Jeffrey A Brinker, M.D.
- Professor of Medicine
- Joint Appointment in Radiology and Radiological Science
If a limited obstetric ultrasound is performed on a woman who has not previously had a standard or detailed ultrasound examination purchase 25 mg antivert free shipping medicine dictionary pill identification, a subsequent standard or detailed ultrasound should be obtained where appropriate purchase antivert 25mg free shipping symptoms genital herpes. In patients who require serial ultrasounds and have already had a standard or detailed scan cheap antivert 25 mg fast delivery treatment 7th feb cardiff, some will only need limited scans, whereas others will require standard or detailed follow-up examinations. Clinical judgement should be used to determine the proper type of ultrasound examination to perform and the appropriate frequency for follow-up ultrasound examinations . Specialized Ultrasound Examination A detailed anatomic examination is performed for women at risk for fetal anatomic or karyotypic abnormalities (advanced maternal age, maternal medical complications of pregnancy, or pregnancy after assisted reproductive technology) or when an anomaly is suspected on the basis of history, abnormal biochemical markers, or the results of either the limited or standard scan . Documentation that satisfies medical necessity includes 1) signs and symptoms and/or 2) relevant history (including known diagnoses. Additional information regarding the specific reason for the examination or a provisional diagnosis would be helpful and may at times be needed to allow for the proper performance and interpretation of the examination. The request for the examination must be originated by a physician or other appropriately licensed health care provider. The accompanying clinical information should be provided by a physician or other appropriately licensed health care provider familiar with the patient’s clinical problem or question and consistent with the state’s scope of practice requirements. Indications for first trimester3 ultrasound examinations include, but are not limited to: a. Diagnosis or evaluation of multiple gestations including determination of chorionicity [26-28]. Imaging as an adjunct to chorionic villus sampling, embryo transfer, and localization and removal of an intrauterine device l. Imaging parameters Scanning in the first trimester may be performed either transabdominally or transvaginally. If a transabdominal examination is not definitive, a transvaginal or transperineal scan is recommended. The uterus (including the cervix) and adnexa should be evaluated for the presence of a gestational sac. The gestational sac should be evaluated for the presence or absence of a yolk sac or embryo/fetus, and the crown-rump length should be recorded, when possible [17,23-25]. A definitive diagnosis of intrauterine pregnancy can be made when an intrauterine gestational sac containing a yolk sac or embryo/fetus with or without cardiac activity is visualized. In very early intrauterine pregnancy, small, eccentric intrauterine fluid collection with an echogenic rim can be seen before the yolk sac and embryo. In the absence of sonographic signs of ectopic pregnancy, the fluid collection is highly likely to represent an intrauterine gestational sac. Caution should be used in making the presumptive diagnosis of a gestational sac in the absence of a definite yolk sac or embryo. If the embryo is not identified, the mean sac diameter may be useful for determining timing of ultrasound follow up. However, the crown-rump length is a more accurate indicator of gestational age than the mean gestational sac diameter. Presence or absence of cardiac activity should be documented with a 2-D video clip or M-mode . With transvaginal scans, cardiac motion is usually observed when the embryo is 2 mm or greater in length; if an embryo less than 7 mm in length is seen without cardiac activity, a subsequent scan in one week is recommended to ensure that the pregnancy is nonviable [18-22]. Amnionicity and chorionicity should be documented for all multiple gestations [26-28]. Appropriate fetal anatomy for the first trimester should be assessed and include the calvarium, fetal abdominal cord insertion, and presence of limbs when fetus is of sufficient size [31-35]. The nuchal region should be imaged, and abnormalities such as cystic hygroma should be documented. A quality assessment program is recommended to ensure that false-positive and false-negative results are kept to a minimum [11,12]. The image must be magnified so that it is filled by the fetal head, neck, and upper thorax. The fetal neck must be in a neutral position, with the head in line with the spine, not flexed and not hyperextended. Electronic calipers must be placed on the inner borders of the nuchal line with none of the horizontal crossbar itself protruding into the space. The uterus, including the cervix, adnexal structures, and cul-de-sac, should be evaluated. The presence, location, appearance, and size of adnexal masses should be documented. The measurements of the largest or any potentially clinically significant leiomyomata should be documented. Includes suspected placenta previa, vasa previa, and abnormally adherent placenta r. Suspected uterine anomalies In certain clinical circumstances, a more detailed examination of fetal anatomy may be indicated . Fetal cardiac activity (by video clip or M-mode), fetal number, and presentation should be documented. Abnormal heart rate and/or rhythm should be documented Multiple gestations require the documentation of additional information: chorionicity, amnionicity, comparison of fetal sizes, evaluation of amniotic fluid volume in each gestational sac, and fetal genitalia (when visualized. A qualitative or semiquantitative estimate of amniotic fluid volume should be documented. The placental location, appearance, and relationship to the internal cervical os should be documented. The umbilical cord should be imaged, and the number of vessels in the cord documented. The placental cord insertion site should be documented when technically possible [70,71]. It is recognized that apparent placental position early in pregnancy may not correlate well with its location at the time of delivery.
Social class in asthma and allergic rhinitis: a national cohort study over three decades purchase antivert us medications januvia. Poverty purchase antivert 25mg overnight delivery medicine 3x a day, dirt best order antivert 68w medications, infections and non-atopic wheezing in children from a Brazilian urban center. Wade S, Weil C, Holden G, Mitchell H, Evans R, 3rd, Kruszon-Moran D, Bauman L, et al. Continued exposure to maternal distress in early life is associated with an increased risk of childhood asthma. Lower cortisol levels in children with asthma exposed to recurrent maternal distress from birth. Prenatal and passive smoke exposure and incidence of asthma and wheeze: systematic review and meta-analysis. Impaired airway function and wheezing in infancy: the influence of maternal smoking and a genetic predisposition to asthma. Kulig M, Luck W, Lau S, Niggemann B, Bergmann R, Klettke U, Guggenmoos-Holzmann I, et al. Effect of pre and postnatal tobacco smoke exposure on specific sensitization to food and inhalant allergens during the first 3 years of life. The role of passive smoking in the development of bronchial obstruction during the first 2 years of life. Influence of cigarette smoking on inhaled corticosteroid treatment in mild asthma. Smoking affects response to inhaled corticosteroids or leukotriene receptor antagonists in asthma. Cigarette smoking impairs the therapeutic response to oral corticosteroids in chronic asthma. Association between air pollutants and asthma emergency room visits and hospital admissions in time series studies: A systematic review and meta-analysis. Peanut, milk, and wheat intake during pregnancy is associated with reduced allergy and asthma in children. Fish intake during pregnancy and the risk of child asthma and allergic rhinitis longitudinal evidence from the Danish National Birth Cohort. Maternal obesity in pregnancy, gestational weight gain, and risk of childhood asthma. Nutrients and foods for the primary prevention of asthma and allergy: systematic review and meta-analysis. Effect of vitamin D3 supplementation during pregnancy on risk of persistent wheeze in the offspring: A randomized clinical trial. Paracetamol exposure in pregnancy and early childhood and development of childhood asthma: a systematic review and meta-analysis. Paracetamol in pregnancy and the risk of wheezing in offspring: a systematic review and meta-analysis. Use of prescription paracetamol during pregnancy and risk of asthma in children: a population-based Danish cohort study. Migliore E, Zugna D, Galassi C, Merletti F, Gagliardi L, Rasero L, Trevisan M, et al. Prenatal paracetamol exposure and wheezing in childhood: Causation or confounding Endotyping asthma: new insights into key pathogenic mechanisms in a complex, heterogeneous disease. Narrative review: the role of Th2 immune pathway modulation in the treatment of severe asthma and its phenotypes. The role of dendritic and epithelial cells as master regulators of allergic airway inflammation. Emerging roles of pulmonary macrophages in driving the development of severe asthma. Asthma endotypes: a new approach to classification of disease entities within the asthma syndrome. Pro-angiogenic hematopoietic progenitor cells and endothelial colony-forming cells in pathological angiogenesis of bronchial and pulmonary circulation. Parameters associated with persistent airflow obstruction in chronic severe asthma. Corticosteroid resistance in patients with asthma and chronic obstructive pulmonary disease. Influence of treatment on peak expiratory flow and its relation to airway hyperresponsiveness and symptoms. Peak flow variation in childhood asthma: correlation with symptoms, airways obstruction, and hyperresponsiveness during long-term treatment with inhaled corticosteroids. Multi-ethnic reference values for spirometry for the 3-95-yr age range: the global lung function 2012 equations. Evaluation of peak expiratory flow variability in an adolescent population sample. An official American Thoracic Society/European Respiratory Society statement: asthma control and exacerbations: standardizing endpoints for clinical asthma trials and clinical practice. Which index of peak expiratory flow is most useful in the management of stable asthma Validity of peak expiratory flow measurement in assessing reversibility of airflow obstruction. Distribution of peak expiratory flow variability by age, gender and smoking habits in a random population sample aged 20-70 yrs. Effect of the number of peak expiratory flow readings per day on the estimation of diurnal variation. An official American Thoracic Society clinical practice guideline: exercise-induced bronchoconstriction.
The primary Stiff-knee gait > Definition Constant or asynchronous activity of the rectus femoris muscle prevents knee flexion in the swing phase order cheap antivert on-line symptoms 9 days past iui. If the rectus femoris muscle is out of phase or constantly ac tive buy antivert line symptoms 89 nissan pickup pcv valve bad, this muscle will prevent adequate flexion during the swing phase despite a crouch gait discount antivert online amex treatment yeast uti. Although extension of the knee flexors will then produce a more upright gait, the defective rectus activity prevents forward swinging of the leg because the knee is inadequately flexed [10–12]. Gait with hyperextension of the knee > Definition the knee is overstretched in the early stance phase and remains in this position until the end of the stance phase. The spastic contraction of the triceps surae muscle stiffens the ankles and blocks the dorsal extension movement Fig. The insufficiency of this muscle produces forward of the foot in the stance leg phase during walking. The inclination of the lower leg, requiring compensatory flexion at the thigh then continues its forward motion in relation to the knee and hip in order to keep upright lower leg and the knee is hyperextended (during normal 324 3. If full extension is achieved, the knee flexors are spasticity is present, the intrinsic triceps reflex can even regularly extended sufficiently by standing – and pos move the lower leg in the opposite direction of walking, sibly also by walking – thereby improving the gait [2, 3, 9, which likewise produces hyperextension and is ineffi 12, 20]. In both cases, the treatment 15° involves intensive physical therapy with stretching must address the functional or structural equinus foot exercises, backed up in individual cases by knee exten 3 ( Chapter 3. If the knee flexion contractures increase, lengthening of the knee flexors is indicated – regardless Structural changes of the patient’s age – if these muscles are contributing to the contractures. Before this muscle group is lengthened, other muscle activity possible causes of the crouch gait must be ruled out Table 3. Temporary hip extensor weakness has been reported after the lengthening of the hamstring muscles. Hence Contracture of the hamstring muscles hamstring lengthening needs to be done very cautiously. Preoperative gait analysis is also needed to establish > Definition whether any additional deformities of other joints also Structural contracture of the hamstrings is present even require correction and the extent to which any defective at rest, thereby preventing extension of the knee. Walking function will cial factor in evaluating the functional significance of be improved [12, 20] and energy expenditure reduced a contracture of the hamstring muscles. The degree of  only if the contractures of all the affected leg joints knee extension with the hip flexed, on the other hand, are corrected. If contractures that have developed by way provides information about the length of the knee flex of compensation are not addressed at the same time, the ors and their contribution to the extension deficit of the lengthening of the hamstring muscles will not prove very knee. Only with a knee flexion the splint is used to increase the stretching of both contracture of approx. This also of the stretching can be adapted to the patient’s symp increases the load on the extensor mechanism, which al toms, and the splint can be removed for nursing care ways has to perform the necessary postural work by way procedures. If posture the splint can be used in the immediate postoperative can no longer be controlled, the patient’s ability to walk period it must be prepared before the operation. Structural deformities in spastic locomotor disorders Deformity Functional benefit Functional drawbacks Treatment Contracture of ham (Hip extension) Energy use increases during Lengthening string muscles walking and standing Patellar dislocation – Pain Recentering of the patella (Green, Stanisavljevic, Elmslie) Instability Rotational deformity Compensation of rotational Entanglement of feet, feet not in Correction osteotomy deformities in the hip and foot the direction of walking 325 3 3. If the contractures have been present for a If the contractures had been slight, the follow-up prolonged period we recommend lengthening of the knee treatment phase is relatively short, particularly because flexors and follow-up treatment until no further progress the quadriceps will not have adapted by lengthening can be made. A supracondylar extension osteotomy is excessively in performing its postural work. In tion is not carried out until the knee flexor contractures either case, the goal of treatment must be full extension at are very pronounced (80° –90° ), the follow-up treatment the knee. The more residual flexion remains, the greater and rehabilitation will last for years because of the insuffi the likelihood of a recurrence. It is more useful, We use the extension splint as follows: Directly after therefore, to shorten any excessively long knee extensors the operation, the splint is worn at all times (except for in the affected segment and thus restore its proper ten nursing care procedures. Otherwise a relapse will occur because the patients been achieved, the splint may be worn for shorter periods. When full extension has eral years, the joint capsule and ligaments will also have been restored, a recurrence can be delayed, or even pre shortened, in which case a simple muscle-tendon length vented, by wearing the splint for approx. If severe contractures are present it may prove capsule of the knee can also be released in the same pro necessary to use the knee extension splint as a functional cedure (we do not have any experience with this method. The decision to proceed with surgical lengthening, and particularly the timing of the operation, must be based on the functional handicap and the extent of the deformity rather than the patient’s age. In addition to knee extension, spasticity can also block knee flexion during the swing phase. The result is de layed flexion, after which there is insufficient time for the extension and the knee remains in the flexed position during foot-strike. In such cases, the rectus femoris muscle can be transposed to the knee flex ors (gracilis or semitendinosus muscles) [10, 11, 22]. Less than 20% of knee extension force is lost as a result of this procedure, whereas knee flexion is improved by 10–20° in the swing phase . By contrast, injections of botulinum toxin into the rectus femoris muscle produce disappoint ing results in our experience. Habitual dislocation of the patella > Definition Repeated, and in some cases very frequent, disloca tions occurring as a result of poor dynamic control of the patella. Habitual dislocation can occur as a result of poor coor dination of the muscular control of the patella, although Fig. Knee extension splint as follow-up treatment after length it is much more common in patients with primarily dys ening of the knee flexors. The knee flexion position can quickly and tonic and slightly atactic disorders than in severely spas simply be adjusted via the strap on the extension rod tic patients. They may extensive lateral release (according to Green), particularly help, however, in bridging the period till the surgical in the cranial direction . Transfer of the tibial tuberos deformities must be accepted or surgically treated. An abduction flat foot cannot be left untreated in order to compensate for Rotational deformities any internal rotation but must also be corrected.
Ribavirin increases didanosine phosphorylation and increases risk for mitochondrial toxicity leading to lactic acidosis purchase antivert 25 mg amex symptoms of colon cancer, hepatic decompensation discount 25mg antivert with mastercard medicine lake, and death generic 25mg antivert with mastercard medicine education. Retention hyperkeratosis can look warty in appearance with surrounding purple color or erythema. Hemoptysis and hematochezia may indicate that patients will likely require chemotherapy. Triangular blisters that represent shearing of the skin due to the separation of the epidermis from the dermis. With proximal tubular acidosis (renal tubular acidosis type 2) and global proximal tubular dysfunction, also known as “Fanconi’s syndrome. Thrush usually presents as white plaques called “pseudomembranes” on areas of less friction such as under the tongue and the posterior buccal wall. Resistant forms of thrush (Candida glabrata) require non–azole-based therapy, such as echinocandins and amphotericin B. Symptoms may include blurred vision, decreased visual acuity, increasing “floaters,” or a clear visual field cut. Weight loss > 10% of body weight with either chronic diarrhea or weakness and fever for > 30 days. Anemia occurs in up to 80%, neutropenia in 85%, and thrombocytopenia in 65% of cases. The temporal relationship of symptoms to initiation of medication is the only way to implicate a drug side effect as the etiology of the neuropathy. Principles and Practice of Infectious Diseases, ed 6, Philadelphia, 2005, Churchill Livingstone. Inordertobe transportedout of the cellintocirculation,Fe2hasto be convertedbackto Fe3(byhephaestinand other enzymes. Ferroprotein transports Fe3into the circulation, but only a limited amount of iron circulates. The transferrin receptor in the hematopoietic precursors binds transferrin (iron bound) and creates an endosome to liberate the iron within the cell. An acute-phase reactant that inhibits iron egress from the cells by binding to and inactivating the iron transport protein ferroprotein. Intestinal absorption of iron and iron release by macrophages is also negatively influenced by hepcidin. Levels > 300 ng/dL in males and > 200 ng/dL in females are suggestive of hemochromatosis. Ferritin is an acute-phase reactant and may be elevated in inflammatory conditions. The serum transferrin saturation (serum iron divided by the total iron-binding capacity) is also frequently used to screen for hemochromatosis. A serum transferrin saturation > 50% for women and > 60% for men suggests the possibility of iron overload. Use of this genetic method in population studies shows that not all patients who appear to have the hemochromatosis genotype develop clinical iron overloading. If C282Y mutation is absent or the patient is not Caucasian and the patient is young (<30 yr), thinking about hemojuvelin or hepcidin mutation is appropriate. When iron overload is present in patients with normal or low transferrin saturation, a plasma ceruloplasmin should be drawn to exclude aceruloplasminemia. Initially with weekly phlebotomy as long as the ferritin is > 300 for males and > 200 for females. Once this level is achieved, phlebotomy continues every other week until the ferritin is < 50. If the hemoglobin (Hb) is < 11, phlebotomy is contraindicated and iron chelators may be needed. Le Lan C, Loreal O, Cohen T, et al: Redox active plasma iron in C282Y/C282Y hemochromatosis, Blood 105:4527–4531, 2005. Beutler E, Waalen J: the definition of anemia: What is the lower limit of normal of the blood hemoglobin concentration The mechanisms of anemia include underproduction, destruction (hemolysis), and blood loss. Most anemias are chronic and allow the body to compensate to maintain sufficient Hb levels. Milman N: Prepartum anemia: prevention and treatment, Ann Hematol 12:949–959, 2008. The interpretation, though, can vary among pathologists, and this method is not useful for diagnosis after replacement with parenteral iron therapy. A ferritin < 30 mg/dL is diagnostic of iron deficiency, but relying only on this cutoff would miss milder forms of iron deficiency. Usually oral ferrous sulfate, 325 mg three times/day until the anemia corrects and then continued for an additional several months. Patients usually need to start at once-daily dosing and gradually increase to three times/day to improve tolerance. When is it appropriate to order Hb electrophoresis to evaluate hypochromic microcytic anemia The microcytic disorders that may be detected are b-thalassemia minor and the so-called thalassemic hemoglobinopathies (including hemoglobin E [HbE] in Asians. Iron deficiency results in a decreased pool of alpha chains, for which the beta chain of HbA and the delta chain of HbA2 must compete. Beta chains are more successful, resulting in diminished HbA2 during iron deficiency.
No muscle forces are required in the frontal the method can be applied to girls from a skeletal age plane order antivert discount treatment ketoacidosis. The situation is different for a single-leg stance of 10 years and buy 25 mg antivert with mastercard medications not to be crushed, correspondingly discount antivert american express medications that cause hair loss, to boys from 12 years or during the stance phase while walking. The various sizes of the template are shown counting the rectangles and triangles located under the in Fig. This pattern can be copied onto a sheet of anterior or posterior rim of the acetabulum, the percent transparent film. The sheet with the template of the ap 3 age of the covered area in relation to the total surface propriate size is placed over the hip x-ray ( Fig. Schematic view of the forces in the hip according to Pauwels  a in the normal hip, b valgus hip and c varus hip. The diagram shows the effect produced by a change in the lever arms on the acting forces (G Center of gravity, W Body weight, R Force resultant in the hip, M Forces of the abductors) a b c Fig. The percentage in relation to the total surface area of femoral head and the anterior and posterior acetabular rims can also the sphere (lower figure) can be calculated by counting the segments be entered on the templates (also Fig. A method based on the same principle but employing more sophis ticated computer calculation was recently described . The figures marked on the template also allow an estimate to be made of the angles between the center of the femo ral head and the anterior and posterior acetabular rims. The two angles for the anterior and posterior sides are read off the template and then marked on the x-ray. The acetabular orientation in both the sagittal and anatomical planes can be determined by drawing a line between the two marks entered for the angles on the ventral and dorsal sides . The sections bounded by the anterior erally forms an angle of 17° from the vertical, the nearest and posterior rims of the acetabulum are counted and converted into sector boundary to the vertical on the template can be the percentage of the total surface area of the sphere used as an approximation, since the angle between the a b Fig. Angles between the center of the femoral head and the anterior b the nomogram can used to determine the acetabular orientation () and posterior (’) acetabular rims. The plane between these two (anteversion/retroversion) by drawing a line between these two scales points corresponds to the acetabular orientation or anteversion. The point at which this line crosses the force the posterior wall sign on both sides (the corresponding contours are resultant R (at an angle of approx. Labral lesions are clearly visible on both sides up to the determined anterior boundary. This bounded area can be calculated very simply using the template (C Head center. This load-relevant area can sively large and deep acetabulum can lead to impingement be calculated very simply by counting the rectangles and (known as a »pincer effect«. A projecting the freedom of movement between the femoral head and anterior inferior iliac spine that is positioned too low (e. Various anatomical and responsible for the femoral neck striking the acetabu biomechanical studies have identified the factors which, lar rim, as typically occurs in slipped capital femoral instead of a smooth sliding movement between the femo epiphysis ( Fig. On the one hand, this damages ral head and acetabulum, cause the femoral neck to strike the acetabular labrum (known as a »cam effect«) and, on the acetabulum, in turn triggering a shear movement of the other, produces a shear movement of the head within the head in the joint [9, 19, 21, 24]. The shear movement mainly occurs during pingement« may lie in the acetabulum, the femur or both flexion, but can even be present during normal walking components together. The impingement As regards acetabular causes, reduced anteversion can be reduced by external rotation of the leg during ( Fig. The excessively small loading area is a factor in the above-listed situations 1, 2, 4, 5 and 6. In many cases, the resulting shear forces cause arthroses that used to be described as »idiopathic«. In a triple osteotomy, all three bones (ilium, pubis and ischium) are divided, while the cut in a periacetabular osteotomy goes around the acetabulum (and thus through the triadiate cartilagetriradiate cartilage, as well. The acetabulum is not actually enlarged but is rather rotated laterally and – if necessary – anteriorly, thereby enlarging the relevant Fig. This op old female athletic patient with apophyseal avulsion and excessively low growth of the anterior inferior iliac spine (arrow), resulting in eration is particularly suitable if the bony components are impingement with the femoral neck during flexion roughly spherical but inadequate lateral acetabular cover age exists. In this case the anterior coverage is improved at the expense of the posterior coverage. Amtmann E, Kummer B (1968) Die Beanspruchung des menschli Effects of incorrectly shaped bony chen Huftgelenks. Braune W, Fischer O (1889) Uber den Schwerpunkt des menschli the crucial question in every case is whether an incor chen Korpers. Brinkmann P, Frobin W, Hierholzer E (1980) Belastete Gelenkflache rectly shaped component can lead to premature osteo und Beanspruchung des Huftgelenks. Elke R, Ebneter A, Dick W, Fliegel C, Morscher E (1991) Die sonog following anatomical changes are present: raphische Messung der Schenkelhalsantetorsion. J Bone Jt Surg A pre-arthritic condition probably also exists in cases of: Br 83: 171–6 10. J Bone risk of premature osteoarthritis in the case of an: Joint Surg (Br) 75: 750–4 12. Kummer B (1968) Die Beanspruchung des menschlichen Huftge tions do not constitute pre-arthritis : lenkes. Morscher E (1992) Biomechanik als Grundlage der Orthopadie congenital form of hip dislocation .
Purchase antivert visa. Symptoms Diagnosis and Treatment Pneumonia.
Rationale—By supplying the proper sensory input of what a muscle contraction or limb movement feels like and visual information about the appearance of the action purchase antivert overnight delivery treatment glaucoma, electrical stimulation can enhance a motor response discount antivert amex medicine allergic reaction. It also may prevent decreases in muscle oxidative capacity and provide an articial drive to inactive synapses in some circumstances buy antivert 25 mg on line symptoms type 1 diabetes. Indications—Any patient for whom a motor and sensory-augmented muscle response would assist in better performance of his or her own voluntary actions 4. Parameters—Pulse duration, 100 to 200 msec; pulse rate, 35 to 50 Hz; intensity, to a tolerable motor level up to 3+/5; ramp, 1 to 3 sec up/down; on/off, 1:1 ratio set or hand-held switch; treatment time, 5 to 30 min, 1 to 3 times/day, 3 to 7 days/week, 1 to 2 weeks; polarity, not applicable 5. Special considerations—Facilitation and reeducation require active participation by the patient and may be limited by patient tolerance, cooperation, and attention span. Studies support the use of high-intensity electrical stimulation but do not consistently support the use of low-intensity or battery-powered stimulators when the desired objective is the recovery 86 Electrotherapy and Modalities of quadriceps femoris muscle force production. A study by Snyder-Mackler and colleagues indicates that training contraction intensity is positively correlated with quadriceps femoris muscle recovery, with an apparent threshold training contraction intensity of 10% of the maximal voluntary contraction of the uninvolved quadriceps femoris muscle. Outline an appropriate protocol for muscle strengthening in terms of purpose, rationale, indications, parameters, and special considerations. Purpose—To increase muscle strength, encourage muscle hypertrophy, and facilitate normal motor response 2. Rationale—Electrical stimulation can be used to help patients achieve a volitional contraction sufcient to increase strength and prevent disuse atrophy if they are unable to do so on their own. Indications—Any patient in need of increasing girth and strength of an atrophied muscle 4. Special considerations—This program should be used with patients with sufcient innervation to make muscle strengthening practical. Strengthening and muscle girth improve in orthopaedic patients, and shoulder subluxation, in particular, can be prevented or corrected in neurologically involved patients. Reduced postsurgical muscle atrophy, increased muscle torque values, improved quadriceps femoris muscle strength, and improved functional recovery are some of the benets. Three training sessions per week for 4 weeks have been shown to be effective for strength gains versus two training sessions per week for 4 weeks. Can electrical stimulation protocols developed for a certain muscle group be used for training muscles with a different ber-type composition Research suggests that variable frequency stimulation can augment the force of skeletal muscle irrespective of ber type. Is there a relationship between muscle contraction strength or fatigue and type of waveform used with electrical stimulation Recent evidence suggests that monophasic and biphasic waveforms generate greater torque and are less fatiguing than polyphasic waveforms. Conventional Low Rate Brief Intense Phase duration 60-100 µsec 200-400 µsec 250 µsec Pulse rate 80-125 Hz 2-4 Hz 125 Hz Intensity Sensory just below Muscle fasciculation Sensory just below muscle motor Treatment duration As needed 30-45 min 10-15 min Onset of relief 10-20 min 25-30 min 1-5 min Carryover 30 min to 2 hr Hours to days Short Indications Acute, supercial Acute to chronic Wound debridement and deep pain, rst time pain ber massage application Theory Gate theory Gate theory Gate theory Opiate mediated Opiate mediated Opiate mediated Placebo Placebo Placebo Other Other 50. Protocols should begin with simple one-plane joint movements, use antigravity starting positions with a rest between movements, and progress to antigravity positions without a rest between movements. Reasonable 88 Electrotherapy and Modalities parameters are the following: intensity, to a tolerable motor level up to 3+/5; frequency, 35 to 50 Hz; phase duration, 100 to 200 msec; ramp, 4 to 5 sec progressing to 3 sec; on/off, as required to achieve desired range of motion; treatment time, 30 min/day, 50 to 100 repetitions, as needed. The contraction of skeletal muscles by electrical stimulation can produce a muscle contraction capable of aiding lymphatic and venous flow. The intervention can be enhanced further by combining it with other forms of management, such as elevation, rest, and compression. Reasonable stimulation parameters should focus on producing a nonfatiguing muscle contraction: pulse rate, 4 to 10 Hz; phase duration, ±300 µsec; waveform, biphasic or high volt; polarity, not applicable with this protocol; intensity, visible contraction of muscles in the area where edema is noted, 1/5 to 3/5; time of treatment, 30 min, 2 to 3 times/day, 1 to 2 weeks; electrode placement, muscle bulk of an involved muscle or an involved joint. This protocol should be used in conjunction with ice application and elevation of the affected area. Delitto A, Snyder-Mackler L: Two theories of muscle strength augmentation using percutaneous electrical stimulation, Phys Ther 70:158-164, 1990. Delitto A et al: Electrical stimulation versus voluntary exercise in strengthening thigh musculature after anterior cruciate ligament surgery, Phys Ther 68:660-663, 1988. Draper V: Electromyographic biofeedback and recovery of quadriceps femoris muscle function following anterior cruciate ligament reconstruction, Phys Ther 70:11-17, 1990. Draper V, Ballard L: Electrical stimulation versus electromyographic biofeedback in the recovery of quadriceps femoris muscle function following anterior cruciate ligament surgery, Phys Ther 71:455-461, 1991. An overview and its application in the treatment of sports injuries, Sports Med 13:320-336, 1992. Iontophoresis, Ultrasound, Phonophoresis, and Laser Therapy 89 Laufer Y et al: Quadriceps femoris muscle torques and fatigue generated by neuromuscular electrical stimulation with three different waveforms, Phys Ther 81:1307-1316, 2001. Snyder-Mackler L et al: Use of electrical stimulation to enhance recovery of quadriceps femoris muscle force production in patients following anterior cruciate ligament reconstruction, Phys Ther 74:901-907, 1994. Snyder-Mackler L et al: Strength of the quadriceps femoris muscle and functional recovery after reconstruction of the anterior cruciate ligament. A prospective, randomized clinical trial of electrical stimulation, J Bone Joint Surg Am 77:1166-1173, 1995. Chapter 11 Iontophoresis, Ultrasound, Phonophoresis, and Laser Therapy Fredrick D. Ions are introduced with iontophoresis, whereas molecules are introduced by the ultrasound waves. Furthermore, because sound waves are not electrical in nature, no ionization takes place. In 1908 Leduc showed that ionic medication could penetrate intact skin and produce local and systemic effects in animals. Two rabbits were placed in series in the same direct current circuit so that the current had to pass through both rabbits to complete the circuit.