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The accentuation of the arch reduces the lower leg in relation to the foot on the ground during the cushioning function of the foot premarin 0.625 mg discount. A self-supporting arch standing and brakes this motion in the stance phase dur- (similar to a Roman archway) that no longer permits cush- ing walking buy premarin 0.625 mg on line. The pes calcaneus results from a weakness ioning develops from the longitudinal foot arch cheap premarin 0.625mg free shipping. The main load is transferred to the heel the heel and the ball of the foot are overloaded particularly and the lower leg stands in a forward lean generic 0.625mg premarin amex. By way of during walking discount 0.625 mg premarin fast delivery, leading to increased callusing and sub- compensation, the knees and hip must be held in flexion sequently to local painful conditions. Symptoms are rare, to ensure that the whole sole strikes the ground, other- therefore, for as long as the pes cavus remains mobile. Without inserts, the foot is functionally stretched and flexed dur- The triceps surae muscle normally acts to stabilize the ing walking and thus remains mobile. Inserts, on the ankle and thereby prevent the lower leg from sinking 437 3 3. Functional deformities in primarily flaccid locomotor disorders Deformity Functional benefit Functional drawbacks Treatment Pes calcaneus – Crouch gait Functional orthosis (muscle transfer) position Arthrodesis Functional Compensates for in- Walking/standing Functional orthosis abducted pes creased internal rota- aggravated Cast correction planovalgus tion of the leg Risk of dislocation in the Lengthening of the triceps surae and/or peroneal muscles tarsal bones (pain) Lengthening of lateral column of foot Arthrodesis forward during standing and walking. A precondition appears to be suffer a loss of power during a paresis or myopathy (the adequately free plantar flexion, which is no longer present same symptoms are also observed after excessive tendon in most cases. The affected patients have to stand on their heels only to offset this weakness. But since the Functional abducted pes planovalgus resulting ground contact area is too small and the stabil- > Definition ity inadequate, some patients will sink forward with the The foot gives way under load as a result of the absent, foot and lower leg, causing them to stand and walk in a or insufficient, activity of the muscles that stabilize the crouch position, i. The arches are flattened out, the heel is in a valgus sition requires more power and energy for walking and position and the forefoot is abducted. The skeleton is standing, and the flexed positions of the joints become normal when the foot is not weight-bearing. The ability to walk and For the functional form of abducted pes planovalgus in stand is then jeopardized with increasing age, weight muscle weakness due to a paresis or myopathy, the same and height. The orthosis must be of a can be achieved only by means of an external appliance rigid design since it has to replace the absent muscle activ- (orthosis) or a surgical procedure. During walking, the orthosis prevents the premature throdesis of the lower ankles (usually an extra-articular forward movement of the tibia in relation to the foot in Grice operation) is performed to stop the foot from going contact with the ground and ensures adequate knee exten- over. For growing children there is no alternative to an ing valgus component of the foot. An excessive dorsiflex- orthosis, since an arthrodesis will inhibit foot growth and ion, as also observed in insufficiency of the triceps surae, leave the feet smaller than normal. Only on completion remains, and this is much more disruptive from the func- of growth can the orthosis be replaced surgically with an tional standpoint. Since an orthosis will still be required arthrodesis, which must incorporate the upper and lower the benefit for the patient from a procedure such as the ankle. Due to a lack of mobility, and hence of compensa- Grice arthrodesis is minimal. Maintaining mobility is therefore favorable Structural deformities in functional feet, especially if sensation is not normal. A Structural deformities in primarily flaccid locomotor disor- muscle transfer procedure to replace the absent plantar ders and muscular dystrophies are shown in ⊡ Table 3. Although good results have been Structural deformity of the foot caused by reduced or described, our everyday experience with our patients has absent muscle activity. The shortening of the Achilles tendon represents a Definition logical alternative. However, this procedure is reputed to A contracture of the triceps surae muscle is present, produce poor results. Although it can prove helpful in regardless of the muscle activity and power, which extreme cases, the chances of a good result in neuro-or- prevents dorsiflexion even with a flexed knee. This must be prepared difficult for the body to keep in balance over the flaccid leg. Otherwise the only bilizers that would have to keep the foot on tiptoe are also option for protecting the knee from giving way in flexion insufficient. The foot skeleton becomes deformed and fixes is by supporting it with the hand ( Chapter 4. The ability to A slight hyperextension of the knee of up to 5° is 3 walk and stand can be further impaired as a result. Ideally, the hyperextension should be permits weight-bearing without deformation of the foot prevented indirectly by a corresponding orthosis for the skeleton.

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The increase in VE/VCO2 reflects respi- ISOTONIC/DYNAMIC CONTRACTIONS ratory compensation for rise in blood lactate generic premarin 0.625 mg fast delivery. Specific types of dynamic contractions include concentric buy discount premarin 0.625mg on line, MAXIMAL HEART RATE eccentric safe premarin 0.625 mg, and isokinetic purchase 0.625mg premarin with mastercard. This is also known as test is not possible buy premarin 0.625mg otc, then age-predicted heart-rate for- positive work. Two formulas used are: Maximal When the direction is reversed and the weight is low- HR = 220 – age or 208 – 0. More fast-twitch motor units are may be more accurate for older persons and is inde- activated during eccentric contractions. It is important to ISOKINETIC CONTRACTIONS note that an estimated maximal HR may be 5 to 10% Isokinetic machines make these contractions possible: (10 to 20 bpm) higher or lower than the actual value. The applied resist- influenced by body position and amount of muscle ance during the contraction is increased or lowered at mass involved. HEART RATE RESERVE Diagnostic strength equipment use isokinetic tension, so more accurate measures of strength can be made at The difference between maximal HR during maximal varying joint angles. If maximal HR is 205 bpm and resting HR is BORG SCALE OR RATING OF 55 bpm, then HRR would be 205 – 55 = 150 bpm. The PERCEIVED EXERTION smaller the difference, the lower the reserve and the narrower the range for exercising. The original Borg scale ranges from 6 to 20, with each number anchored Atraining program requires calculating a target heart range. To calculate the lower and upper target heart TABLE 8-4 The Original and New Borg Scales for Rating rates, 60–90% of maximal heart rate or 50–85% of of Perceived Exertion heart rate reserve can be used. Examples of isometric CHAPTER 8 BASICS IN EXERCISE PHYSIOLOGY 41 by a simple verbal expression: a person exercising at For example, work for cycle ergometry is measured as: 130 bpm should report a RPE of 13. A variant scale resistance (kg) × rev/min × flywheel distance (m) × using 0 to 10 as the numeric ratio has been proposed. If a 80-kg male cycled at 100 rpm against a 3-kg load for 20 min (flywheel distance of 6 m), then: Work = 3 kg × 100 rpm × 6 m/rev × 20 min = 36,000 MEASUREMENTS OF ENERGY, kgm Power = 36,000/20 min = 1,800 kgm/min = WORK, AND POWER 1800/6. WORK EFFICIENCY Energy: The capacity to do work, with energy meas- ured in Joules: 4. Work is often Net work efficiency is the ratio of mechanical work expressed in kilogram-meters or kgm, where 1 kcal = output to total energy expended minus resting EE. For rate, speed of movement, and muscle fiber composi- direct calorimetry, both external work and heat output tion, and a variety of biomechanical factors, such as are measured, and heat production is used as an esti- equipment and clothing. For indirect calorimetry, either open or closed circuit spirometry can be used. Simplistically RER can be added to 4 and then multiplied by L of Economy of movement is defined in terms of VO2 O2/min to derive kcal/min. METABOLIC ENERGY EQUIVALENT Metabolic energy equivalent (MET) is the energy cost CALCULATING WORK AND POWER of activities in terms of multiples of resting metabolic rate. If 1 MET (resting metabolic rate) is taken as W ork and power are calculated based on the particu- 3. For many treadmill protocols, an increase Energy expenditure for activities such as eating, in VO2 <0. BASIC CONCEPTS IN AEROBIC AND VO2peak: When an exercise tests is terminated and the ANAEROBIC EXERCISE criteria described are not met, the higher VO2 achieved is referred to as VO2peak. MAXIMAL AEROBIC POWER Ventilatory threshold: Ventilatory threshold is the point where VE begins to increase disproportionately Maximal aerobic power, or VO , is the greatest to VO2 during incremental exercise testing. It is a 2max measure of “excess” ventilation and has been termed amount of O2 a person can consume during physical exercise. HR at sub- and O2 transport systems, and is considered “power” maximal work rates can be plotted against VO2 and then because it is a rate: L of O2/min. Cycle tests are most appropriate because there are expected VO2 values as a function of Watts (see ing for body weight would yield values of 60 and 45. If person one weighed 70 kg nonexercise data can also be used to estimate VO2max.

As these events accumulate generic premarin 0.625 mg overnight delivery, the patient becomes imbedded in a narrative buy premarin 0.625mg low cost. This narrative is a tapestry of meaningful connections specific to the individ- ual from which he develops an understanding of his own existence and sets of assumptions about his roles in the world 0.625mg premarin. At times order premarin 0.625mg overnight delivery, a person experiences the unintended consequences of past events generic premarin 0.625mg online. When life turns out differently from what was expected, the outcome is demoralization. This loss is not the result of the bro- ken part caused by a disease but of an individual left wanting something better from life. Evaluation within the domain of life stories involves knowing more of the personal story and appreciating the patient’s meaningful understanding of those events. In treatment, the patient is persuaded by the physician to give up his current interpretation of those events for another. A new interpretation is not necessarily a more ‘correct’ or ‘true’ interpretation. An infinite number of meanings can be generated for a given set of historical life events. The impor- tance of the new interpretation is that it tries to be useful and restore a sense of mastery for the patient. If the patient can embrace a new understanding of his situation and why it has occurred, he can go forward with a renewed sense of control over his life that now again has the potential for success. An example is a patient who in childhood grew up in an extremely authoritarian environment with unreasonable expectations and few rewards for success. The patient was expected to get A’s in school and anything less was equivalent to failure. This patient found that illness produced decreased expectations for his performance and was ‘rewarded’ for circumstances of illness with decreased expectations. As an adult, the patient is perfectionistic and chronically dissatisfied with his own performance. A knee injury made it difficult for him to perform at work and ultimately the patient was encouraged to accept disability to decrease the burden on his employer. This produced a feeling of uselessness and disappointment but the patient was trapped by his handicap. Rehabilitative psychotherapy reframed the performance of overcoming the handicap as a success and rewarded the efforts of physical therapy and vocational rehabilitation as a triumph over the adversity of illness. Ultimately, therapy was able to get the patient to recognize the pattern in his life of illness decreasing distress by lowering self-imposed expectations. The patient was successfully able to return to work with ongoing psychotherapy. Recognizing recurring patterns of events would allow for changes to avoid future circumstances of the same kind and restore the individual’s sense of mastery. Clark/Treisman 10 The cognitive-behavioral model of chronic pain assumes individual perceptions and evaluations of life experiences affect emotional and behavioral reactions to these experiences [Keefe et al. If patients believe pain, depression, and disability are inevitable and uncontrollable, then they will expe- rience more negative affective responses, increased pain, and even more impaired physical and psychosocial functioning. The components of cognitive- behavioral therapy (CBT) such as relaxation, cognitive restructuring, and coping self-statement training interrupt this cycle of disability and enhance operant- behavioral treatment [Turner, 1982a, b; Turner and Chapman, 1982]. Patients are taught to become active participants in the management of their pain through the utilization of methods that minimize distressing thoughts and feelings. Outcome studies of CBT in patients with syndromes ranging from specific painful diseases to vague functional somatoform symptoms have demonstrated significant improvements in pain intensity, pain behaviors, physical symptoms, affective distress, depression, coping, physical functioning, treatment-related and indirect socioeconomic costs, and return to work [Hiller et al. The effectiveness of cognitive behavioral treatments in adults with chronic pain has been documented in a meta-analysis across numerous outcome domains [Morley et al. Pain reduction and improved physical function have been found to continue up to 12 months after the completion of active cognitive-behavioral treatment [Gardea et al. Ultimately, the goal of treating patients with chronic pain is to end disability, return people to work or other productive activities, and improve quality of life.

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A gallium bone scan The disease manifests itself clinically either during the can be helpful in establishing the existence of a bacterial course of childhood (type III) or during adolescence infection generic premarin 0.625 mg amex. Type III is additionally characterized Treatment of the underlying disorder by muscle hypotonia with gait abnormalities premarin 0.625 mg otc, strabismus A breakthrough was made some years ago in the treat- and psychomotor retardation purchase premarin 0.625mg with amex. These are soon followed ment of Gaucher disease effective 0.625 mg premarin, following the production of the by anemia 0.625 mg premarin with mastercard, bleeding tendency and repeated infections. The The following skeletal changes are observed: Infiltration missing enzyme can now be substituted with Ceredase of the bone marrow, bone necroses, »bone crises«,. The treatment is very expensive, but is capable of pathological fractures, osteolysis and osteomyelitis. The metaphysis and diaphysis of the affected bone are widened and the corti- Orthopaedic treatment cal bone becomes thinner (⊡ Fig. The orthopaedic treatment depends on the nature of the These changes often remain asymptomatic for a fairly complication. The storage of Gaucher cells can ultimately lead logical fractures and osteomyelitis. The fracture manage- to impairment of the blood supply and thus to necrosis. Long periods of immobilization tial confusion with Legg-Calvé-Perthes disease, although are frequently required. The osteomyelitis is treated by the necrosis can also occur in the head of the humerus or local clearance and the administration of antibiotics. This is characterized by intense ing kyphosing at the thoracolumbar junction (⊡ Fig. The frequently occurring femoral head necrosis can warmth, redness and occasionally fever as well. During result in premature osteoarthritis of the hip and the need the crisis, an increased uptake is apparent on the techne- for a total hip replacement. AP x-ray of the pelvis in a 7-year old girl with Gaucher disease and an intertrochanteric fracture of the right femur 699 4 4. The proliferating cells are derived either from the Schwann cells or accompanying cells. Viewed macroscopically the neurofibromas are bright, relatively compact nod- ules that are connected to the peripheral nerves. Neurofibromas also occur in the central nervous system (brain, spinal cord). Occurrence After Down syndrome, neurofibromatosis is the most common hereditary disease. In Israel, prevalence figures of 104/1,000,000 males and 119/1,000,000 females have been reported. Type II neurofibromatosis is much less common (1/1,000,000 inhabitants). Neurofibromatosis type I Clinical features, diagnosis At least two of the following clinical characteristics are required before a diagnosis of neurofibromatosis can be made: ⊡ Fig. X-ray of the spine of a 9-year old boy with Gaucher disease ▬ Café-au-lait spots: Light brown, regular pigmented le- and a low thoracic kyphosis sions that can cover large areas. Dystrophic scoliosis sues associated with the central and peripheral nervous is short-curved and has a kyphotic component. Typical or- vertebral bodies show a curved indentation, the ribs thopaedic problems include leg lengthening, congenital are thinned on the concave side facing the spine and tibial pseudarthroses and short-curved progressive sco- markedly rotated (⊡ Fig. In 1918 Gould mentioned nection with substantial accumulations of subcutane- the occurrence of scolioses in connection with neurofibromatosis. Such lengthening man with a grotesquely deformed skull who was the subject of a play occurs in approx. However, more recent investigations of his Neurological lesions: Discrete neurological changes, skull have revealed that John Merrick had suffered not from neurofi- particularly sensory abnormalities, occur in 15% of bromatosis, but rather from Proteus syndrome. In addition to the neurofibromatosis solitary at least two must be present, the following additional neurofibromas are also present in Proteus syndrome, al- changes can occur: though these do not usually affect children and adoles- ▬ Elephantiasis (pachydermatocele): hypertrophy of the cents, but patients aged between 20 and 40 years. Within the population of neuro- Patients with neurofibromatosis have a largely normal life fibromatosis patients, however, tibial pseudarthrosis expectancy.

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