine tok G r-birth vaso L-vessel tom o Gr-to cut ven L-vein toxo Gr-poison ventr L-belly trabecul L-a small bean vermi L-worm tracheo G r-w indpipe vesicul L-blister trachy Gr-rough via L-way trem at Gr-hole villi L-shaggy tri Gr-three vita L-life tricho G r-hair vitr L-glassy troch Gr-pulley vivi L-alive trom bid Gr-timid vora L-to devour 230 xantho G r-yellow zoo Gr-life, anim al xero G r-dry zygo Gr-yoke xylon G r-wood zym Gr-ferm ent L Latin derivation G r G reek derivation 231 Ancillary Testing from the Necropsy Table these testing techniques are intended to be sim ple and relatively easy procedures to follow or even precede the actual necropsy at the nec ropsy table. They have been used over the last 50 years by the authors and have proven useful for gaining additional inform ation to aid or com plem ent the diagnoses. Certainly not all necropsy facilities will have the equipm ent dis cussed in these procedures, but m aybe because o f their proven value they m ay be obtained in each laboratory w ith time. Alan Woolf, Southern Illinois University, Carbondale, Illinois W eighing o f the carcass: Scales are available m ost everyw here ex cept not in less accessible locations including jungles, forests, etc. Even at less w ell-equipped necropsy facilities this technique can be m odified for use as needed. O ur initial use has been to w eigh adult m oose, bears and caribou in a research project in N ew foundland under the auspices o f Dr. Stuart Peters, the D irector o f W ildlife, N ew foundland, in determ ining the cause o f severe die-offs o f caribou calves there. The pine forests there supplied the 9 -1 0 foot straight poles, three o f which, cleared o f branches, w ere used to construct a tripod tied at the top w ith very strong nylon parachute cord. A double piece o f cord hung down from the apex about 12 inches as an open loop through w hich a fourth cleared pole was inserted into its approxim ate equilibrium position. The long, thin end o f the pole also has a larger loop o f the sam e cord loosely hung over this pole in order to pull the longer lever arm portion down, allowing a know n weight, usually the pathologist or biologist, to step into the loop. This allowed the loop to be m oved closer to or further from the fulcrum to achieve balance. A lm ost any tall enough structure could be used as the fulcrum, even a stout branch o f a standing tree. Even weighing each other researcher with this technique was never m ore than 3-5 pounds off by actual scale comparison. In the postm ortem room, it is often w anted to have a rapid answ er to the question, Were the nervous signs seen in this animal the result o f an infection, or possibly due to the often com m on effect o f a m etabolic disease, as w ith fever or grass tetany, by w hich this sim ple test for excess protein w ould be helpful differentially. The phenol crystals will dissolve and when allowed to cool, the upper layer o f clear fluid will be supersaturated phenol test solution, while the darker fluid at the bottom is the liquified phenol itself. A black or at least a dark back ground will help in visualizing the opaque w hite positive protein denatur ation change. Rabies and listeria will alw ays be positive and should be considered if it is positive.
Tuberculosis is diagnosed in an individual with infection who also has signs medications after stroke cheap xalatan 2.5 ml with amex, symptoms treatment juvenile arthritis buy xalatan 2.5 ml amex, positive cultures medicine plus purchase generic xalatan canada, or radiographic manifestations of M tuberculosis treatment mastitis order genuine xalatan line. Isolation of M tuberculosis by culture from early morning gastric aspirate, sputum, pleural fluid, or other body fluids establishes the diagnosis of active dis ease. Mycobacterium tuberculosis is slow growing, usually requiring 2?10 weeks for isolation from cultured materials. Smears to demonstrate acid-fast bacilli should be performed on sputum and body fluids. Latent tuberculosis infection is defined by a positive Mantoux tuberculin skin test or interferon-gamma release assay in an individual with no physical findings of disease and either a normal chest X-ray or only granuloma or calcifi cation in the lung parenchyma, or regional lymph nodes, or both. The purpose of treating latent tuberculosis infection is to prevent progression to disease. When the result of a tuberculin skin test or interferon-gamma release assay is positive, the time of conversion usually is not known. If a chest X-ray is normal, some experts prefer to delay treatment of latent tuberculosis infection until after delivery because preg nancy itself does not increase the risk of progression to disease and because of an increased risk of drug-induced hepatotoxicity during pregnancy and immediately postpartum. Although isoniazid is not known to be teratogenic, most experts recommend waiting to start therapy until the second trimester of pregnancy. Treatment regimens for tuberculosis are based on the presence or absence of tuberculosis disease, primarily determined by chest X-ray findings and sputum culture and, in the absence of disease, the likelihood of progressing to disease. For this reason, the recommended medication in women known to have converted within the previous 2 years (such as known contacts of other tuberculosis cases) but with no evidence of disease is isoniazid (300 mg per day) starting after the first trimester and continuing for 9 months. All pregnant women receiving isoniazid also should take pyridoxine (50 mg daily) to mitigate the risk of peripheral neuritis. If tuberculosis is diagnosed in a pregnant woman (by positive cultures, com patible clinical findings, or X-ray findings), prompt, multidrug therapy is rec ommended to protect both the woman and the fetus. Isoniazid and rifampin, supplemented initially by ethambutol are recommended drugs. Pyrazinamide frequently is used for the first 2 months in a three-drug or four-drug regimen. Although safety data in pregnancy have not been published, many experts have used the drug in pregnant women with no apparent problems for the woman or the fetus. Therapy with isoniazid and rifampin is continued for at least 6 months for drug-susceptible disease. Neonatal Management In utero infection can occur as a result of hematogenous dissemination, which seeds the placenta; or as a result of aspiration of infected amniotic fluid in utero. Neonatal infection may occur at the time of delivery as a result of aspiration of 426 Guidelines for Perinatal Care tubercle bacilli in women with tuberculosis endometritis. On the rare occasions in which congenital tuberculosis is suspected, diagnostic evaluations and treat ment of the infant and the mother should be initiated promptly. Management of a newborn whose mother (or other household contact) is suspected of having tuberculosis is based on individual considerations. The mother has a positive tuberculin skin test or interferon-gamma release assay result but a negative X-ray result. If the mother is asymptomatic, the infant needs no special evaluation or therapy and no separation of the mother and the infant is required. Because the tuberculin skin test or interferon-gamma release assay result could be a marker of an unrecog nized case of contagious tuberculosis within the household, other house hold members should be tested and have further evaluation, as needed. The radiographic abnormality in this cir cumstance probably is because of another cause or because of a quies cent focus of tuberculosis. In the latter case, the mother may develop contagious, pulmonary tuberculosis, if untreated, and should receive appropriate therapy if not treated previously. The mother should be reported immediately to the public health department so that investigation of all household members can be per formed within several days. All contacts should have a tuberculin skin test or interferon-gamma release assay, chest X-ray, and physical exami nation. The mother and the infant should be separated until both are receiving appropriate therapy and the mother is deemed to be not contagious. Women with tuberculosis disease who have been treated appropriately for 2 or more weeks and who are not considered contagious can breastfeed. If congenital tuberculosis is excluded, isoniazid is given until the infant is 3?4 months of age, at which time a tuberculin skin test should Perinatal Infections 427 be performed. If the tuberculin skin test result is positive, the infant should be reassessed for tuberculosis disease. If the skin test result is nega tive and the mother and other family members with tuberculosis have good adherence and response to treatment, and are no longer infectious, isoniazid may be discontinued. Because the response to the vaccine in infants may be delayed, the infant should be separated from the ill family member for at least several weeks after vaccination. In general, in the United States directly observed therapy of the infant is preferred. An expert in childhood tuberculosis should be consulted when this is a consideration. Breastfed infants of women taking isoniazid therapy should receive a multivitamin supplement, including pyridoxine. Bacille Calmette?Guerin vaccine is a live vaccine prepared from attenuated strains of Mycobacterium bovis. Acquired 428 Guidelines for Perinatal Care syphilis almost always is contracted through direct sexual contact with ulcer ative lesions of the skin or mucous membranes of infected people. Congenital syphilis most often is acquired through hematogenous transplacental infection of the fetus, although direct contact of the infant with infectious lesions during or after delivery also can result in infection. Transplacental infection can occur throughout pregnancy and at any stage of maternal infection. Antepartum Management All pregnant women should be serologically screened for syphilis as early as possible in pregnancy. False-negative serologic test results may occur in early primary infection, and infection after the first prenatal visit is possible. For communities and populations with a high prevalence, serologic testing also is recommended at 28?32 weeks of gestation and at delivery (as well as after exposure to an infected partner). Microscopic dark-field and histologic examinations for spirochetes are most reliable when lesions are present. Pregnant women with syphilis should be treated with a penicillin regimen appropriate to the stage of infection. Women who are allergic to penicillin should be desensitized and then treated with the drug. Erythromycin and azithromycin are suboptimal treatment options because neither reliably cures maternal infection nor treats an infected fetus. Women should be observed for signs of a Jarisch Herxheimer reaction (an immune response to toxins released when spirochetes die), which may cause fever, nonreassuring fetal status, and preterm labor. Women with syphilis should be queried about illicit substance use, espe cially cocaine. Management decisions are based on the three possible maternal situations: 1) maternal treatment before pregnancy, 2) adequate maternal treatment and response during pregnancy, or 3) inad equate maternal treatment or inadequate maternal response to treatment (or reinfection) during pregnancy. The dosage should be based on chronologic age rather than gestational age and is 50,000 units/kg, intravenously, every 12 hours (for infants 1 week of age or younger) or every 8 hours (for infants older than 1 week). Alternatively, procaine penicillin G, 50,000 units/kg, intramuscularly, can be administered as a single daily dose for 10 days; no treatment failures have occurred with this formulation despite its low cerebrospinal fluid concentrations. Algorithm for evaluation and treatment of infants born to mothers with reactive serologic test results for syphilis. For example, a titer of 1:64 is fourfold greater than a titer of 1:16, and a titer of 1:4 is fourfold lower than a titer of 1:16. If a single dose of benzathine penicillin G is used, then the infant must be fully evaluated, full evaluation must be nor mal, and follow-up must be certain. When possible, a full 10-day course of penicillin is preferred, even if ampicillin initially was provided for pos sible sepsis. Use of agents other than penicillin requires close serologic follow-up to assess adequacy of therapy. Infants who have a normal physical examination and a serum quantitative nontreponemal serologic titer either the same as or less than fourfold (eg, 1:4 is fourfold lower than 1:16) the maternal titer are at minimal risk of syphilis if they are born to mothers who completed appropriate penicillin treatment for syphilis during pregnancy and more than 4 weeks before delivery, and if the mother had no evidence of reinfection or relapse. Although a full evaluation may be unnecessary, these infants should be treated with a single intramuscular injection of penicillin G benzathine because fetal treatment failure can occur despite adequate maternal treatment during pregnancy. Alternatively, these infants may be examined carefully, preferably monthly, until their nontrepone mal serologic test results are negative.
No clinical trials have been performed using cervical traction to medicine 5113 v discount xalatan 2.5 ml with visa treat cervicogenic headache symptoms dehydration purchase 2.5 ml xalatan with amex, but two case studies suggest that cervicogenic headache can be treated successfully with traction treatment 2nd degree heart block buy 2.5 ml xalatan. Using 25 to medicine 2015 cheap 2.5 ml xalatan visa 30-lb home traction and cervical exercise, Olson reported success with two dif? The cervical exercise consisted of postural correction and stabilization exercises. It is generally advisable to use a cervical traction system that pulls from the occiput, rather than placing pressure on the chin. If the patient has known temporomandibular dysfunction, a chin halter should never be used. Cervical traction studies show that narrowing of the intervertebral spaces can actually occur during the traction treatment in patients who are unable to relax. While it is true that posterior separation does increase with more flexion, anterior separation decreases with flexion. In most cases, clinicians should try to achieve a combination of a posterior and anterior stretch. Thus the ideal traction device will flex the head and neck somewhat, but pull at a relatively flat angle. Herniated disk is usually treated more effectively in static mode or with longer hold-rest periods (3 to 5-minute hold, 1-minute rest) in intermittent mode. Joint dysfunction and degenerative disk disease usually respond to shorter hold-rest periods (1 to 2-minute hold, 30-second rest) in intermittent mode. As the disk space widens, the intradiskal pressure decreases, causing the herniated disk material to be retracted into the disk space. The decrease in pressure is temporary, however, because eventually the decreased intradiskal pressure will cause fluid to be imbibed into the disk. When pressure equalization occurs, the suction effect on the disk protrusion is lost, and it is possible for patients to experience a sudden increase in pain when traction is released. Four reviews summarizing lumbar traction studies have concluded that there is no signi? Some of the studies that showed lumbar traction was ineffective were performed with low forces. Most studies tended to group all patients with low back pain together and did not distinguish between subgroups or by diagnosis. In our experience, disk herniation is most effectively treated with the patient lying prone with a normal lordosis. However, this position is not always possible because the patient with acute herniated disk may not tolerate any position of normal lordosis. Foraminal (lateral) stenosis is usually more effectively treated with the lumbar spine in a flexed (flattened) position initially, with the goal of achieving a neutral lordosis when possible. Soft tissue stiffness/hypomobility and degenerative disk or joint disease may be treated in neutral position or some degree of flexion or extension, depending on the goals of treatment. Colachis S, Strohm M: Cervical traction: relationship of traction time to varied tractive force with constant angle of pull, Arch Phys Med 46:815-819, 1965. Colachis S, Strohm M: A study of tractive forces and angle of pull on vertebral interspaces in cervical spine, Arch Phys Med 46:820-830, 1965. Constantoyannis C et al: Intermittent cervical traction for cervical radiculopathy caused by large-volume herniated disks, J Manipulative Physiol Ther 25:188-192, 2002. Franks A: Temporomandibular joint dysfunction associated with cervical traction, Ann Phys Med 8:38-40, 1967. Harris P: Cervical traction: review of literature and treatment guidelines, Phys Ther 57:910, 1977. Hattori M, Shirai Y, Aoki T: Research on the effectiveness of intermittent cervical traction therapy using short-latency somatosensory evoked potentials, J Orthop Sci 7:208-216, 2002. Komori H et al: the natural history of herniated nucleus pulposus with radiculopathy, Spine 21:225-229, 1996. Moetti P, Marchetti G: Clinical outcome from mechanical intermittent cervical traction for the treatment of cervical radiculopathy: a case series, J Orthop Sports Phys Ther 31:207-213, 2001. Olson V: Case report: chronic whiplash associated disorder treated with home cervical traction, J Back Musculoskel Rehabil 9:181-190, 1997. Olson V: Whiplash-associated chronic headache treated with home cervical traction, Phys Ther 77:417-423, 1997. Onel D et al: Computed tomographic investigation of the effect of traction on lumbar disc herniations, Spine 14:82-90, 1989. Philadelphia Panel Evidence-Based Clinical Practice Guidelines on Selected Rehabilitation Interventions for Low Back Pain, Phys Ther 81:1641-1674, 2001. Saal J et al: Nonoperative management of herniated cervical intervertebral disc with radiculopathy, Spine 21:1877-1883, 1996. Yates D: Indications and contraindications for spinal traction, Physiotherapy 58:55, 1972. Swing limb advancement 119 120 Special Topics During weight acceptance, body weight is accepted onto the limb that has just completed swinging forward. The limb must absorb shock arising from the abrupt transfer of body weight, while remaining stable and allowing continued forward progression of the body. During single limb support, only the stance limb is in contact with the ground, and the limb must remain stable while allowing continued forward progression of the body over the foot. Swing limb advancement includes the phase when weight is being transferred from the reference limb to the opposite limb as well as the entire reference limb swing period. Describe the key motions and muscular activity patterns at the ankle, knee, and hip during weight acceptance. At the beginning of weight acceptance, the ankle is positioned in neutral, the knee observationally appears to be fully extended (it is actually in 5 degrees of flexion), and the hip is flexed approxi mately 20 degrees (relative to vertical) in the sagittal plane. During weight acceptance, as the foot positions itself flat on the ground, the ankle moves into 5 degrees of plantar flexion, controlled by eccentric activity of the dorsiflexors. The knee moves into 15 degrees of flexion, controlled by eccentric activity of the quadriceps. The knee moves from 15 degrees of flexion to what observationally appears to be full extension (actually 5 degrees of flexion by motion analysis), in part as a result of concentric activity of the quadriceps (early single limb support) in combination with passive stability achieved when the ground reaction force vector moves anterior to the knee joint (late single limb support). The hip moves from 20 degrees of flexion to 20 degrees of apparent hyper extension (a combination of full hip extension, anterior pelvic tilt, and backward pelvic rotation), in part as a result of concentric activity of the single joint hip extensors (early single limb support) in combination with passive stability achieved when the ground reaction force vector moves posterior to the hip joint. Describe the key motions and muscular activity patterns at the ankle, knee, and hip during swing limb advancement. Initially, as the more proximal joints begin to flex, the foot remains in contact with the ground and the ankle moves passively into a position of 15 degrees of plantar flexion. Once the foot lifts from the ground, the ankle moves to neutral dorsiflexion owing to concentric activity of the pretibial muscles. The knee initially moves into 40 degrees of flexion (while the foot is still on the ground) primarily as a result of passive forces. As the foot is lifted from the ground, the knee moves into 60 degrees of flexion, owing to concentric activity of knee flexors (biceps femoris short head, gracilis, and sartorius). In late swing, hip flexion decreases to 20 degrees as the hamstrings decelerate further progression of the leg. Movement of the foot into 5 degrees of eversion functions to unlock the midtarsal joints (talonavicular and calcaneocuboid), creating a more flexible foot that is able to adapt to uneven surfaces. As a result, the knee and hip are able to achieve a fully extended position with only minimal muscle activity requirements. Name key factors that are essential to ensure forward progression during the gait cycle. Collectively, the three rockers reflect a combination of joint motions and muscle actions that contribute to the smooth transition of body weight from the heel to the forefoot during stance. A gradual increase in eccentric calf muscle activity allows the tibia to remain stable as body weight progresses in front of the ankle. During weight acceptance, subtalar eversion is important for unlocking the midtarsal joints (calcaneocuboid and talonavicular) and creating a more flexible foot that is able to adapt to uneven surfaces. During single limb support, a reduction in the amount of subtalar eversion (motion toward inversion) functions to lock the midtarsal joints, creating a rigid forefoot lever over which the body weight can progress.
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