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During aging, a hypertrophy of the ligamentum flavum is often observed [12, 72, 125, 156, 160]. This thickening together with a loss of disc height during degeneration causes bulging of the ligamentum flavum and therefore contributes to the narrowing of the spinal canal. All these changes will alter the biomechanics of the spine and can contribute to a compression of neural structures (spinal stenosis) [37, 54]. Aging decreases ligamentous stabilization and can contribute to spinal stenosis Yellow ligament hypertrophy contributes to spinal stenosis 112 Section Basic Science Spinal Muscles Normal Anatomy and Structure Skeletal muscles provide active movement of the articulated skeleton and maintenance of its posture. The basic property of the skeletal muscle is the contractility of its protoplasm (sarcoplasm). The basic structure of the skeletal muscle is the muscle fiber, which is a fusion of many cells. This multinucleated cell can vary in size depending on the function of the muscle. An anterior horn cell in the myelon, its axon, the myoneural junction and the individual muscle fiber is called a "motor unit". The muscles of the trunk and pelvis have a major role in motion as well as dynamic and static stabilization of the spine (see Chapter 2). Postural dorsal (intrinsic) and abdominal muscles (extrinsic) are constantly active in a standing position. In motion, both muscle groups permit equilibrium and control of stability through antagonistic action to each other. Although the effect of intrinsic and extrinsic actions of the muscles was not included in the model of KirkaldyWillis, Goel et al. The presence of muscles also led to decrease in stresses in the vertebral body, the intradiscal space and other mechanical parameters of importance. This observation provided evidence for a neuromuscular feedback system that is compromised by degenerated motion segments. Therefore, trunk muscles not only stabilize the spine but are also affected by degenerative alterations of the spine. Age-Related Changes Age-related muscle degeneration is characterized by:) decrease in size (loss of muscle mass)) fatty infiltration) deposits of connective tissue Loss of muscle mass resulting from a decrease in the number and size of muscle cells appears to be the major cause of this change. Starting at the age of 25 years, skeletal muscle mass declines at a rate of 3 8 % per decade until the age of 50 years; thereafter the rate of decrease increases to 10 % per decade [89, 90]. This age-related loss of muscle mass, also called sarcopenia, is thought to be caused by immunological and hormonal changes that occur with increasing age . Interestingly, the factors found to be involved in sarcopenia vary between genders. Although several studies found a correlation between fat deposits in paraspinal muscles and the occurrence of low back pain, it is not yet clear if muscle atrophy, determined by higher amounts of fat, causes low back pain, or if muscle atrophy is a sequela to muscle disuse due to chronic low back pain [65, 91, 109]. This age-related loss of muscle mass might compromise the stabilization of the spine by disrupting the balanced antagonist action of extensor and flexor muscles. The resulting imbalance, together with age-related alterations in other parts of the spine, might cause conditions such as degenerative scoliosis and may be a starting point for progressive disorganization of the spine . One example of destabilization of the spine due to muscle loss is known as progressive lumbar kyphosis. This condition is believed to be caused by a non-specific myopathy of the paraspinal muscles resulting in a forward flexion of the trunk. Although denervation was also seen in asymptomatic controls, the authors suggest that paraspinal denervation might play a role as a cause or exacerbator of the degenerative cascade described by Kirkaldy-Willis (see Chapter 19). However, often the musculoskeletal system is able to compensate for muscular degeneration and restore stabilization of the spine. In this study, no correlation was found between isometric strength of the muscles and their cross-sectional area. Symptomatic patients with muscle degeneration did show better strength testing than asymptotic patients with an identical degree of muscle degeneration.
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Normally, the ductus narrows and closes shortly after birth to form the ligamentum arteriosum. The apex (lower left ventricle) of the heart lies in the left midclavicular line at the fifth intercostal space. Its forceful contraction as it pumps blood into the aorta and systemic circulation is easily heard over this area. The left brachiocephalic vein passes across the trachea and is very near the sixth cervical vertebra; moreover, in a young child it can lie above the level of the manubrium of the sternum. A tracheotomy is made below the cricoid cartilage and thyroid gland and just superior to this vein at about the level of the C6 vertebra. The posterior interventricular branch supplies the remainder of the interventricular septum. The shunting of blood from the left to right ventricle results in right ventricular hypertrophy and pulmonary hypertension. The first heart sound is made by the closing of the two atrioventricular valves (tricuspid and mitral valves). The sternal angle is a good landmark for determining the level of the tracheal bifurcation, the location of the aortic arch, and the articulation of the second ribs with the sternum. The second pair of arches largely disappears (it forms the small stapedial artery of the middle ear); the third pair forms the common carotid arteries and a small proximal portion of the internal carotid artery; the right fourth arch forms the brachiocephalic trunk and proximal right subclavian artery; the fifth pair disappears; and the sixth pair forms the proximal pulmonary arteries and, on the left, the ductus arteriosus. It is located at the T10 vertebral level as the esophagus passes through the diaphragm. Other resistance points include the pharyngoesophageal junction, the area posterior to the aortic arch, and the area posterior to the left main bronchus. The middle cardiac vein parallels the inferior (posterior) interventricular coronary artery and drains into the large coronary sinus, which drains into the right atrium. The needle usually is inserted, with ultrasound guidance, in the left fifth intercostal space just to the left of the sternum. In emergencies, if echocardiography is not available, a subxiphoid approach is used just between the xiphisternum and the left costal margin. The horizontal fissure of the right lung courses along the path of the fourth rib. Both lungs possess an oblique fissure, but only the right lung has a horizontal fissure and three lobes; the left lung has two lobes. This duct returns lymph from three quarters of the body to the venous system at the junction of the left internal jugular vein and left subclavian vein where they form the proximal left brachiocephalic vein. Although sympathetic fibers relax the smooth muscle of the tracheobronchial tree (allowing for increased respiration associated with the fight-or-flight response), postganglionic parasympathetic fibers constrict this smooth muscle and, therefore, must be inhibited. The right main bronchus is more vertical and shorter and wider than the left main bronchus, so most (but not all! The tertiary bronchus is usually too small for an object as large as a peanut to be aspirated into it. Deep dimpling of the skin results from the tension and retraction of the suspensory ligaments of the breast. The mitral valve is heard downstream from the valve as the turbulent flow of blood carries the sound into the left ventricle. The valve is best heard near the apex of the left ventricle, which is at about the fifth intercostal space and to the left of the sternum. In males, this is usually just below the left nipple; in females, the nipple location can vary, depending on the size of the breast. The intercostal muscles are skeletal muscles and are innervated by anterior rami of the spinal nerves, which contain three types of nerve fibers: somatic efferents, somatic afferents, and postganglionic sympathetics. Only the somatic efferent nerve fibers cause contraction of the skeletal muscle, however. Baroreceptors and chemoreceptors associated with the heart are found primarily on the aortic arch. These specialized receptors monitor the blood pressure (baroreceptors), blood pH, and partial pressure of oxygen and carbon dioxide in the blood (chemoreceptors). Cervical and thoracic cardiac nerves contain postganglionic sympathetic fibers that travel to the heart and increase the heart rate and force of contraction. Their preganglionic sympathetic neurons arise in the upper thoracic (T1-T4) intermediate (intermediolateral) gray matter of the spinal cord, and the postganglionic cell neurons are in the sympathetic trunk ganglia (cervical and upper thoracic regions). A tumor pressing on the aortic arch could involve the left vagus nerve as it courses over the arch and gives rise to the left recurrent laryngeal nerve.
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The agency pays for prescriptions using the criteria found in the Prescription Drug Program Medicaid Provider Guide. The agency does not pay for the following radiology services: Bilateral X-rays for a unilateral condition X-rays in excess of three views X-rays that are ordered before the client is examined the agency does not pay podiatric physicians or surgeons for X-rays for any part of the body other than the foot or ankle. A waiver is required when clients choose to pay for a foot care service to treat a condition not listed in the Acute Conditions of the Lower Extremities by Diagnosis table. When billing, the diagnosis code for the acute condition listed in the Acute Conditions of the Lower Extremities by Diagnosis table must be on the service line for the foot care service being billed. Providers must use an appropriate procedure code with the word "pair" in the description when billing for fabrications, casting, or impressions of both feet. Authorization for concurrent/curative services the agency requires authorization for all concurrent/curative care. Community providers must request authorization for these services, including treatment planning, actual treatment, and related medications. Note: See Prior Authorization for the documentation required for prior authorization. Providers must submit a comprehensive treatment plan including any treatment protocols, the estimated timeframe for treatment, and any ancillary services. Once the treatment plan is reviewed by the agency and approved, follow the guidelines in the box on next page if: Additional services are needed. There are additional providers who will be administering care related to the approved concurrent treatment plan. Submit additional information to a request as follows: Go to Document Submission Cover Sheets. In the box, put the Reference (authorization) number from the agency and press enter. Print and attach only the additional information behind the barcode sheet and fax to the number on the bottom of the page. Beginning with dates of service on and after July 1, 2012, physicians/clinical providers also receive enhanced rates for qualified trauma care services provided to managed care enrollees who meet trauma program eligibility criteria. Qualified trauma care services also include inpatient rehabilitation and surgical services provided to Medical Assistance clients within six months of the date of the qualifying injury when the following conditions are met: (a) the follow-up surgical procedures are directly related to the qualifying traumatic injury. The transfer must be to a higher level designated trauma service center, and the transferring hospital must be at least a level 3 hospital. Claims for trauma care services provided to a fee-for-service client must be submitted to the agency. Note: the agency takes back the original payment when processing an adjustment request. Electronic claims get a Julian date stamp on the date received, including weekends and holidays. Paper claims received outside of regular business hours get a Julian date stamp on the following business day. All claims and claim adjustments are subject to federal and state audit and review requirements. The services of some specialists listed above are eligible for enhanced rates only when provided in the context of major trauma care. Dental disease prevention services the agency pays enhanced fees to certified participating primary care medical providers for delivering the following services: Periodic oral evaluations. Dietary counseling: Talk with the parent(s)/guardian(s) about the need to use a cup, rather than a bottle, when giving the child anything sweet to drink. N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N Short Description Drainage of skin abscess Remove foreign body Drainage of hematoma/fluid Debride infected skin Deb skin bone at fx site Deb subq tissue 20 sq cm/< Deb bone 20 sq cm/< Biopsy, skin lesion Biopsy, skin add-on Exc face-mm b9+marg 0. N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N Short Description Intmd wnd repair face/mm Intmd wnd repair face/mm Intmd wnd repair, face/mm Intmd wnd repair face/mm Intmd rpr face/mm 20. The agency contracts with Qualis Health to provide web-based access for reviewing medical necessity for: Outpatient advanced imaging services Select surgical procedures Outpatient advanced imaging Spinal injections, including diagnostic selective nerve root blocks Qualis Health conducts the review of the request to establish medical necessity, but does not issue authorizations. Note: this process through Qualis Health is for Medicaid clients enrolled in feefor-service only. Only the performing provider or facility (site of service) can request the medical necessity review by Qualis Health. Note: Billing entities such as clearinghouses do not request authorization through Qualis Health or the agency.
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A systematic review within the framework of the Cochrane collaboration back review group. A randomized controlled trial of progressive resistance training in depressed elders. Injuries and adherence to walk/jog and resistance training programs in the elderly. Comparison of hemodynamic reponses to cycling and resistance exercise in congestive heart failure secondary to ischemic cardiomyopathy. Resistance-training experience and the pressor response during resistance exercise. Direct measurements of arterial blood pressure during formal weightlifting in cardiac patients. The latter is primarily relevant to team sports, but also other sports where the athletes have close physical contact, before, during or after training and competition. Furthermore, suggestions on guidelines are provided, which primarily pertain to adult individuals, to counselling for healthcare personnel as well as others in the management and counselling of athletes affected by acute infections. Lastly, concrete retraining programmes are proposed after mononucleosis, which can also be used after pneumonia and other powerful infections. Definitions, occurrence and causes the infections that are in question in sports medicine in the Nordic region are caused by viruses or bacteria. They are caused by viruses and are largely complication-free and self-healing, but sometimes bacteria can "take over" and give rise to complications such as sinus infections, ear infections and, in worst case, pneumonia. Sore throats (tonsillopharyngitis) are also most often caused by different viruses, but sometimes it is a matter of an infection by beta-streptococci, which requires antibiotic treatment. It is viral, often has an extended course of disease and requires extra attention with careful follow-up and special advice to athletes. Infections of the heart muscle (myocarditis) can be caused by multiple viruses and bacteria, and like mononucleosis, constitute a special problem area in sports medicine, 9. Acute diarrhoea diseases (gastroenteritis) always give rise to fluid loss, which more or less affects performance capacity. Infections of the skin and soft tissue requiring treatment are more common among athletes than the average population, although it is most often a matter of skin damage, such as scrapes, that seldom obstruct training and competition. The herpes virus causes small blisters on the skin, most often around the mouth, but also in other places. Herpes is not more common among athletes than others, but in contact sports can spread to other athletes. Herpes gladiatorum is classic, where blisters develop at several different places where the skin has been damaged. A borrelia infection in the skin (erythema migrans) is seen among athletes exposed to tick bites. Irritation of the nasal mucous membrane with a running nose and nasal congestion with or without a sore throat are most common as well as bronchitis with coughing and hoarseness in worse colds. Viruses that accumulate in the surface of the mucous membrane (epithel layer) damage it. Bacteria can then more easily gain a foothold and cause complications to the cold such as an ear infection (otitis media) and a sinus infection (sinusitis). A feeling of having an ear blockage, reduced hearing and pain in the ear and, respectively, thick green-yellow mucous and pressure at the base of the nose and cheeks with or without a fever are then common symptoms. With these conditions, anti-inflammatory preparations for the mucous membranes and, as a rule, antibiotic treatment are administered. Bacterial tonsillitis (tonsillopharyngitis caused by beta-streptococci) usually starts abruptly with a fever, often up to 39 degrees, and painful swallowing in contrast to viral throat infections. As a rule, the soft palate and palatal arches are intensively red, usually with elements of skin bleeding (petechiae). Bacteria can be directly indicated with the help of a rapid test or culture from the throat.
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This should be documented since the anesthesiologist has a responsibility to avoid further neurological deterioration during maneuvers such as tracheal intubation and patient positioning. Congenital kyphosis and scoliosis, postinfectious scoliosis, neurofibromatosis and patients with skeletal dysplasias carry an increased neurological risk as well as patients with neurological deficits prior to surgery. Avoid further neurological deterioration during tracheal intubation and patient positioning Perioperative Drug Therapy There is a need to assess the present drug therapy and any history of potential drug allergies. Together with the history and physical examination this will help to decide which drugs should be stopped, continued or added to provide the best possible perioperative conditions. Even on the day of surgery, treatment of systemic hypertension should be continued with antihypertensive drug therapy as usual. It is important that patients under therapy with beta-blocking agents continue to receive their medication to avoid complications that accompany a sudden withdrawal. Therapy with digoxin should be continued perioperatively, but control of serum concentration is recommended in the elderly patient if the renal function is impaired, if patient compliance is doubtful or comedication with. Patients with increased cardiac risk can receive a benefit from prophylaxis (for up to 5 7 days postoperatively) with cardioselective beta-blocking agents such as atenolol, metoprolol and bisoprolol by the blocking of adverse cardiac effects of an activated sympathetic tone. It has been shown that this perioperative medication can prevent perioperative cardiac complications, can reduce the incidence of perioperative ischemic episodes and can improve survival rate up to 2 years postoperatively [26, 47]. Treatment of systemic hypertension should be continued Perioperative prophylaxis with beta-blocking agents is advised in patients with increased cardiac risk 380 Section Long-acting antihyperglycemic drugs should be stopped preoperatively Peri- and Postoperative Management Oral antihyperglycemic drugs should be stopped preoperatively because of potential dangerous hypoglycemic episodes. Long-acting insulins are preferably changed to intermediate- or short-acting insulins that offer better glucose control in the perioperative setting. The use of bronchodilating agents such as q 2-agonists may be of value in optimizing respiratory function preoperatively in patients with chronic obstructive pulmonary disease. Chronic neurotrophic medication with:) tricyclic antidepressants) selective serotonin reuptake inhibitors) lithium, neuroleptic agents) anti-Parkinson drugs should all be continued perioperatively. However, therapy with first generation inhibitors of monoaminoxidase should be interrupted 2 weeks prior to surgery. Patients who have received potentially adrenal gland suppressive doses of steroids. This medication should be continued perioperatively and these patients require careful observation so as not to miss an acute adrenal insufficiency; sometimes they will require perioperative steroid supplementation. Drugs such as penicillamine, methotrexate and azathioprine have immunosuppressant properties and may retard wound healing. In patients with a high spinal cord lesion, or those undergoing fiberoptic intubation, administration of anticholinergic agents such as atropine should be considered. Many patients will have factors which increase the risk of regurgitation and aspiration of gastric contents such as:) high spinal cord injury) recent traumatic injury) stomach ulcers and gastritis) gastroesophageal reflux disease) nasogastric tubes in situ (compromise of the upper esophageal sphincter) In these circumstances, it may be prudent to premedicate patients with a histamine-2 receptor antagonist, a proton pump inhibitor or even sodium citrate . No single drug or dose will accomplish this satisfactorily and it must be decided for every patient what and how much to use. Thromboembolic Prophylaxis the risk of developing a venous thromboembolism increases continuously with aging. While clear schemes do exist for the prevention of venous thromboembolism in orthopedic hip and knee surgery, there is little concordance in spine surgery. If the decision is made to perform antithrombotic therapy for spine surgery, the question arises about the onset and modality. In Europe the initiation of the thromboembolic prophylaxis starts on the preoperative evening with mostly one dose of 0. The second administration takes place about 8 h postoperatively and then is dispensed once daily. In a literature review, taking the levels of evidence into account, the following schedule is proposed [17, 37]: the most effective timing for prophylaxis onset is 2 h preoperatively, but increases the risk of bleeding tremendously. A suggested timing for antithrombotic treatment in spine surgery is to administer 0. In a retrospective review of 1 400 patients whose spines were operated on in our institution, 16 (1.
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The shape of the neural arch changes from L5 S1 to L1L2 and may negatively influence the ability to resist shear at the upper levels. The collagen fibers in the intervertebral disks themselves are poorly oriented to resist shear. If the zygapophyseal joints are removed and the motion segment is subjected to shear loading, the segment will creep to twice the degree compared to that possible with intact zygapophyseal joints (Cyron and Hutton, 1981). More than 20 mm creep possible in severe shear loading with removed zygapophyseal joints, and greater creep are typically seen with more degenerated disks (Cyron and Hutton, 1981). Younger spines (b 30 yrs) may be more susceptible to shear forces due to more elastic disks and incomplete ossification of the neural arch (Cyron and Hutton, 1978). However, the loss of bone mineral content with old age may also lead to an increased propensity for zygapophyseal joint failure. Spinal structures failing in shear Shear loading of the pars interarticularis indicates that this structure can resist approximately 2 kN when subjected to a single load to ultimate stress (Adams et al. Fractures of this sort are often seen in spondylolysis, and shear loading of the spine may be a possible factor in the development of this disorder. Capsule tears and laxity are also likely consequences of shear loading (Beadon et al. A cadaver study on human spines indicated that shear forces are associated with certain patterns of endplate fracture, with increased shear associated with the development of a stellate fracture pattern (Gallagher et al. Lower shear forces tended to result in a depression of the endplate without fracture. Shear tolerance of spinal tissues There appear to be a limited number of studies specifically examining shear tolerance of the human lumbar spine, much of which is older, and which have a somewhat limited number of female specimens. Searches of the PubMed database resulted in 6 and 7 papers to queries "shear fatigue failure spine" and "lumbar spine shear tolerance", respectively, most of which were already contained in the database. However, based on these searches, and examination of reference lists of articles in the database, 2 additional relevant articles were added. Fatigue failure Few studies have looked at the effects of repetitive shear loading on the failure of spinal motion segments. Cyron and Hutton (1978) subjected the inferior articular facets of 74 cadaveric lumbar vertebrae (aged 1480) to cyclical shear loading of 380760 N for up to 400,000 cycles or until failure. The range of the shear loads applied was fairly low compared to the ultimate shear stress limits observed in previous studies, and unsurprisingly the vertebrae were generally able to withstand tens or hundreds of thousands of cycles. Only a few working age specimens (9 out of 50) lasted less than 10,000 cycles, and only three out of fifty lasted less than 1500 cycles. Summary of studies examining the ultimate shear stress of human lumbar motion segments (error bars represent the range of shear tolerance values observed in these studies). Marras / Clinical Biomechanics 27 (2012) 973978 975 human ex vivo specimens using a cyclic shear model. Porcine studies Several investigators have used porcine models to investigate shear tolerance of spinal motion segments. Such studies can have substantial value in terms of understanding the biomechanical properties of spinal columns, especially in terms of loading relationships and their effects on spinal tissues. However, it must also be kept in mind that differences exist in size and shape of porcine spines as opposed to human spines. For example, the cross-sectional area of porcine spines is only about 60% that of human spines. Nevertheless, some have found that porcine specimens possess similar load tolerance values to humans, including shear tolerance (McGill et al. Ultimate shear stress Yingling and McGill (1999b) examined the failure mechanics of porcine cervical spine motion segments (C3C4 and C5C6) under posterior shear loads at load rates of 100 N/s or 10,810 N/s in a flexed or neutral posture tested to failure. The average ultimate load at failure was 2065 N for whole specimens, and slightly (but not significantly) less for specimens without ligaments (1955 N). Predominant injuries from posterior shear loading were avulsions of the endplates. Five fresh functional spinal units (three L6S1 and two L4L5) were subjected to cyclic loading (300600 N for 7200 cycles at 2 Hz), then a combination of the same cyclic load plus a sudden impulse loading (1500 N every 1200 cycles) until a slippage of 15% was achieved.
- Hemihypertrophy in context of NF
- Complex 3 mitochondrial respiratory chain deficiency
- M?llerian duct abnormalities galactosemia
- Markel Vikkula Mulliken syndrome
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- Juvenile cataract cerebellar atrophy myopathy mental retardation
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Insulin stimulates cell proliferation (cell division), inhibits apoptosis (cell death), and impacts the synthesis and availability of sex hormones. The close relationship between physical activity and energy balance thus shows that physical activity levels are related to weight development in a population, and weight gain constitutes a risk factor for a number of cancer diseases (of the colon, breast, kidney, uterus). Physical activity also affects the availability of energy, which again plays a role in the overall ability to repair and control cells. Variation in physical activity is associated with systemic inflammation, which in turn is related to a number of chronic diseases, including cancer. The importance of physical activity for these factors in relation to cancer risk is not clear. The immune system plays a role in the development of cancer with respect to identifying and eliminating unknown components. People with inherited immune diseases and/or congenital immune defects have a higher risk of cancer. An increase in physical activity results, in addition, in an increase to a number of immune system components (monocytes, neutrophils), followed by a reduction of these same factors to below-initial levels that lasts from 13 hours. In the case of continuous physical activity, there is a reverse dose-response relationship between these factors in the immune system and physical activity. The actual importance of physical activity and its effect on the immune system in relation to cancer development has, however, not been established. Physical activity reduces this transit time and thus also the time that intestinal cells are subjected to potentially carcinogenic substances. One randomised controlled intervention study shows that physical activity reduces cell proliferation (cell division) in the colon (10). Physical activity also affects lung function, and improved lung capacity reduces the time that lung cells are in contact with carcinogenic elements in the air. Mechanisms Energy metabolism Blood flow Mechanical transit time stomach-intestine Respiration Heat/trauma Sex hormones Insulin and glucose Effect Fat deposits that store/metabolise carcinogenic elements are reduced, carcinogens are reduced. Reduction of the cumulative levels of hormones that affect the growth of all cell types. Type of cancer All types of cancer All types of cancer Stomach-intestinal cancer Lung cancer All types of cancer Breast, uterine and prostate cancer Colon, breast, pancreatic, oesophageal, kidney, thyroid and uterine cancer All types of cancer All types of cancer Inflammation Immune function Reduces the ability of cells to repair themselves. Measuring physical activity in relation to cancer Different methods are used to measure physical activity in studies relating to cancer (1, 11, 12), which can make comparison difficult. Self-reported measurements like questionnaires and recorded data are often used, though in recent years direct observation and more objective measurements such as heart rate and fitness tests have also been used (1). This data is often linked to validation associated to energy metabolism and metabolic profile, and researchers have later attempted to gain knowledge of the total daily physical activity. The most accurate self-reported measures of physical activity provide information about the type, intensity, frequency, duration and reason for the activity. Calculations like these are important in order to study the doseresponse relationship, a critical value related to specific cancer risk and survival. Another important factor is that the level of physical activity differs in different phases of life and varies over time, which appears to be significant for specific types of cancer. These levels vary between studies and are therefore often related to country, social group, age and gender. The levels of physical activity that form the basis for who is classified as inactive therefore vary between studies. Primary prevention factors Colorectal cancers the relationship between physical activity and the risk for colorectal cancers has been investigated in many observation studies, epidemiological studies in several countries, in both men and women of different ages and ethnic groups. In healthy men and women who engage in regular physical exercise, the risk of colon cancer is reduced by 1070 per cent (1, 5, 1315). A threshold value for physical activity has not been able to be established, but studies indicate that the dose-response relationship is such that the longer the duration and the higher the intensity of physical activity, the higher the protective effect found for colon cancer. Men and women who reported high intensity during three periods of life, and men who burned more than 2500 kcal per week in high intensity physical activity, were shown to be able to cut their risk of developing colon cancer later in life by half (5).
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The studies described below exemplify the effects of physical activity in stroke patients. For further information about the background and effects of fitness training, please refer to subject review articles (17, 18). The effect of muscular training depends ultimately on how well the patient regains motor control. For further information about the background and effects of strength training, please refer to subject review articles (19, 20). Indications Physical activity has a documented primary preventive effect against cardiovascular diseases. This primary prevention of stroke is described in a study on 11,000 American men with an average age of 58. Those who walked 20 km a week were at significantly lower risk of suffering a stroke at follow-up 11 years later (21). Four independent cohort studies show a reverse and dose-dependent relationship between physical activity and the risk of stroke, i. Two other studies revealed a reverse but not dose-dependent relationship between physical activity and the risk of stroke (22). Although the degree of paralysis and sensory disturbances may vary from near normal function to severe disability and significantly reduced mobility, the same principal indications apply to stroke patients as to healthy individuals, i. Since vascular disease is common in stroke patients, the indications for secondary prevention in these people are generally consistent with the indications for these diseases, as well as for diabetes and hypertension. However, scientific evidence showing that physical activity itself has a secondary preventive effect on stroke recurrence is lacking. Prescription At present, there are limited possibilities for continued training once stroke patients have been discharged from a hospital or rehabilitation clinic. Many stroke patients have residual symptoms and find it difficult to keep up with a normal exercise class or other desired physical activity. The risk of feeling dejected and experiencing a lower quality of life due to reduced fitness and strength can easily be avoided by creating opportunities for stroke patients with residual symptoms to continue training. Normal activities that the individual enjoys are recommended, such as walking, climbing stairs, dancing, circuit training, gardening, arm and leg pedaling, training on the exercise bike, walking on the treadmill, wheelchair exercising, group exercise classes and water aerobics. Exercise that can be done with others is both socially and psychologically stimulating. However, the intensity of the training should be adapted to the individual and relevant symptoms. It is important to remember that, along with more organised physical activity/training, 616 physical activity in the prevention and treatment of disease everyday physical activities are also very valuable. If the intensity of the activity is such that the patient is slightly out of breath but can still carry on a conversation, it is quite sufficient for attaining the desired effect and maintain endurance. Using relative heart rate in patients treated with beta blockers may be difficult, however, since beta blockers reduce both maximal heart rate and heart rate during submaximal exercise. According to Еstrand, calculations of maximal oxygen uptake ("aerobic fitness value") based on submaximal exercise testing are also misleading. Measuring the maximal oxygen uptake is usually not possible as motor functions and cardiac limitations, if present, do not allow for maximal exercise testing. Form of training Fitness training Activity Walking Nordic pole walking: Circuit training Ergometer bicycle training Arm/leg cycling Walking on treadmill Step training Water exercises: Dancing Wheelchair driving Weight lifting machines. A concurrent cardiovascular disease may dominate the functional mechanisms of physical activity and training. If no other diseases are present, as in the case of residual lesion following a subarachnoid hemorrhage in younger stroke patients, the functional mechanisms should be identical to those found in untrained healthy individuals of the same age. Skeletal muscle function Strength training facilitates motor unit recruitment and increases discharge rate (23). In order to achieve power, timing and coordination of the muscles stroke patients must be given the opportunity to train at an adequate intensity, frequency and duration. To begin with (68 weeks), the increased muscle strength obtained through physical training is the result of neural adaptation (increased recruitment of motor units, less inhibition, improved coordination, reduced coactivation, etc. Muscle hypertrophy, whereupon muscles cells increase in size, occurs at a later stage.
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If specific restrictions are advised by the surgeon, the patient should be provided with clear and concise instructions. During the first 6 weeks after surgery, lifting more than 5 kg is not encouraged Postoperative Rehabilitation Chapter 22 611 Table 5. If necessary, a supportive pillow is recommended Driving To instruct a patient on how to get in and out of a car. To ensure good compliance and motivation, it is of great importance that the exercises are simple and of short duration. Finally, the home exercise program must be customized in conjunction with the surgeon, based on the surgical procedure, the associated contraindications, and the current functional status of the patient (Tables 6, 7). This can be in the form of group education, brochures and accurate internet web sites. Stretching and strengthening exercises can be intensified and should be performed two to three times a week . In addition, it has been shown that an aerobic exercise program can be beneficial for successful rehabilitation . Depending on the intervention and pain tolerance, the patient should be as active and independent as possible, returning to most of their daily activities. If the postoperative reassessment by the surgeon at 4 6 weeks postoperatively reveals any difficulties or irregularities, the patient is referred to physical therapy. Home exercise program after cervical surgery Exercise Activation of the deep neck flexors Goal To increase the ability of selective deep neck flexor activation Stabilization To facilitate body of the cervical awareness and improve cervical spine posture Stabilization of the cervical spine during movement To facilitate optimal cervical posture in activities of daily living (sit to stand) tion, activity and participation. Moreover, advice on posture, strengthening of impaired muscles and pain-relieving positions and ergonomics is given to the patient. Treatment of a movement disorder focuses on improving hypomobile movement segments and restoring optimal muscle extensibility. Stabilizing exercises with individual focus on the impaired muscle function and postural advice are the main management strategies for a motor control disorder. The rehabilitation program should follow the current guidelines of back and neck pain management in which physical, therapeutic, and recreational exercises are recommended . The continuation of a back- or neck-related home exercise program should be encouraged, with an emphasis on neck and trunk flexibility and strength. Aerobic conditioning should also be encouraged as the benefits to the entire body are evident . Extensive evidence exists legitimizing the need for activity as compared to rest, although to date it remains unclear whether any specific type of exercise is more effective than any other . Physical Rehabilitation Training If a patient still has deficits in function, activity or participation at 3 months postoperatively, a physical rehabilitation program can be started. This rehabilitation program should be performed two to three times a week and continuously intensified . The standard program progresses according to the following stages:) proprioception) strength endurance) acceleration/deceleration training Physical rehabilitation consists of coordination, strength endurance and acceleration/deceleration training Proprioception is trained first in a motor learning approach to improve muscle coordination. This stage of the training will last 3 6 weeks on average and is underloaded, which means the patient can perform the training without fatigue in the target muscles. The strength endurance stage is then reached and the patient will progress until they can perform 8 14 repetitions under load while provoking fatigue in the target muscles. Once the patient can perform the exercises with the required weight for two to three consecutive trainings, the program is progressed to the next stage. Acceleration and deceleration training, which differ from strength endurance training in the rhythm of the performance, is the next stage of the training. Return to Work Return to work is key in postoperative rehabilitation the return to work is not closely correlated with the extent of the intervention. On the contrary, confounding factors seem to play an even more important role [9, 26]. The rate of resumption of heavy work is difficult to determine and will be dictated by the surgeon with consideration of the operative procedure and the degree of postoperative soft tissue and bony alterations. Home exercise program after lumbar surgery Exercise Dead lift Goal To stabilize the trunk during bending activities Progression: dead lift in extension Front press To stabilize the trunk during upper extremity movements Bent over barbell row To stabilize the trunk in an inclined position 616 Section Degenerative Disorders Table 8. It has been found that different factors may influence the time to return to recreational activities. It is suggested that patient motivation influences recovery from spinal surgery and return to recreational activities . Limited data assist with decision-making for return to sport after (thoraco-) lumbar fusion .
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The beam should be collimated to the smallest possible size which will demonstrate the area of clinical interest. Gonad shielding should be employed when it will not obliterate the structures under examination. The fluoroscopic image should be recorded on videotape or other appropriate medium to enable the chiropractor to review the study without requiring excessive repetition of a given movement. Chiropractors performing videofluoroscopic studies should have training in fluoroscopic technique and interpretation. Machine selection: General guidelines provide for the use of recently manufactured equipment which is capable of low dose image acquisition. Shielding: General guidelines provide for the use of shielding to eliminate patient dose over radiosensitive areas outside of the area in interest. Analysis Stress study similarity: Although similar to the analysis of plain film stress studies, which are generally taught in the chiropractic curriculum, the interpretation of videofluoroscopy should be done by a doctor trained in the specific analysis of this type of study. Adjunctive procedure: Videofluoroscopy should be used as an adjunctive procedure to plain film studies, and not as a replacement for those studies. Repeat studies: Due to the dangers inherent in radiation exposure, repeat studies should only be used as clinically required. Ultrasonography Ultrasonography may be used to visualize soft tissue structures of the musculoskeletal system. It is an established procedure for the evaluation of extraspinal soft tissues structures, such as the thyroid gland and the abdominal aorta. In spine imaging, it has been used to measure the central canal to determine stenosis. Clinical Necessity Investigational, ultrasonography has been used for visualizing soft tissue structures of the musculoskeletal system. This use may ultimately provide information which would be germane to chiropractic practice. Rating: Strength: Contrast studies A doctor of chiropractic may refer a patient for contrast studies when clinically indicated. Radioisotope scanning (Nuclear medicine) -304- A doctor of chiropractic may refer a patient for nuclear medicine studies when clinically indicated. Technical Component the technical component is that part of the radiographic service that includes: providing the facilities, equipment, personnel, and supplies necessary to obtain a satisfactory image. Professional Component the professional component is that part of the radiographic service that includes the analysis and documentation of the findings evident on the radiographic image. Medical radiologist use: As some chiropractors use the services of a medical radiologist in obtaining radiographs, it is conceivable that two professional charges may exist for the same study. This does not represent an unethical practice as each provider is producing a unique non-duplicative impression of the radiograph. The medical radiologist is commenting on the medical/pathological significance germane to his/her specialty, and the chiropractor on the vertebral subluxation and other malpositioned articulations and structures analysis germane to his/her specialty. Specialist in Chiropractic Imaging use: Some chiropractors may choose to consult with a chiropractic radiologist for further clarification. As the chiropractic radiologist is a doctor who has completed post graduate studies to obtain a level of interpretive proficiency greater than that taught on the basic chiropractic college level, the use of such a professional is acceptable and may ethically result in two professional charges per study. The use of these codes may be broken into: technical component only, professional component only, or global (combined technical and professional components). Imaging studies may -305- be used to assess the biomechanical component of the vertebral subluxation and other malpositioned articulations and structures complex, as well as determine the presence of traumatic injuries, pathology, and developmental variants which may affect patient care. Procedures which involve the use of ionizing radiation should be employed only when clinical need is established by the history and clinical assessment. The potential benefits of a proposed imaging procedure should be carefully weighed against the risks and cost. The most cost effective procedure which will provide the information needed should be employed whenever possible. Proceedinas of the Scientific Symposium on Spinal Biomechanics, International Chiropractors Association, 1989. Antos J, Robinson K, Keating J, Jacobs G: Interrater reliability of fluoroscopic detection of fixation in the cervical spine. Bale J, Bell W, Dunn V et al: Magnetic resonance imaging of the spine in children. Ball and Moore: Essential Physics for Radiographers, Blackwell Scientific Publications, 2nd Ed.