By U. Gorok. Palmer College of Chiropractic.
EXERCISING THE CHD PATIENT: THE NEED FOR ASSESSMENT AND RISK STRATIFICATION Exercise training in individuals with CHD has been the subject of numerous clinical trials discount fertomid 50mg without prescription menopause crying, with the evidence strongly demonstrating that exercise-based cardiac rehabilitation is associated with a reduction in coronary mortality and morbidity generic fertomid 50mg overnight delivery menopause las vegas. Despite the low incidence of adverse events, most international CR guidelines, nevertheless, recommend that, prior to recruitment to the exercise programme, patients should undergo a comprehensive assessment, including risk stratiﬁcation. Although the data would suggest that the increased myocardial demands of vigorous exercise may precipitate cardiovascular events, i. The risk of cardiac events during exercise is small, particularly where evidence of substantial cardiac disease is absent. Within supervised CR programmes the risk of serious exercise-related cardiac events is also small, with evidence from Paul-Labrador, et al. At their cardiopulmonary research institute there were 25 cardiac arrests between 1968 and 1981 (374, 616hrs), nine of which occurred during the ‘cool-down’ period. Incidents are most likely in the following categories: • patients with marked ST-segment depression on ECG; • patients with an above average exercise capacity; • patients who have shown poor compliance to exercise intensity guidelines. There is, however, little recent data that reﬂect the complexity and varied risk of exercise-related events for the patient group now eligible for CR. In addi- tion, most of the available data are from the United States, where electrocar- diogram (ECG) monitoring and trans-telephonic monitoring are standard, making it difﬁcult to generalise this to other healthcare systems, where appro- priate professional supervision is the predominant monitoring tool. However, adverse events remained consistent with the 1970s data, suggesting that there was a trade-off between the general lowering of risk achieved by develop- ments in treatment and medications and an increase in risk with the inclusion of more complex and older patients in CR exercise. THE PROCESS OF RISK STRATIFICATION The purpose of the risk-stratiﬁcation process is to identify all the factors related to an individual and place them in a risk category based on an increased likelihood of adverse effects. This provides the exercise leader with guidance in respect to exercise prescription, monitoring and supervision. Most risk-stratiﬁcation tools classify individuals into low, medium/moderate and high risk categories. However, at this time, there would appear to be no clearly validated comprehensive risk-assessment tool for entry to the exercise com- ponent of CR. Individu- als who do not meet the classiﬁcation for either low or high are deﬁned as moderate or medium risk. One approach is based on the long-stand- ing, traditional format, established by the AHA (2001) and the AACVPR (2004) and which classiﬁes risk stratiﬁcation into low (class A), intermediate (class B) and high risk (class C) categories. However, it is an approach which seems to reﬂect sound medical judgement and evidence-based practice, but fails to take Risk Stratiﬁcation and Health Screening for Exercise 23 Table 2. Characteristics of low and high risk CR (Adapted from the AACPR, 2004) A low-risk individual would have all of A high-risk individual would have the following: only one of the following: Normal haemodynamic response to Decreased left ventricular function – exercise and recovery ejection fraction <40% No evidence of myocardial ischaemia Abnormal haemodynamic response with exercise and recovery Normal left ventricular function Persistent or recurrent ischaemia at low levels of exercise Functional capacity of 7 METs Functional capacity of <5 METs (metabolic equivalents) or more Absence of clinical depression Survivor of cardiac arrest or sudden death Complicated recovery post-event, i. Angioplasty patients, for example, are currently considered by many to be low risk, but Paul-Labrador, et al. This is an issue which often leads to confusion, particularly where in primary prevention the focus is on lifestyle issues like smoking and the recog- nised risk markers for CHD, e. However, although these are three validated tools they have not been validated for use together. The second Canadian Guideline proposal is worth exploring, as it may give the clinician a more standardised method of risk stratiﬁcation. It takes the process of risk stratiﬁcation a stage further, using a scale that generates a score. Additionally, long-term progression risk is taken into account, where the pres- ence and severity of modiﬁable risk markers are considered. This risk marker score is used in conjunction with the acute risk score giving a quantiﬁable indi- cation of overall risk. This would appear to be the ﬁrst novel approach which attempts to develop a measurable risk-stratiﬁcation process. In practice, this method would support the approach taken by most CR exercise leaders, where experienced profes- sionals utilise their knowledge, experience and expert judgement to determine both the exercise prescription and appropriate monitoring of individuals within the CR programme. In addition, the approach where other health behaviours are integrated into risk stratiﬁcation is worth considering. However, the Canadian Association of Cardiac Rehabilitation recently pub- lished a second edition of their Guidelines (Stone, et al. They continue to advocate the use of key principles: • matching the degree of intervention to the degree of risk; • recognising that the risk factor burden increases the likelihood of ather- osclerotic progression; • recognising that the likelihood of exercise-related adverse events relates to functional capacity, left ventricular function, ischaemic burden and dys- rhythmic monitoring.
Longitudinal Stress Injury Force is transmitted through the metatarsal heads proxi- mally along the rays purchase 50 mg fertomid with amex women's health clinic limerick, with resultant compression of the midfoot between the metatarsals and the talus with the foot plantar ﬂexed discount 50 mg fertomid otc womens health 7 squats. Longitudinal forces pass between the cuneiforms and frac- ture the navicular, typically in a vertical pattern. Lateral Stress Injury This s-called "nutcracker fracture" is a characteristic frac- ture of the cuboid as the forefoot is driven laterally, causing crushing of the cuboid between the calcaneus and the bases of the fourth and ﬁfth metatarsals. This is most commonly an avulsion fracture of the navi- cular with a comminuted compression fracture of the cuboid. In more severe trauma, the talonavicular joint subluxes lat- erally and the lateral column of the foot collapses due to comminution of the calcaneocuboid joint. Plantar Stress Injury Plantarly directed forces may result in sprains to the mid- tarsal region with avulsion fractures of the dorsal lip of the navicular, talus, or anterior process of the calcaneus. Crush injuries Navicular Fractures Eichenholtz And Levin Classiﬁcation Type I: Avulsion fractures of tuberosity Type II: A fracture involving the dorsal lip Type III: A fracture through the body Sangeorzan Classiﬁcation (Figure 3. Sangeorzan BJ, Benirschke SK, Mosca V, Mayo KA, and Hansen ST Jr: Displaced intra-articular fractures of the tarsal navicular. Continued 74 FRACTURE CLASSIFICATIONS IN CLINICAL PRACTICE Type III: Comminuted fracture pattern with naviculo-cuneiform joint disruption; associated fractures may exist (cuboid, anterior calcaneus, calcaneocuboid joints). Cuboid Fractures OTA Classiﬁcation Of Cuboid Fractures Higher letters and numbers denote more signiﬁcant injury. Type A: Extraarticular Type A1: Extraarticular, avulsion Type A2: Extraarticular, coronal Type A3: Extraarticular, multifragmentary Type B: Partial articular, single joint (calcaneocuboid or cubotarsal) Type B1: Partial articular, sagittal Type B2: Partial articular, horizontal Type C: Articular, calcaneocuboid and cubotarsal involvement Type C1: Articular, multifragmentary Type C1. PELVIS AND LOWER LIMB 75 Tarsometatarsal (Lisfranc) Joint Quenu and Kuss Classiﬁcation (Figure 3. Fracture-dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment. Copyright © 1986 by the American Orthopaedic Foot and Ankle Society (AOFAS), originally published in Foot and Ankle Interna- tional, April 1986, Volume 6, Number 5, page 228 and reproduced here with permission. Divergent Partial Total Fractures of the Base of the Fifth Metatarsal Dameron Classiﬁcation (Figures 3. Reprinted from The Journal of the American Academy of Orthopaedic Surgeons, Volume 3 (2), pp. Type II: Transphyseal fracture that exits the metaphysis; the metaphyseal fragment is known as the Thurston- Holland fragment; the periosteal hinge is intact on the side with the metaphyseal fragment; prognosis is excel- lent, although complete or partial growth arrest may occur in displaced fractures. Type III: Transphyseal fracture that exits the epiphysis, causing intraarticular disruption; anatomic reduction and ﬁxation without violating the physis are essential; pro- gnosis is guarded because partial growth arrest and resultant angular deformity are common problems. Type IV: Fracture that traverses the epiphysis and the physis, exiting the metaphysis; anatomic reduction and ﬁxation without violating the physis are essential; pro- gnosis is guarded, because partial growth arrest and resultant angular deformity are common. Type V: Crush injury to the physis; diagnosis is generally made retrospectively; prognosis is poor because growth arrest and partial physeal closure commonly result. It can cause scaring, tethering and arrest of the periphery of the epiphyseal plate, producing angular deformity. SUPRACONDYLAR HUMERUS FRACTURES Classiﬁcation of Extension Type Gartland Classiﬁcation Based on degree of displacement: Type I: Nondisplaced Type II: Displaced with intact posterior cortex; may be slightly angulated or rotated Type III: Complete displacement; Posteromedial or postero- lateral Wilkins Modiﬁcation of Gartland’s Classiﬁcation Type 1: Undisplaced 4. FRACTURES IN CHILDREN 81 Type 2 Type 2A: Intact posterior cortex and angulation only Type 2B: Intact posterior cortex, angulation and rotation Type 3 Type 3A: Completely displaced, no cortical contact, posteromedial Type 3B: Completely displaced, no cortical contact, posterolateral LATERAL CONDYLAR PHYSEAL FRACTURES Milch Classiﬁcation (Figure 4. Type II: Fracture line extends into the apex of the trochlea, rep- resenting a Salter-Harris type II fracture. Group B: Lateral condyle ossiﬁed (7 months to 3 years); Salter- Harris type I or II (ﬂeck of metaphysis). Group C: Large metaphyseal fragment, usually exiting laterally (ages 3 to 7 years). T-CONDYLAR FRACTURES Wilkins and Beaty Classiﬁcation Type I: Nondisplaced or minimally displaced Type II: Displaced, with no metaphyseal comminution Type III: Displaced, with metaphyseal comminution 4. FRACTURES IN CHILDREN 83 RADIAL HEAD AND NECK FRACTURES Wilkins Classiﬁcation (Figure 4.
For about eight months order 50 mg fertomid with amex womens health questions free, we worked weekly order fertomid 50 mg with mastercard pregnancy resources, and Harry’s level of consciousness, ability to feel, and level of interaction improved remarkably (more differentiated and assertive). He invited his family to a session, and his brothers at- tended, which was a breakthrough for him. He was able to share his feel- ings about his passive behaviors, his siblings’ actions, and how these interactions affected his life. The brothers talked about their parents, their culture, and their individual perceptions of their life histories. Harry also discussed his realization about the effect of the Holocaust on his family of origin. At this point in the treatment, Harry requested that Suzanne come back to treatment so they could work on their "stuckness" concerning money and sex in the relationship. Money was an issue that Suzanne Integrative Healing Couples Therapy: A Search for the Self 223 refused to deal with because of the anxiety it caused within her and the re- running of the old tapes from her family of origin. We worked jointly for three months discussing issues related to money and sexuality. Suzanne was interested and committed to overcoming her anxieties and fears in dealing with money. She worked with Harry in pay- ing the bills, taking responsibility for paying some bills, where previously she had worked and kept the money she earned for herself. She started to learn about their investments and began to face her fears of "not having money"(cognitive behavioral strategies). At the same time, the couple’s sex- ual relationship became more satisfying to both. The couple decided to end treatment at this point because they felt they had attained the level of emo- tional and physical interaction they both wanted with each other. In addi- tion, they felt they had made essential changes in their interactions with their families of origin. As a result, both members were empowered to be emotional and financial equals sharing life in a more meaningful way. They were able to have romance and repair the past inherited from their families of origin (resolution and changing the repetition). Through successful fam- ily therapy, not only does the individual grow and differentiate, but the in- dividuals within the systems grow (see how relationships have changed within their nuclear family and family of origin), supporting the mainte- nance of the family structure and individuation of the members. As mentioned earlier (evaluation of the couple and their system), it is es- sential for a therapist to set a road map of treatment enabling the setting of goals and ways to reach them. The road map offers a written and visual tool to enable effective and efficient growth for the couple in relationship to their presenting and evolving issues. The road map evolves as the couple grows in treatment similarly to the way that roads progress in life’s jour- ney. The extended family work was an outcome of the individual work and Suzanne’s readiness to deal with family patterns and interactions. In Step 4, Harry’s individual work begins to give him some understanding of why he acts and reacts as he does. Since the couple has a better under- standing of where they begin and end as individuals and within the system (differentiation), the couple is able to begin improving their com- munication (Step 5). As a result of communication improving, more inter- generational work can be done with Harry’s family (Step 6), allowing him to grow further and differentiate himself. As a result of improved com- munication within the couple, Harry was able to see how he accepted un- warranted projections from Suzanne, which enabled him to further differentiate his functioning and create a more solid self. Harry was able to realize that he needed to do joint work with his family of origin to fur- ther free himself of old roles and patterns of behavior (Step 7). Within the 224 THEORETICAL PERSPECTIVES ON WORKING WITH COUPLES context of Harry’s intergenerational work, communication enhancement between the generations became a focus (Step 8). In integrative healing couples therapy, the growth of one individual en- ables the system.
Anterior Glenohumeral Dislocations Classiﬁcation Degree of instability: Dislocation/subluxation Chronology/Type Congenital Acute versus chronic Locked (ﬁxed) Recurrent Force Atraumatic Traumatic Patient contribution: voluntary /involuntary Direction Subcoracoid Subglenoid Intrathoracic 2 quality 50 mg fertomid pregnancy over 40. Subspinous (very rare): Humeral head medial to the acromion and inferior to the spine of the scapula order fertomid 50mg on-line womens health za. Inferior Glenohumeral Dislocation (Luxatio Erecta) Superiod Glenohumeral Dislocation Proximal Humerus Neer Classiﬁcation (Figure 2. At least two views of the proximal humerus (anteroposterior and scapular Y views) must be obtained; additionally, the axillary view is very helpful for ruling out dislocation. Humeral Shaft Descriptive Classiﬁcation Open/closed Location: proximal third, middle third, distal third Degree: incomplete, complete Direction and character: transverse, oblique, spiral, segmental, comminuted Intrinsic condition of the bone Articular extension 2. SHOULDER AND UPPER LIMB 19 I MINIMAL DISPLACEMENT DISPLACED FRACTURES 2 3 4 PART PART PART II ANATOMICAL NECK III SURGICAL NECK B A C IV GREATER TUBEROSITY V LESSER TUBEROSITY ARTICULAR SURFACE VI FRACTURE- DISLOCATION ANTERIOR POSTERIOR FIGURE 2. Riseborough EJ, Radin EL, Intercondylar T frac- tures of the humerus in the adult. Type II: Lateral trochlear ridge is part of the condylar fragment (medial or lateral). Medial Lateral ANTERIOR POSTERIOR Lateral epicondyle Capitellum Trochlea Olecranon fossa Medial Lateral epicondyle epicondyle Trochlea Trochlear sulcus Trochlear ridge A Capitellotrochlear sulcus LATERAL CONDYLE FRACTURES Type II Type I Type II Type I B MEDIAL CONDYLE FRACTURES Type II Type II Type I Type I C FIGURE 2. Large osseous component of capitellum, sometimes with trochlear involvement Type II: Kocher-Lorenz fragment. Articular cartilage with mini- mal subchondral bone attached: "uncapping of the condyle" Type III: Markedly comminuted FIGURE 2. Reproduced from Heckman JD, Bucholz RW (Eds), Rockwood, Green, and Wilkins’ Fractures in Adults. SHOULDER AND UPPER LIMB 25 CORONOID PROCESS FRACTURE Regan and Morrey classiﬁcation (Figure 2. Some observations on fractures of the head of the radius with a review of one hundred cases. Bado Classiﬁcation Type I: Anterior dislocation of the radial head with fracture of the ulnar diaphysis at any level with anterior angulation. Type II: Posterior/posterolateral dislocation of the radial head with fracture of the ulnar diaphysis with posterior angulation. Type III: Pateral/anterolateral dislocation of the radial head with fracture of the ulnar metaphysic. Type IV: Anterior dislocation of the radial head with fractures of both the radius and ulna within proximal third at the same level. Distal ulnar fracture Fracture Absent Present Extraarticular I II Intraarticular involving radiocarpal joint III IV Intraarticular involving distal radioulnar joint V VI Intraarticular involving radiocarpal and distal radioulnar joint VII VIII DISTAL RADIUS Descriptive Classiﬁcation (Table 2. Fracture of the distal radius including sequelae – shoulder-hand-ﬁnger ayndrome, disturbance in the distal radio-ulnar joint, and impairment of nerve function: a clinical and experimental study. SHOULDER AND UPPER LIMB 31 Comminution Loss of radial length Intraarticular involvement SMITH FRACTURE Modiﬁed Thomas’ Classiﬁcation (Figure 2. Type II: Rolando fracture – requires greater force than a Bennett fracture; presently used to describe a comminuted Bennett fracture, a "Y" or "T" fracture, or a fracture with dorsal and palmar fragments. Extraarticular fractures Type IIIA: Transverse fracture Type IIIB: Oblique fracture Type IV: Epiphyseal injuries seen in children. Each type then divided into three subtypes: Type IIIA: Fracture fragment involving less than one- third of articular surface of distal phalanx Type IIIB: A fracture fragment involving one-third to two-thirds of articular surface Type IIIC: A fragment that involves more than two- thirds of articular surface Chapter 3 Pelvis and Lower Limb PELVIS Young and Burgess Classiﬁcation (Figure 3. Lateral compression (LC): Transverse fractures of the pubic rami, ipsilateral, or contralateral to posterior injury Type I: Sacral compression on the side of impact Type II: Posterior iliac wing fracture (crescent) on the side of impact Type III: LCI or LCII injury on the side of impact; contralat- eral open book injury 2. Anteroposterior compression: Symphyseal diastasis or longi- tudinal rami fractures Type I: <2. Vertical shear: symphyseal diastasis or vertical displaced ante- rior and posterior usually through the SI joint, occasionally through the iliac wing or sacrum. Combined mechanical: combination of injuries often due to crush mechanisms; most common is vertical shear and lateral compression. Tile Classiﬁcation Type A: Stable Type A1: Fractures of the pelvis not involving the ring; avulsion injuries Type A2: Stable, minimally displaced fractures of the ring Type B: Rotationally unstable, vertically stable. Type B1: Open-book Type B2: Lateral compression; ipsilateral Type B3: Lateral compression; contralateral (bucket handle) Type C: Rotationally and vertically unstable. PELVIS AND LOWER LIMB 39 Type C2: Bilateral; one side rotationally unstable, with contralateral side vertically Unstable. Continued 42 FRACTURE CLASSIFICATIONS IN CLINICAL PRACTICE HIP DISLOCATIONS: POSTERIOR DISLOCATION Thompson and Epstein Classiﬁcation of Posterior Dislocations of the Hip (Figure 3.
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