Stephen D. Lee, MD

  • Emergency Medicine Resident, Department of Emergency Medicine,
  • University of Virginia School of Medicine, Charlottesville, VA, USA

Anomalous Lumbar spinal pain for which no other cause has been lumbosacral articulations and low-back pain: evaluation found or can be attributed erectile dysfunction treatment ppt malegra fxt 140 mg on-line. Lumbar spinal pain associated with disease of an ab Patients given this diagnosis could in due course be ac dominal viscus or vessel that reasonably can be inter corded a more definitive diagnosis once appropriate di preted as the source of pain impotence buy malegra fxt 140 mg mastercard. In some Clinical Features instances impotence l-arginine malegra fxt 140mg low cost, a more definitive diagnosis might be attain Lumbar spinal pain with or without referred pain erectile dysfunction at age 29 generic malegra fxt 140 mg with visa, to able using currently available techniques erectile dysfunction caused by prostate surgery buy malegra fxt uk, but for logistic gether with features of the disease affecting the viscus or or ethical reasons these may not have been applied impotence at 40 buy malegra fxt american express. Diagnostic Features Upper Lumbar Spinal Pain of Reliable evidence of the primary disease affecting an Unknown or Uncertain Origin abdominal viscus or vessel. Clinical Features Diagnostic Criteria Spinal pain located in the lower lumbar region. Conjectures may be raised as to the possible origin of this form of pain, such as neuroma formation, deafferen Lumbosacral Spinal Pain of tation, epidural scarring, etc. X7cS Dysfunctional Lumbar spinal pain, with or without referred pain, stemming from a lumbar intervertebral disk. The pathology of internal disk disruption is believed to be due to enzymatic degradation of the internal disk ma Remarks trix. Initially, the degradation is restricted to the nucleus Provocation diskography alone is insufficient to estab pulposus, but eventually it progresses in a centrifugal lish conclusively a diagnosis of discogenic pain because pattern along radial fissures into the anulus fibrosus. If analgesic tion and deaggregation of proteoglycans and diminished diskography is not performed or is possibly false water-binding capacity of the nucleus pulposus. X7*S Dysfunctional Local anesthetic blockade of the nerves supplying a tar References get zygapophysial joint may be used as a screening pro Bernard, T. May be due to small fractures not evident on plain radiography or conventional computerized to Vanharanta, H. May be due to osteoarthrosis, but the radiographic pres ence of osteoarthritis is not a sufficient criterion for the diagnosis to be declared. Definition Sprains and other injuries to the capsule of zyga Lumbar spinal pain, with or without referred pain, pophysial joints have been demonstrated at post mortem stemming from one or more of the lumbar zyga and may be the cause of pain in some patients, but these pophysial joints. Diagnostic Criteria Code No criteria have been established whereby zyga pophysial joint pain can be diagnosed on the basis of the Trauma 533. X6aR the condition can be diagnosed only by the use of diag nostic, intraarticular zygapophysial joint blocks. For the References diagnosis to be declared, all of the following criteria Bough, B. Arthrography must demonstrate that any injection of corticosteroid injections into facet joints for chronic low has been made selectively into the target joint, and back pain, New Engl. The response must be validated by Apophyseal injection of local anesthetic as a diagnostic aid in an appropriate control test that excludes false primary low-back pain syndromes, Spine, 6 (1981) 598-605. Definition Lumbar spinal pain stemming from a lesion in a speci fied muscle caused by strain of that muscle beyond its Lumbar Trigger Point Syndrome normal physiological limits. Diagnostic Criteria Clinical Features the following criteria must all be satisfied. Lumbar spinal pain, with or without referred pain, asso ciated with a trigger point in one or more muscles of the 1. Elimination may be achieved by stretching the nous junction, that elicits and inflammatory repair re affected muscle, dry needling the trigger point, or in sponse. Remarks Pathology this nosological entity has been included in recognition Unknown. However, in the context of spinal pain this entity result of the accumulation of algogenic metabolites. Page 183 Remarks with low-back pain, but although it is associated with For the diagnosis to be accorded, the diagnostic criteria back pain a causal relationship between this type of for a trigger point must be fulfilled. In: the Trigger Point Manual, Williams & Wilkins, spasm-pain cycle in spinal disorders, Clin. Lumbar spinal pain ostensibly due to excessive strains imposed on the restraining elements of a single spinal Clinical Features motion segment. Lumbar spinal pain for which there is no other underly ing cause, associated with demonstrable sustained mus Clinical Features cle activity. Lumbar spinal pain, with or without referred pain, that can be aggravated by selectively stressing a particular Diagnostic Features spinal segment. Palpable spasm is usually found at some time, most of ten in the paravertebral muscles. Remarks While there are beliefs in a pain-muscle spasm-pain cy Pathology cle, clinical tests or conventional electromyography have Unknown. Presumably involves excessive strain im not been shown to demonstrate reliably the presence of posed by activities of daily living on structures such as sustained muscle activity in such situations. The strong the ligaments, joints, or intervertebral disk of the af est evidence for repeated involuntary muscle spasm fected segment. For this diagnosis to be sustained it is critical that the clinical tests used be shown to be able to stress selec Ligament sprain is an acceptable diagnosis in the context tively the segment in question and to have acceptable of injuries of the joints of the appendicular skeleton be interobserver reliability. To date, no studies have estab cause the affected ligament is usually accessible to pal lished validity for any techniques purported to demon pation for tenderness and because the ligament can be strate segmental dysfunction. Definition Clinical Features Lumbar spinal pain arising from a lesion in the anulus Lumbar spinal pain, with or without referred pain, ag fibrosus of an intervertebral disk caused by excessive gravated by active or passive movements that strain the strain of the anulus fibrosus. Clinical Features Diagnostic Criteria Lumbar spinal pain, with or without referred pain, ag All the following criteria should be satisfied; otherwise gravated by movements that stress an anulus fibrosus, the diagnosis can only be presumptive. A history of an acute or chronic mechanical distur bance of the vertebral column which would be ex Diagnostic Criteria pected to have strained the specified ligament. A history of activities or injury consistent with the lectively, or affected anulus fibrosus having been strained. Partial or complete tears Periostitis as a result of repeated contact between the of the anulus fibrosus in a location consistent with the two bones, progressing to sclerosis of the contact sites of nature of the precipitating stress; typically: circumferen the two bones. Pain arises either as a result of an in the radiographic presence of a pseudarthrosis in a pa flammatory repair response to the injured collagen fibers tient with spinal pain is insufficient grounds alone to or as a result of excessive strain imposed by activities of justify the diagnosis. The pseudarthrosis must be shown daily living on the remaining, intact collagen fibers of to be symptomatic. Relief of pain following infiltration the anulus fibrosus, which alone are insufficient to sus of local anesthetic into the lesion is not necessarily at tain these loads within their accustomed, normal physio tended by relief following surgical treatment. X1oS Any clinical test used to diagnose sprain of the anulus fibrosus should be shown to be valid and reliable. Such clinical tests as have been advocated for this condi tion (Farfan 1985) have not been assessed for validity. XlnS Definition Lumbar spinal pain ostensibly due to excessive or ab Reference normal motion of lumbar motion segment that exhibits Farfan, H. Lumbar, lumbosacral, or sacral spinal pain associated with midline tenderness over the affected interspinous Pathology space, the pain being aggravated by extension of that Loss of stiffness in one or more of the elements of a segment of the vertebral column. The pain presumably arises as a result of exces Diagnostic Criteria sive stresses being imposed by movement on structures the pseudarthrosis must be evident radiographically and such as the ligaments, joints, or anulus fibrosus of the must be shown to be symptomatic by having the pain affected segment. This diagnosis is, Page 186 therefore, offered only as one of association between Clinical Features lumbar spinal pain and demonstrable movement abnor Lumbar spinal pain, with or without referred pain, in malities. No studies have vindicated any clinical test for association with a radiographically demonstrable pars instability. Consequently, the diagnosis can be sustained interarticularis defect that has been shown to be the only if the radiographic criteria are strictly satisfied. X7jS Remarks References this classification should not be used unless the diag Kalebo, P. The presence of a pars inter radiography of lumbar segmental instability, Spine, 15 (1990) articularis defect on radiographs or nuclear scans in a 351-355. The consistency and accuracy of roentgenograms for ticularis defect: the prognostic value of pars infiltration, Spine, measuring sagittal translation in the lumbar vertebral motion 16, Suppl. Sacral spinal pain occurring in a patient with clinical and/or other features of an infection, in whom the site of Diagnostic Features infection can be specified and can reasonably be inter A presumptive diagnosis may be made on the basis of preted as the source of the pain. Absolute confirmation relies on obtaining Sacral spinal pain with or without referred pain, associ histological evidence by direct or needle biopsy. I (S)(R) elevated white cell count or other serological features of Primary Tumor of the Sacrum infection, together with imaging evidence of the pres Code 533. X4pR Diagnostic Features Imaging or other evidence of arthritis affecting the sac roiliac joints. Page 189 System no evidence that the constrictive effects of spinal steno Musculoskeletal system. These latter forms of pain ostensibly arise from the disorders of one Main Features or more of the disks or zygapophysial joints whose os Patients usually have a long history of gradually increas teophytic overgrowth coincidentally causes the stenosis. Walking also pathology is restricted to a single intervertebral foramen produces overt or subtle neurological features in the and as such does not encroach upon the vertebral canal lower limbs that range from sensations of heaviness or as a whole. The onset of Treatment these neurological features may be measured in terms of Surgical decompression. Differential Diagnosis Peripheral vascular claudication, sciatic nerve compres Associated Symptoms sion, osteoarthritis of hip or knee, retroperitoneal tu There may be paresthesias and bowel or bladder distur mors, other tumor or abscess, prolapsed lumbar disk. X6*R Legs Signs and Laboratory Findings X-rays usually demonstrate diffuse severe degenerative disease with facet hypertrophy and a shallow anteropos terior diameter of the lumbar canal. The dilemma posed by this condition is the Definition discrepancy between physical signs, which are usually Sacral spinal pain associated with a congenital vertebral not great, and the subjective complaints. Diagnostic Features Pathology Imaging evidence of a congenital vertebral anomaly Encroachment upon and narrowing of the vertebral canal affecting the sacrum. Congenital narrowing of the There is no evidence that congenital anomalies per se vertebral canal may predispose to this condition insofar cause pain. Although they may be associated with pain, as symptoms may arise in the face of osteophytes and the specificity of this association is unknown. This clas syndesmophytes that in other individuals would not sification should be used only when the cause of pain cause significant encroachment. The mechanism of the cannot be otherwise specified, but should not be used to neurological features is unknown but may involve con imply that the congenital anomaly is the actual source of striction of the dural sac with obstruction of flow of the pain. X0*R other compromise of one or more nerve roots but there is Page 190 Pain Referred from Abdominal or sis. Sacral spinal pain associated with disease of an abdomi Patients given this diagnosis could in due course be ac nal or pelvic viscus or vessel that reasonably can be in corded a more definitive diagnosis once appropriate di terpreted as the source of pain. In some instances, a more definitive diagnosis might be attain Clinical Features able using currently available techniques, but for logistic Sacral spinal pain with or without referred pain, together or ethical reasons these may not have been applied. X8*S Diagnostic Features Imaging or other evidence of the primary disease affect ing an abdominal or pelvic viscus or vessel. Definition Sacral spinal pain occurring in a patient whose clinical Pathology features and associated features do not enable the cause Unknown. Presumably the pain is caused by excessive and source of the pain to be determined, and whose stresses being imposed on the ligaments of the sacroiliac cause or source cannot be or has not been determined by joint as a result of some structural fault in the joint itself special investigations. Remarks this category does not encompass sacroiliitis, ankylos Diagnostic Features ing spondylitis, or seronegative spondylarthropathies Sacral spinal pain for which no other cause has been that may be demonstrated by radionuclide imaging other found or can be attributed. While there are beliefs that such disorders can befall the sacroiliac joint, no clinical tests Remarks of laudable validity and reliability have been devised this definition is intended to cover those complaints that whereby this condition can be diagnosed. The presence for whatever reason currently defy conventional diagno Page 191 of such a condition, however, in the absence of any overt Code inflammatory joint disease, is implied by a positive re 533. Until such time as appropriate clinical tests are demon Reference strated to be valid and reliable, any diagnosis of sacroil Waisbrod, H. X8hS features and associated features do not enable the cause and source of the pain to be determined, and whose cause or source cannot be or has not been determined by special investigations. Definition Diagnostic Features Pain perceived in the coccygeal region, stemming from Coccygeal pain for which no other cause has been found one or both of the posterior sacrococcygeal joints. Diagnostic Criteria Remarks Complete relief of pain upon infiltration of the puta this definition is intended to cover those complaints that tively symptomatic joint or joints with local anesthetic, for whatever reason currently defy conventional diagno provided that the injection can be shown to have been sis.

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An interosseus mem brane adds further stability between the two bones of the leg (see erectile dysfunction treatment after prostate surgery purchase line malegra fxt. Lateral malleolus Medial malleolus Calcaneus Tarsals Cuboid Fifth metatarsal First metatarsal Middle phalange Proximal phalange Distal phalange Distal phalange A the soleal line of the tibia marks the attachment of Neck of fibula the soleus muscle intracavernosal injections erectile dysfunction buy cheap malegra fxt 140 mg on line. Tibia Fibula Medial malleolus the subtalar joint is located distal to the talocrural joint and includes articulations between the talus and calcaneous erectile dysfunction doctors in brooklyn order malegra fxt 140 mg without prescription. It works with the Lateral malleolus talocalcaneonavicular joint to allow Talus inversion and eversion of the foot erectile dysfunction genetic discount malegra fxt 140 mg free shipping. Medial malleolus the posterior inferior Posterior talofibular ligament stabilizes these structures impotence 16 year old order malegra fxt in united states online, which tibiotalar the backof the ankle form the posterior ligament Lateral malleolus portion of the deltoid ligament impotence clinic discount malegra fxt generic, limit medial Tibiocalcaneal ligament the posterior talofibular ligament motion of the talocrural stabilizes the back of the ankle, joint preventing the talus from sliding forward on the tibia. Achilles tendon the calcaneofibular ligament limits lateral motion of the talocrural joint. These movements are important in are the deltoid ligament, a strong, triangular-shaped ligament helping us to maintain balance when walking on uneven sur that joins the medial malleolus to the talus, navicular, and faces or as we shift our weight from one foot to the other. The spring ligament joins the talus to the calca Several intertarsal joints combine to permit the move neus. The posterior talofibular ligament joins the lateral ments of eversion and inversion. The calcaneofibular ligament joins the and calcaneus, the joint between the talus and the navicular, lateral malleolus to the calcaneus. Many other ligaments con and the joint between the calcaneus and the cuboid are the tribute to the stability of the ankle joint. Remaining Joints Within the Foot Despite the significant number of ligaments helping to the joints between the tarsals and metatarsals are plane or stabilize this joint, and despite the shapes of the articular gliding joints, which permit limited side-to-side movement. When we lose balance, we put huge amounts of stress terphalangeal joints are hinge joints and permit flexion and on the ligaments that support this joint, often tearing or extension only. The ligaments positioned to cross the lateral side of the ankle joint are most vulnerable to injury. Joints That Permit Inversion and Eversion Recall that inversion is the foot movement that results in turn Deep Investing Fascia and Iliotibial Band ing the plantar surface of the foot inward toward the midline. The thigh contains a layer of fascia, which wraps all the mus Eversion is the foot movement that causes the plantar surface cles of the thigh. The this dense band of connective tissue runs from the ilium to anterior leg compartment lies between the anterior aspects of the lateral aspect of the lateral condyle of the tibia. When describing the location of each of the mus to stabilize the knee from a lateral perspective. Fascial Compartment Divisions in the Leg Plantar Fascia or Aponeurosis the leg muscles are wrapped by investing fascia in a manner the plantar fascia runs from the calcaneus to the proximal similar to the thigh. This crural (leg) fascia joins with inter phalanges of the plantar surface of the foot. Figure 5-12 muscular sheets of fascia called septa, to divide the leg into illustrates the plantar fascia. Two compartments are this structure provides support to the longitudinal arch of located in the posterior leg and are called the deep posterior the foot. It can become inflamed, resulting in a condition leg compartment and the superficial posterior leg compartment. Massage of the posterior leg muscle may the deep posterior leg compartment contains three muscles. We have a group of deep lateral rotators, located deep the hip flexors cross the front of the hip joint, and the hip ex in the buttock region. The name gemellus inferior indicates that there are two gemelli (twins) muscles and that this one is in ferior to the other. Obturator internus and externus indicate the location of two muscles around the obturator foramen. Location All six of the deep lateral rotators of the thigh lie deep in the buttock region. Piriformis lies in the greater sciatic notch and is superficial to the sciatic nerve. Gemellus Inferior and Quadrates Femoris Notable Muscle Facts Origin: ischial tuberosity Piriformis is a thick muscle that lies directly superficial to the Insertion: greater trochanter sciatic nerve. Thus, piriformis is in a position to impinge the sci Obturator Internus and Externus atic nerve and cause a type of sciatica called piriformis syndrome. Origin: obturator foramen Implications of Shortened and/or Lengthened/ Insertion: greater trochanter Weak Muscle Actions Shortened: the group of lateral rotators can cause a posture Laterally rotate the thigh in which the toes point out to the sides. It Posterior runs down the thigh before cutaneous nerve branching into the common peroneal and tibial nerves at the popliteal fossa. Muscular branches of sciatic nerve Vastus lateralis muscle Semitendinosis muscle the popliteal artery and vein lie within the popliteal fossa, along with the tibial nerve. Biceps femoris muscle (long head cut) Tibial nerve Medial sural the common peroneal cutaneous nerve nerve lies lateral to the head of the fibula. Feel through gluteus max (medially rotate hip/thigh) imus for the density of piriformis. The other lateral rotators are not easy to distinguish but can be massaged deep in the buttock Innervation and Arterial Supply region. Innervation: lumbosacral plexus, with the exception of ob turator externus, which is innervated by the obturator nerve How to Stretch this Muscle Arterial supply: obturator artery and superior and inferior Medially rotate the hip. It is Inferior pubic ramus, ishail the largest and deepest of the thigh adductors. This muscle tuberosity has two distinct sections, an anterior section, which is more and ishial ramus proximal, and a posterior section, which is more distal. Adductor magnus Origin and Insertion Origin Origin: inferior pubic ramus Insertion Insertion: linea aspera and adductor tubercle. Linea aspera (not visible) and the femoral artery and femoral vein pass through the ad adductor tubercle ductor hiatus on their way to the popliteal fossa. Once they enter the popliteal fossa, they become the popliteal artery and popliteal vein. Some sources also cite that the anterior por tion of adductor magnus allows hip flexion, and the posterior portion of adductor magnus permits hip extension. In addition, the origin of the more proximal, anterior section of this muscle on the pubis is anterior to the insertion on the linea aspera, and thus can pull the femur for ward, causing hip flexion. On the other hand, the origin of the more posterior, distal section of the muscle is posterior to the insertion, and thus contraction pulls the femur posteri orly, resulting in hip extension. When the weight is on the limb, contraction of adductor magnus helps to keep the pelvis centered over the foot. In addition, adductor magnus assists during walking by keeping the thigh adducted when our heel strikes the ground and when our lower limb swings forward with each step. Teaching Weak Muscle your client to provide self-massage to the hip adductor mus Shortened: Limited ability to abduct the thigh and a posture cles can be a useful way to address the more proximal aspect in which the feet are close together is noted. Fric Synergists tion to the area of the tear can assist healing, limit scar tissue Adductor longus, adductor brevis, pectineus, and gracilis formation, and reduce the likelihood of repeat injury. Effleurage and Innervation and Arterial Supply petrissage are appropriate strokes to apply to the hip adduc Innervation: sciatic and obturator nerves tor muscles. A: Adductor longus; B: Adductor brevis Meaning of Name Actions Adductor refers to the adduction of hip action. Longus means Adduct the thigh; some sources state that adductor longus longer than adductor brevis, and brevis means shorter than and adductor brevis assist in hip flexion. Explanation of Actions Location By pulling the insertion on the linea aspera medially toward Adductor longus and brevis are medial thigh muscles. A sec ductor longus is the most anterior of the adductor muscles ondary action of adductor brevis and adductor longus, thigh and forms the medial border of the femoral triangle. Figure flexion, is possible due to the fact that the origin on the pubis 5-17 shows the femoral triangle. Adductor brevis is more is anterior to the insertion on the linea aspera, and thus these proximal and deeper than adductor longus. Origin and Insertion Notable Muscle Facts Origin: anterior pubis the thick tendon of the origin of adductor longus makes it Insertion: linea aspera the most palpable tendon in the area of the anterior pubis. Femoral artery and vein the deep inguinal nodes lie Deep subinguinal node alongside the femoral artery within the femoral triangle. Supercial subinguinal nodes Deep lymph vessels the femoral artery and vein run together with the femoral nerve deep to the inguinal ligament and through the femoral triangle. Supercial lymphatic vessels Femoral artery and vein and deep lymph vessels the great saphenous Great saphenous vein vein on the medial thigh runs superiorly to join the femoral vein. Teaching Weak Muscle your client to provide self-massage to the hip adductor mus Shortened: Inability to fully abduct the thigh is noted. When cles can be a useful way to address the more proximal aspect the hip adductor muscles are shortened, they are more sus of these muscles. Friction to the area of the tear can assist Synergists healing, limit scar tissue formation, and reduce the likelihood Adductor magnus, pectineus, and gracilis of repeat injury. Antagonists Gluteus medius, gluteus minimus, tensor fascia latae, and sar Palpation and Massage torius the adductors of the thigh are easy to palpate as a group. Effleurage and Innervation and Arterial Supply petrissage are appropriate strokes to apply to the hip adduc Innervation: sciatic nerve tor muscles. In addition, the origin is medial to the insertion on the pectineal line of the femur. Notable Muscle Facts this muscle is designed to accomplish its actions of adduc tion and flexion with power, rather than speed. Implications of Shortened and/or Lengthened/ Weak Muscle Shortened: A shortened pectineus can cause an anterior pelvic tilt. When any of the hip ad ductor muscles are shortened, they are more susceptible to is possible in this area, when done with care. Many times, it tearing, which is a common occurrence when a muscle is is more appropriate to teach self-massage to a client rather overstretched quickly. Chronic groin pulls, or recent groin pulls that have healed to the extent that inflammation is no longer present, can be ad How to Stretch this Muscle dressed. Friction to the area of the tear can assist healing, Abduct the thigh with the knee flexed. Additional stretch can limit scar tissue formation, and reduce the likelihood of re be achieved by extending the hip. It may be best to teach your client to apply fric tion to this muscle on his or her own, rather than for you to Synergists touch this sensitive area so close to the genital area. Adductor magnus, adductor longus, adductor brevis, and Lengthened: Reduced ability to flex and adduct the thigh is gracilis noted. Antagonists Palpation and Massage Gluteus medius, gluteus minimus, tensor fascia latae, and sar this muscle lies right in the femoral triangle and thus is dif torius ficult to palpate or massage due to the femoral artery, vein, and nerve in this area (see. Find the inguinal liga Innervation and Arterial Supply ment just lateral to the pubic symphysis, and palpate just in Innervation: femoral nerve ferior to the inguinal ligament. Anterior pubis Origin and Insertion Origin: body and inferior ramus of the pubis Insertion: pes anserinus Actions Gracilis Adducts the hip and flexes and medially rotates the knee Origin Insertion Explanation of Actions Gracilis is a hip adductor because the origin is medial to the insertion; thus, contraction pulls the femur medially, causing hip adduction. Gracilis crosses the posterior aspect of the knee, and its origin is above the insertion. Finally, the proximal, medial, anterior tibia is Proximal, medial, anterior pulled posteriorly, thus causing the tibia to rotate medially. Notable Muscle Facts Gracilis is the second longest muscle in the body, next to sar torius. Gracilis has a role in stabilizing the medial aspect of the knee, due to the placement of its tendon of insertion. Lengthened: Due to the relative weakness of this muscle, torius, popliteus, and plantaris (flex the knee); semitendi lengthening of gracilis results in no substantial loss of func nosus and semimembranosus (medially rotate the knee) tion. In fact, gracilis is a common muscle for surgeons to use in muscle replacement surgery, especially to replace a muscle Antagonists in the hand. Gluteus medius, gluteus minimus, tensor fascia latae, and sar Palpation and Massage torius (abduct the hip); quadriceps femoris group (extend the knee); biceps femoris (laterally rotates the knee) this muscle can be palpated along the most medial superfi cial aspect of the thigh. It runs as a pant seam does, along the Innervation and Arterial Supply inner thigh and leg. Innervation: obturator nerve How to Stretch this Muscle Arterial supply: deep femoral and obturator arteries Abduct the thigh. Posterior illium Location In the lateral hip, gluteus minimus covers a sizable portion Gluteus minimus of the external surface of the ilium. Origin Insertion Origin and Insertion Origin: external surface of the lateral ilium Anterior surface Insertion: greater trochanter of greater trochanter Actions Gluteus minimus and gluteus medius perform the same ac tions: abduction and medial rotation of the hip. In addition, both gluteus minimus and gluteus medius play an important role in stabilization of the hip, particularly when one is walking. The origin of gluteus minimus and gluteus medius on the lat Palpation and Massage eral ilium is superior to the greater trochanter of the femur. In addition, these muscles cross the lateral side of the hip Gluteus minimis and medius can be palpated by pressing into joint. Thus, the muscles Gluteus medius, tensor fascia latae (medially rotate the hip), pull the greater trochanter forward, causing the femur to ro and sartorius (abducts the hip) tate medially. Antagonists Notable Muscle Facts Piriformis, gemellus superior, gemellus inferior, obturator the anterior section of gluteus minimus is thicker and internus, obturator externus, quadratus femoris, iliopsoas, sar stronger than the posterior portion. Posterior ilium including iliac crest Location Gluteus medius is located on the lateral hip, on the external Gluteus medius surface of the ilium. Origin Insertion Origin and Insertion Origin: external surface of the lateral ilium Greater Insertion: greater trochanter trochanter Actions Gluteus minimus and gluteus medius perform the same actions: abduction and medial rotation of the hip. Explanation of Actions Palpation and Massage the origin of gluteus minimus and gluteus medius on the lat Gluteus minimis and medius can be palpated by pressing into eral ilium is superior to the greater trochanter of the femur. Direct pressure and friction are easily addition, these muscles cross the lateral side of the hip joint.

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If patient is provided with care by someone who is not a family member impotence bicycle seat order generic malegra fxt from india, a caregiver must be chosen who is accepted by the patient erectile dysfunction treatment without side effects purchase malegra fxt in india. A relationship of trust between the patient and the caregiver is indispensable for quality and personalised care erectile dysfunction treatment shots buy generic malegra fxt 140mg online. The caregiver has to complete different caring tasks in the different stages of dementia impotence zantac quality 140 mg malegra fxt. Initially the patient is self-sufficient while with the progression of the disease he/she will need 24-hour surveillance and care impotence from priapism surgery discount 140 mg malegra fxt otc. It is necessary to find out what activities the patient with dementia can do on his/her own and let him/her to do those erectile dysfunction australian doctor malegra fxt 140mg with amex, even if he/she fulfills the given task slower. It is important that the caregiver should wait until the patient accomplishess a given task. During daily care it is important to set up a daily routine which will help the caregiver and the patient as well in everyday life. In the moderate/severe stage the patient will not be able to fulfill the given task despite the instruction. According to his theory needs can be organised into groups and people have to satisfy their basic needs first, only after that will higher level needs arise. Maslow says that one of the basic needs is the physiological need which can be found at the lowermost level of the pyramid. Physiological needs include lower level needs such as nutrition, breathing, 39 hygiene, clothing, rest, moving, etc. Protein intake can be provided by meat, eggs, dairy products, seeds and leguminous plants. Consuming fish is the easiest way to ensure the intake of Omega-3 polyunsaturated fatty acid which is indispensable for natural nutrition. For a fibre-rich diet the elderly person should consume whole wheat bread, fruit and vegetables on a daily basis. Fat intake is indispensable for the absorption of vitamins as well, but the consumption of too fatty food should be avoided because they burden the digestion of the elderly person and may lead to obesity. Physical activity declines with ageing therefore calorie requirement of the body decreases. A low-calorie daily diet is necessary for the elderly person preferably with five meals per day. The caregiver should provide balanced diet by taking into consideration the condition. If communication is impaired and comprehension difficulties occur as well, the presentation or initiation of certain movements may help. Difficulties in using the cutlery may occur in the moderate or severe stage of the disease. If the patient is not able to eat soup with a spoon due to hand tremors, it is recommended to put fluid food into a mug that is provided with a spouted lid and handles. Figure 4: A mug that is provided with a spouted lid40 Figure 5: A mug that is provided with a spouted lid and handles41 With the progression of the disease, considerable difficulties in using the cutlery may occur. In order to keep the environment clean, it is recommended to protect the table. Instead of a fork and a knife, it is advisable for the patient to use a spoon with which he/she can eat independently. If possible, choose thick-handled cutlery, which is available in medical equipment shops. It is advisable to make toothsome bites that the person with dementia can easily eat with a spoon or with his/her hands. Since dysphagia may lead to severe consequences (damage to the oesophagus, suffocation), it is important to take the necessary precautions. Food is advisable to be pureed, smoothies can be prepared from vitamin-rich fruits. At the onset, the patient consciously drinks less in order to avoid unpleasantness related to urination or incontinence. It is vital for the caregiver to control fluid intake because 2 percent fluid loss may lead to dehydration, which may damage health (confusion, unrest, kidney problems, etc. Hygiene, Bathing, Incontinence the recognition and satisfaction of hygiene needs are vital. It can be an alerting symptom when the relative who has been neat so far becomes visibly neglected. The occurrence of these symptoms means that the disease has reached a stage in which self-sufficiency has declined. If the person with dementia did not have a bath on a daily basis before the appearance of the disease, daily bathing should not be forced. The patient may refuse having shower or washing hair because he/she: feels ashamed to be nude, is unable to fulfil the task properly and a sense of failure develops, had an unpleasant experience during/after bathing or showering. Therefore, the patient him/herself should choose these products during a joint shopping. These problems can be solved if a family member who is accepted by the patient initiates the activity. If the patient is able to carry out some activities alone, he/she should be allowed to do so. The bathroom should be heated up to a pleasant temperature (the patient should not be cold during bathing), water temperature should be adjusted to the patient before bathing. A sense of shame develops and the patient tries to hide the traces of urine (puts paper or rag into the underwear). It is hard to explain to people living with dementia why the use of aids like diapers or sanitary pads is so important. When involuntary urination occurs, it is advisable to apply diaper panties instead of underwear. Since 45 diaper panties are similar to normal underwear, patients with dementia accept them easier. Skincare One of the physiological changes of the elderly is the alteration of skin structure and quality. The most common symptom is dry and itchy skin, causing discomfort for the person with dementia. Therefore, if the patient is fidgety and regularly scratches and/or rubs his/her forearms or legs but there is no sign of bites or rashes, then the skin is dehydrated. An ingrown toenail may annoy the person with dementia because it may cause pain when walking. If proper nail care is problematic for the caregiver, a pedicurist is needed, who has the appropriate tools for precise nail clipping. In the severe stage of dementia, the patient may become bedridden which may cause bedsore. If the patient is able to turn over in the bed on his/her own, it is recommended to remind him/her in every 2 hours to change position. If the patient is unable to turn over on his/her own, the caregiver should do that. In order to prevent bedsore, it is indispensable to provide proper hygienic conditions and skincare. Bloodstream can be improved and tissue necrosis can be reduced with regular massage of the pressured areas. The following medical aids can be used if needed: Heel cushion and elbow cushion: the development of bedsore can be avoided with the use of medical aids since they reduce pain and provide comfort. The most well-known types of anti-bedsore mattress are the custom-designed foam mattress. Dressing Up In the initial stage of dementia, neither the selection of seasonal clothing nor dressing up is problematic. With the progression of the disease, it may be an alarming symptom that the person with dementia does not wear seasonal clothes. Keeping only seasonal clothes in the wardrobe helps the patient in choosing the appropriate pieces. It is recommended on the one hand to keep the clothes in the wardrobe folded and grouped, on the other hand to label or put pictograms on the shelves. The patients have difficulties in handling the buttons from 49 gyogyaszati. With the progression of the disease, the patient may become unable to choose the proper clothes. Therefore, the caregiver shoud do that and help the patient in dressing up by making requests. A frequent problem is that the person with dementia does not want to change clothes because insists on what he/she is wearing. In this case, it is practical to buy more of the given item at once, thus the clothes become washable and changeable. The patient should be 51 provided with just as much help as he/she needs in the given condition. Appropriate Physical Activity During caring, the opportunity to do appropriate physical activity. Physical activity is indispensable for normal muscle functions, digestion, immune system, while it may also influence blood pressure, the level of blood lipids, prevent obesity and eliminate sleep disorders etc. When choosing the form of physical activity the highest priority is personal safety. Balance problems occur quite soon in old age, particularly within the syndrome of dementia. The form of physical activity should always be chosen in accordance with the abilities of the patient. The patient should be provided 52 with comfortable clothing for physical activity. Sleeping Caregivers often report that the patient with dementia suffers from sleep disorder. Sometimes the patient interchanges the parts of the day (sleeps during the day, walks at night). With the progression of dementia, a new habit may appear: the patient repeatedly takes the clothes out from the wardrobe then puts them back during the night. Experience shows that if people with dementia do regular physical and daytime activities. In the severe stage of the disease, the patient is hardly able to express him/herself, if at all. If sleep disorder is persistent or returns regularly, medication treatment is necessary 53 in order to protect the patient and the caregiver as well. Communication with a Person with Dementia Information is exchanged during communication, which may happen verbally or non-verbally (facial expression, posture, gesture, mimicry). Communication skills of people living with dementia decline gradually with the progression of the disease. Initially the patient has fluttering thoughts, he/she loses focus in conversations, sometimes suffers from word-finding difficulties. If deterioration in sight or hearing occurs, it is necessary to purchase a pair of glasses or hearing aid. With the progression of the disease, communication difficulties exert an increasing impact on the life of the person with dementia. The patient finds expressing his/herself more difficult, and he/she is unable to participate in longer conversations. Due to the failures, the patient speaks less which may lead to isolation and loneliness. If the patient has self-expression difficulties, he/she should be given enough time to try to tell what he/she wants.

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Ellestad S erectile dysfunction doctor boston order 140mg malegra fxt free shipping, Nagle R erectile dysfunction doctors in toms river nj buy malegra fxt uk, Boesler D erectile dysfunction doctor edmonton discount malegra fxt 140mg line, Kilmore M: Electromyographic and skin resistance responses to osteopathic manipulative treatment of low back pain drugs for erectile dysfunction in nigeria 140mg malegra fxt overnight delivery. Feldman F erectile dysfunction pump amazon order malegra fxt in united states online, Nickoloff: Normal thermographic standards for the cervical spine and upper extremities injections for erectile dysfunction after prostate surgery buy malegra fxt canada. Figar S, Krausova L: A plethysmographic study of the effects of chiropractic treatment in vertebrogenic syndromes. Figar S, Krausova L, Levit K: Plethysmographic examination following treatment of vertebrogenic disorders by manipulation. 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Prodromas C, Andriacohi T, Galante J: A relationship between gait and clinical changes following high tibial Osteotomy. Quigley F, Paris L, Duncan H: A comparison of doppler ankle pressure and skin perfusion pressure in subjects with and without diabetes. Medical thermography: theory and clinical applications, Los Angeles: Brentwood, 1976. Reeves J, Jaeger B, Graff-Radford S: Reliability of the pressure algometer as a measure of myofascial trigger point sensitivity. Part I, development of a reliable and sensitive measure of disability in low-back pain. In: Lawrence D (ed): Fundamentals of chiropractic diagnosis and management, Baltimore: Williams & Wilkins, 1991. Shambaugh P: Changes in electrical activity in muscles resulting from chiropractic adjustment: a pilot study. Spector B: Surface electromyography as a model for the development of standardized procedures and reliability testing. Triano J, Baker J, McGregor M, Torres B: Optimizing measures on maximum voluntary contraction. 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Elements common to all primary care practitioners include sufficient history taking and record keeping, thorough examination, timely re-evaluation procedures throughout the course of case management, good communication with the patient and appropriate response in the event that an unexpected incident does occur. If a significant adverse result from a procedure is apparent, it is of critical importance that the intervention or procedure associated with the onset of the complication not be repeated. The evidence of low incidence of injury or complications from adjustments is promoted by quality care which follows professional judgment consistent with the objectives of chiropractic care. Chiropractic professional judgment includes, without limitation, appropriate response to unexpected findings and reevaluation of the suitability of a particular technique or procedure associated with the discovery of a complication. The chiropractor should be alert to the possibility of encountering unusual findings in any phase of care. These two factors assist in evaluating any risk that may be associated with the application of chiropractic care. The primary focus of the chiropractic management of complications is the recognition of unusual findings that may require modification of the plan of care when the unusual finding is observed. This list is not a list of conditions for which chiropractic procedures are contraindicated. Conditions selected have come from a review of the chiropractic, scientific and medical/legal literature as well as insurance claim information. The appropriate chiropractic management of patients with these and related conditions is described in this chapter. Since its inception as a separate and distinct health care profession, chiropractic has established itself as the safest primary care profession by far. Despite the high volume of patients and the great diversity of conditions with which they present, chiropractic can claim the lowest complication rate, the lowest malpractice insurance rates and the highest rates of patient satisfaction of any doctor level provider. Their findings were emphatic: the conspicuous lack of evidence that chiropractors cause harm or allow harm to occur through neglect of medical referral can be taken to mean only one thing: that chiropractors have on the whole an impressive safety record. Over the past two decades there has been an interesting growth of literature on general manipulation-induced accidents or injuries. This body of information clearly distinguishes the safety record of chiropractic because the vast majority of recorded injuries are found to be at the hands of non-chiropractic providers attempting to apply chiropractic like procedures, without the highly developed skill and experience of the doctor of chiropractic. There can be little doubt that the elevated level of reporting arises from a general increase in awareness of complications by all professionals interested in spinal manipulative therapy, and an increased incidence of the use of manual procedures by professionals not thoroughly trained in the arts of manipulation or adjustment. As well, since many alleged "consequences" are consistent with the natural history of a condition, anecdotal or polemic reports must be distinguished from those that 345 provide objective evidence of true manipulation-induced injuries. Many case reports of injury have proven to be unfounded upon further unbiased inquiry. With respect to the frequency of possibly genuine complications, Ladermann (1980) identified 135 case reports of serious complications over a 30 year period from 1950-1980, a time period during which tens of millions of adjustments were administered by a variety of practitioners. Kleynhans (1980), analyzing some of these case studies, outlined a number of likely practitioner-related causes of adverse reactions and suggested three main factors: lack of knowledge or diagnostic error; lack of technique skill; and lack of rational clinical attitude in case management. These causes could well account for a number of iatrogenic injuries reported in the literature. Jasoviak (1981) and Terrett (1987) specifically dealt with case reviews on the adverse effect of cervical adjustment where vertebrobasilar insufficiency was evident. Gutmann (1984), Terrett (1987), Theil (1991) and Schmitt (1991) have recently described or studied the biomechanical effects of head and neck movement and cervical adjustment in association with vertebral artery injury. Adjustment has been identified as only one of many activities or health care procedures that may result in damage to the vertebral artery. Rare case reports of adverse events following spinal adjustment exist in the literature. In the case of strokes purportedly associated with adjustment, significant shortcomings in the literature were noted. According to data obtained from the National Center for Health Statistics, the mortality rate from stroke was calculated to be 0. If this data was accurate, the risk of death from stroke after cervical adjustment is less than half the risk of fatal stroke in the general population! LeBoeuf-Yde et al suggested that there may be an over-reporting of spinal adjustive related injuries. The authors reported cases involving two fatal strokes, a heart attack, a bleeding basilar aneurysm, paresis of an arm and a leg, and cauda equina syndrome which occurred in individuals who were considering chiropractic care, yet because of chance, did not receive it. Had these events been temporally related to a chiropractic office visit, it is likely that they would have been inappropriately attributed to the chiropractic care. In many cases of strokes attributed to chiropractic care where the operator was not a chiropractor at all. The value of this test for screening patients at risk of stroke after cervical adjustment is questionable. It is thought that cervical rotation combined with extension and traction may have some obstructive effect on perfusion of the vertebral artery on the contralateral side of rotation. If the ipsilateral artery is diseased or hypoplastic, symptoms of hind brain ischemia may occur because the dominant healthy artery is under partial physiological compression, resulting in a loss of sufficient or compensatory blood flow. Further, this may lead to stroke or stroke-like complications in susceptible patients. While incidence figures vary, it is generally agreed that the risk of serious neurological complications is extremely low, and is approximately one or two per million cervical adjustments. Structural abnormalities, particularly where mechanical instability pathological bone disorders, dislocations and fractures of the cervical spine are present may also lead to mechanical strain of the vertebral arteries (Terrett, 1987; Jaskoviak, 1981; Ladermann, 1981). Dislocation in the upper cervical spine due to inflammatory or traumatic rupture of the transverse atlantal or alar ligaments warrants particular caution (Yochum and Rowe, 1980, 1987; Jeffreys, 1980; Sandman, 1981; Redlund-Johnell, 1984). Though rarely reported in literature, empirically the most common complaint of adjustment of the thoracic region occurs when forceful or poorly applied manipulations cause costovertebral strains, rib fractures and costochondral separations (Grieve, 1986). Excessive thoracolumbar torque in the side posture position as well as inappropriately applied posterior to anterior techniques may cause thoracic cage injuries particularly in the elderly. While it is suggested that the forces required to cause a disruption of the annular fibers of the healthy intervertebral disc well exceed that of a rotational adjustive thrust (Adams and Hutton, 1981, 1983; Farfan, 1983; Gilmore, 1986; Triano, 1991), some disc herniation/protrusion may certainly be aggravated by an inappropriately applied adjustive maneuver, as it may be by the other simple activities of daily living such as bending, sneezing, lifting. The most frequently described severe complication is compression of the cauda equina by massive midline nuclear herniation at the level of third, fourth or fifth intervertebral disc (Lehmann et al. Of the thirty cauda equina complications associated with adjustment reported in the French, German and English literature over an 80 year period, only eight were allegedly related to chiropractic care (Ladermann, 1980). Had these patients not been manipulated, the outcome may have been the same with menial effort or impulsive strain replacing the rupturing effect alleged to arise from the adjustment. However, this clinical outcome does stress the need for particular care in this susceptible 347 subgroup of patients. However, given the frequency of lumbar adjustment and the few reported complications over a long period of time, it does not appear that there is any risk associated with appropriately applied adjustment techniques including those utilizing high velocity thrust. To sum it up, it appears that lumbar roll type techniques, whether done with (Christman etal. Groh), or without (Ewer, Mensor) narcosis and hyperextension techniques without narcosis are safe compared to the lumbar hyperextension (Durchang of the German authors) under narcosis. Psychological factors including pain intolerance, hysteria conversion reactions, hypochondriasis, malingering, etc. Aside from the risk of creating a dependency for care that may or may not be indicated, chiropractic care itself may aggravate or contribute to real or imagined harm. It is important, therefore, to protect the public and insure quality and safety of care, that throughout all the professions a standard minimum training greater than or equal to that of a doctor of chiropractic in adjustive/manual procedures be required prior to performance of manual procedures to the human spine. The literature and clinical experience show that the most common therapeutic procedure in chiropractic practice, and the one most likely to result in complications, is the adjustment or high velocity manipulative thrust. The following assessment criteria and recommendations relate to this procedure applied to , or adjacent to , the anatomical site of pathology. Assessment criteria developed and used in this chapter relate to: A) Rating of conditions B) Severity of complication C) Quality of evidence D) Level of identifiable contraindication: based on the above factors and the probability of complication A. Rating of Conditions: Type I: A condition for which high-velocity thrust procedures have been shown to be comparatively safe and effective so long as an adequate patient assessment has been made and an intervention trial is rationally applied. Careful clinical judgment is required as high-velocity thrust procedures may require modification or be inappropriate.

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