By S. Kulak. University of Northern Colorado.

    Impairments can usually be objec- tively specified by an observer such as a physician or surgeon discount zovirax 800 mg overnight delivery, and are classified in a standard text order zovirax 200mg with amex, the American Medical Association Guide to Impairment buy generic zovirax 200mg online. For example, a limitation in shoulder range of motion secondary to a cerebral vascular accident may greatly affect the life of an active patient and be of little importance to a sedentary elderly patient. We will focus our discussion on the disablement model developed by Saad Nagi, a sociolo- gist,12 the International Classification of Impairments, Disabilities and Handicaps (ICIDH-1),13 and its current revision, the International Classification of Functioning, Disability and Health (ICF). It may not constitute a disability for some occupations (manual laborer) but would produce complete disability for others (concert pianist, surgeon). This is a fundamental distinction of critical importance to scholarly discussion and research related to disability phenomena. We will not review the ICIDH-1 classification except to note that in principle this original system was designed as a model for coding and manipulating data on the consequences of health conditions. Part 1 covers functioning and disability including body functions, structures, activities, and participation. Each component consists of various domains and, within each domain, categories that are the units of classification. This view fails to recognize that disablement is more often a dynamic process that can fluctuate in breadth and severity across the life course; it is anything but static or unidirectional. More recent disablement formulations and elaborations of earlier models have explicitly acknowledged that the disablement process is far more dynamic. In these newer concepts, a given disablement process may lead to further downward spiraling consequences. Pope and Tarlov15 use secondary conditions to describe any type of secondary consequence of a primary disabling condition. Commonly reported sec- ondary conditions include pressure sores, contractures, depression, and urinary tract infections, but it should be understood that they can be pathologies, impairments, functional limitations, or additional disabilities. Longitudinal analytic techniques now exist to incorporate secondary conditions into research models and are beginning to be used in disablement epidemiologic investigations. Because patient satisfaction is a multidimensional concept, it is important to start by understanding its multiple definitions. Patient satisfaction is a complex concept that may incorporate sociode- mographic, cognitive, and affective components. Although many theories for patient satisfaction have been proposed, few have been extensively tested and validated in different health care settings. Moreover, few studies have been conducted to explain associations between patient satisfaction and patient characteristics or subsequent patient behaviors. Although theories of patient satisfaction are difficult to categorize in an organized and easily comprehensible fashion, one may group these theories into intrapatient comparisons (disconfirmation theory) and differences between individual patients and health care providers (attribution theory) or other patients (equity theory). Intrapatient comparison theories explain the satisfaction phenomenon by a match between patient expectations and perceptions of medical care. Differences between what is expected and what is perceived to occur will contribute to patient satisfaction or dissatisfaction. This theory is the dominant model of nonmedical customer sat- isfaction in which consumers compare their perceptions of a product or service against prior expectations. Equity theories are based on the premise that patient satisfaction relates to whether patients believe they have been fairly treated. Equity occurs when patients compare their balances of inputs (time and money) and outputs (medical care and its results) with those of other patients. Patient satisfaction occurs when people perceive they are treated fairly; it may increase when patients perceive their outcomes as more favorable than those of other patients with the same conditions. A related concept is gap analysis in which identification of differences between provider and patient perceptions of services occurs. Addressing potential gaps arising because providers focus primarily on delivery of medical care and patients focus on services used may increase patient satis- faction. The difficulty in measuring patient satisfaction lies in the fact that satisfaction is a multidimensional concept with inputs or determinants that are not yet clearly defined. One of the major criticisms of patient satisfaction research relates to methodologic issues including lack of psychometric standards, reliability, and validity of surveys.

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    Correction of underlying somatic dysfunction in the sacroiliac joint 800 mg zovirax with visa, hip and hamstrings will provide a more accurate straight leg-raising test purchase 800 mg zovirax mastercard. Sacroiliac joint dysfunction is also capable of placing biomechanical stress on the 76 posterior sacroiliac ligament order zovirax 200mg without prescription. This ligament has been shown to create a pain pattern similar to that of the gluteus minimus. Significant stress on this ligament, and the piriformis muscle as well, is seen after certain traumatically induced shearing forces into the sacroiliac joint, creating non-physiological somatic dysfunction (dysfunction that is not a normal part of the motions of this joint while walking, breathing and bending). Often resolution of low back pain with radiation down the leg is delayed until the sacral or innominate shearing dysfunction is corrected. Such somatic dysfunction has been documented by Greenman to be two of the top six diagnoses responsible for recurrent 77 low back pain otherwise unresponsive to conservative care. Piriformis muscle dysfunction is another diagnosis that should be ruled out in patients with a sciatic pain distribution. Travell and Simons document entrapment of the sciatic nerve (or more commonly the peroneal fibers within) with myofascial trigger points in this muscle and the osteopathic literature discusses the piriformis syndrome as having the 78 potential to maintain irritability of the underlying sciatic nerve. In the case of true entrapment, there may be some weakness in testing muscles innervated by the peroneal nerve and the Complementary therapies in neurology 82 Figure 6 Anatomic variations of relationship between the sciatic nerve and the piriformis muscle: neurologic implications of piriformis somatic dysfunction vary with structure as does treatment with injection therapy. Reproduced with permission from reference 78 patient may notice a slight foot drop when tired. Other critical diagnostic findings include ipsilateral external hip rotation and palpable hypertonicity generally with the potential for local myofascial trigger points (Figure 6). Tenderness over the sciatic nerve without these Osteopathic considerations in neurology 83 palpable changes in the piriformis muscle or its function would rule out piriformis 2 dysfunction as the cause of the symptoms. A final caveat in this discussion is offered based upon the multiple models applied to diagnosis and treatment in this region; co-existing and overlapping diagnoses are quite common here. A variety of effective OMT techniques can be applied to correct sacroiliac, gluteus 81 and piriformis dysfunction. Because of the potential for co-existing pathology, dysfunction in the presence of preliminarily positive neurological testing is most commonly treated with counterstrain, indirect myofascial release, or muscle energy techniques. For pelvic shearing somatic dysfunction, a gentle springing or, occasionally, a direct reversal of the traumatic shearing forces will provide dramatic relief. Care in positioning to avoid aggravation of any existing dysesthesia or pain is the rule. A more complete description of an osteopathic approach to lower motor neuron disorders will appear at the end of this chapter. Other common neurological tests and syndromes with somatic differentials As noted above, an important component of the osteopathic approach to patients presenting with signs and symptoms of what might be a neurological disorder involves ruling out and/or treating certain somatic dysfunctions considered to be important in the differential diagnosis or that might confound the neurological tests used. In definitive neurological disorders, the co-existence of somatic dysfunctions that produce similar symptoms makes the diagnosis and treatment of somatic dysfunction in these patients an important component to be considered. The constraints on the length of this chapter do not allow the use of the same level of detail as used in the previous section concerning radiculopathy and sciatica. Table 3, however, provides a partial list of entrapment neuropathies, neurological tests that might be altered by certain somatic dysfunctions, and pain and dysfunction patterns that are 4,40,51,82,83 similar to neurological disorders. While Table 3 Examples affecting differential diagnosis Condition Somatic dysfunction (SD) with similar presentation. Should be ruled out or, if present, treated first Examples of upper extremity entrapment neuropathies Median nerve carpal tunnel, pronator teres muscle, anterior interosseous membrane Ulnar nerve ulnar general: cubital tunnel, canal of Guyon, thoracic outlet, first rib, flexor digitorum muscle, flexor carpi ulnaris muscle ulnar deep motor branch: opponens digiti minimi muscle Complementary therapies in neurology 84 Radial nerve radial general: triceps brachii muscle radial sensory: brachialis muscle radial superficial sensory: supinator muscle radial deep: middle scalene muscle Musculocutaneous coracobrachialis muscle nerve Brachial plexus anterior and middle scalene muscles lower trunk: thoracic outlet, first rib, scalene trigger points, pectoralis minor muscle Examples of lower extremity entrapment neuropathies Sciatic nerve (sciatica) piriformis syndrome or trigger point Common peroneal fibular head posterior SD (fibular) nerve Posterior tibial nerve tarsal tunnel Examples of nerve entrapment neuropathies (cranial Greater occipital nerve semispinalis capitis muscle Cranial nerve VI petrosphenoidal ligament secondary to temporal SD (medial strabismus) Examples of altered neurological sign/test Muscle strength tests myofascial trigger point or prolonged strain in that phasic muscle Straight leg raising myofascial trigger point hamstrings Extraocular muscle petrosphenoidal ligament secondary to temporal SD testing Balance tests sternocleidomastoid myofascial trigger point temporal bone SD Sciatic posturing psoas syndrome Examples of similar pain or dysesthesia patterns L5, S1 radiculopathy gluteus minimus myofascial trigger point posterior sacroiliac ligament strain Migraine cephalgia trapezius myofascial trigger point sphenosquamosal pivot SD Carpal tunnel syndrome forearm myofascial trigger points Brachial plexopathy scalene trigger points, first rib SD Sciatica piriformis syndrome varying degrees of documentation exist for items listed, the couplings are clinically useful in teaching osteopathic students to broaden their differential diagnosis and it takes only a few extra minutes to evaluate and treat as needed to obtain a more accurate diagnosis. The potential for recurrence of the somatic dysfunction and/or the neurological findings are dependent upon whether the clinician discovers and treats both the primary cause and any perpetuating factors. At the end of this chapter an osteopathic approach to Osteopathic considerations in neurology 85 a few of the above disorders will demonstrate that OMT is sometimes a primary treatment and often an adjunctive treatment. TREATING SOMATIC DYSFUNCTION In the USA, a physician capable of fully assessing risk/benefit ratios and cost- effectiveness of all potential treatment modalities directs the OMT prescription, if indicated, and its implementation. A complete manual medicine education is also extremely important for assessing its place in the total management of the patient and selecting the type of manual method, activating force, frequency and duration of this form of treatment.

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    This model predicts a large set of reaction time effects based on the fact that more highly preactivated field sites reach thresholds faster than less highly preactivated sites purchase zovirax 400 mg on line. Based on the directional tuning curves of individual motor cortical neurons order 200 mg zovirax free shipping, determined during reaction time cheap zovirax 200 mg fast delivery, distributions of the population activation were constructed, which were then extended into the preparatory period (Figure 8. The authors found that these distributions were preshaped by prior information, with a peak of activation centered over the precued movement direction. Wider ranges of precued movement directions were represented by broader distributions, and the peak shifted to the requested movement direction as soon as it was specified by the response signal. The monkey had to execute a delayed multidirec- tional pointing task in six movement directions (see Figure 8. Note that the population distribution is preshaped in response to the preparatory signal (PS). Location and width of activation reflect precisely prior information as early as it is provided. The activation peak is localized over the precued target during the preparatory period and the distribution increases in acti- vation and sharpens subsequent to the response signal (RS). These findings extend our knowledge about neuronal mechanisms underlying motor preparation. In particular, the concept of specific preactivation of distributions of population activation defined over the relevant movement parameter space appears to be a powerful one, which accounts for how partial prior information is integrated with new sensory information during movement preparation. The preshape concept may be relevant quite generally for examining context-dependent processes underlying behavior. For instance, the method of constructing distributions of population activity with a preshaping approach might be useful for getting further insight into processes that underly decision-making — as, for instance, in Go–NoGo tasks,70,71 stimulus–response-compatibility tasks,72,73 and categorization tasks. However, it is much less clear how these networks organize dynamically in space and time to cope with momentary computational demands. The concept emerged that some computational processes in the brain could also rely on the relative timing of spike discharges among neurons within such functional groups,75–80 commonly called cell assemblies. In other words, neurons may participate in different cell assemblies at different times, depending on stimulus context and behavioral demands. To test whether such a temporal scheme is actually implemented in the central nervous system, it is necessary to observe the activities of many neurons simultaneously, and to analyze these activities for signs of temporal coordination. Indeed, it has been argued that the synaptic influence of multiple neurons converging onto others is much stronger if they fire in coincidence,82,83 making synchrony of firing ideally suited to raise the saliency of responses and to express relations among neurons with high temporal precision. If cell assemblies are involved in cortical information processing, they should be activated in systematic relation to the behavioral task. We simultaneously recorded the activity of a small sample of individual neurons in the motor cortex of monkeys performing a delayed multidirectional pointing task. Interestingly, they did not continually synchronize their activity during the whole task, but they were transitorily “connected” by synchrony during the transition from preparation to execution. The classification of the two neurons forming the pair based on their firing rate would by no means allow one to describe the functional link between them, which can only be detected by means of the synchronization pattern. Transient synchronization of spiking activity in ensembles of coactive neu- rons may help to strengthen the effectiveness within such groups and thereby help, for instance, to increase performance speed, complementary to the already described increase in firing rate (see Section 8. Indeed, it has been demonstrated that both the strength of synchronous activity19 and the temporal precision of statistically significant synchrony increased toward the end of the preparatory period. In the preceding sections, only spatial and kinematic aspects of movement preparation were taken into account. The problem of time uncertainty, however, Copyright © 2005 CRC Press LLC Spike Rates, neuron 1 (solid), neuron 3 (dashed) A 40 20 0 Coincidence Rates: measured (solid), expected (dashed) B 4 2 0 Significance Level C 2 0 –2 PS 250 500 750 RS FIGURE 8. For calculation, a sliding window of 100 msec was shifted along the spike trains in 5 msec steps.

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    At these locations discount zovirax 800 mg otc, block of the activation of mus- Central nervous Decreased concentration and memory; carinic receptors can increase the tone provided by the system drowsiness; sedation; excitation; ataxia; adrenergic input cheap 200mg zovirax fast delivery. Atropine can also facilitate atrioventricular Although muscarinic agonists typically do not exhibit (A-V) conduction and block parasympathetic effects on selectivity among muscarinic receptors (see Chapter the cardiac conduction system and on myocardial con- 12) buy zovirax 800 mg on line, some muscarinic antagonists are selective in their tractility. Blood Vessels Heart Atropine and other muscarinic antagonists produce Intravenous administration of low doses of atropine or minimal effects on the circulation in the absence of cir- scopolamine often produces slight bradycardia, whereas culating muscarinic agonists. This reflects the relatively higher doses produce tachycardia by directly blocking minor role of cholinergic innervation in determining the parasympathetic input to the sinoatrial node. Atropine can produce Although it has been suggested that the bradycardia re- flushing in the blush area owing to vasodilation. One plau- sible explanation for the paradoxical bradycardia pro- Gastrointestinal Tract duced by low doses of muscarinic blockers is that they block presynaptic muscarinic receptors that normally Muscarinic antagonists have numerous effects on the provide feedback inhibition of the release of ACh. The inhibition of Antagonism of these presynaptic muscarinic receptors salivation by low doses of atropine results in a dry prevents feedback inhibition and increases the release mouth and difficulty in swallowing. Antimuscarinic 136 II DRUGS AFFECTING THE AUTONOMIC NERVOUS SYSTEM drugs also inhibit gastric acid secretion and gastroin- By this mechanism they can block reflex laryngospasm testinal motility, because both processes are partly un- during surgery. Relatively large hibitors of secretions throughout the respiratory sys- doses of atropine are required to inhibit acid secretion, tem, from the nose to the bronchioles. Although the antimuscarinic drugs are normally selec- tive for muscarinic cholinergic receptors, high concen- trations of agents with a quaternary ammonium group Bladder (e. However, these blocking the excitatory effect of ACh on the detrusor effects are generally not clinically important at usual muscle of the bladder. Central Nervous System ABSORPTION, METABOLISM, AND EXCRETION Although atropine and scopolamine share many prop- erties, an important difference is the easier entry of Both atropine and scopolamine are tertiary amines that scopolamine into the CNS. At venous injection of atropine (DL-hyoscyamine), the bio- intermediate doses (2–10 mg), memory and concentra- logically inactive isomer, D-hyoscyamine, is excreted un- tion may be impaired, and the patient may be drowsy. The active isomer, however, can doses of 10 mg or more are used, the patient may ex- undergo dealkylation, oxidation, and hydrolysis. Large doses of scopolamine amounts of these compounds are eliminated in the feces can produce all of the responses seen with atropine. The blood-brain barrier Other tertiary amine compounds with muscarinic re- prevents quaternary ammonium muscarinic blockers ceptor blocking activity have similar central effects. Eye CLINICAL USES Antimuscarinic drugs block contraction of the iris sphincter and ciliary muscles of the eye produced by Cardiovascular Uses ACh. This results in dilation of the pupil (mydriasis) and paralysis of accommodation (cycloplegia), responses Atropine can be useful in patients with carotid sinus that cause photophobia and inability to focus on nearby syncope. Ocular effects are produced only after higher of afferent neurons whose stretch receptors are in the parenteral doses. By reflex mechanisms, this excessive affer- responses lasting several days when applied directly to ent input to the medulla oblongata causes pronounced the eyes. If sinus bradycardia is due to ex- Lung tracardiac causes, atropine can generally elicit a tachy- Muscarinic antagonists inhibit secretions and relax cardic response, whereas it cannot elicit tachycardia if smooth muscle in the respiratory system. Under cer- pathetic innervation of respiratory smooth muscle is tain conditions, atropine may be useful in the treatment most abundant in large airways, where it exerts a domi- of acute myocardial infarction. In agreement with this innerva- occurs after acute myocardial infarction, especially in tion pattern, muscarinic antagonists produce their the first few hours, and this probably results from ex- greatest bronchodilator effect at large-caliber airways. The increased tone and bradycardia 13 Muscarinic Blocking Drugs 137 facilitate the development of ventricular ectopy. Systemic absorption of Although atropine sulfate has proved beneficial in pa- these drugs from the conjunctival sac is minimal, but tients whose bradycardia is accompanied by hypoten- significant absorption and toxicity can occur if the an- sion or ventricular ectopy, it is generally not otherwise timuscarinic drugs come into contact with the nasal and recommended in this condition. To mini- without hazard, because cardiac work can be increased mize this possibility, pressure should be applied to the without improved perfusion, and ventricular arrhyth- lacrimal sac for a few minutes after topical application mias may occur.

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