By L. Leon. Medaille College. 2018.

For these reasons the specificity of vibration for primary spin- Tendon organs dle endings needs to be addressed order 5mg proscar with visa mens health protein. There are many fallacious or over-interpreted reports in the litera- Some tendon organs can respond to tendon vibra- turebasedontheassumptionthattransversetendon tion in relaxed muscles and many do so during vol- vibration in intact human subjects can be a selec- untary contractions order proscar 5 mg with amex prostate oncology yuma. Indeed, all three tendon organs tive stimulus for primary spindle endings, driving in the study of Burke et al. That all did so may be the result of a sam- intact subject, vibration is commonly not selective pling bias of microneurography towards stretch- for muscle spindle receptors and, in intact human responsive receptors (see p. Further studies subjects, it may not excite only the primary spindle isolating Ib afferents during a voluntary contrac- ending. Nevertheless, response of the primary ending switches off during the data in Figs. Responses during voluntary Cutaneous mechanoreceptors movements will not be accurately predictable, par- Most cutaneous mechanoreceptors respond to ticularlyifthevibratorisnotservo-controlledsothat vibration (e. Ribot-Ciscar, Vedel & Roll, 1989), and there is a constant force of application to the mov- it is probable that Ruffini endings in joints do so as ing tendon (Cordo et al. Motor tasks and physiological Contracting muscles implications In contractingmuscles,fusimotordrivecanenhance the spindle response to vibration (Burke et al. First, the application of the vibra- Remote contractions may be of limited functional tor to the tendon is not exactly the same as in the significance, but the mechanisms responsible for relaxed state, secondly, the spread of the vibration the widespread reflex enhancement accompanying wave to the muscle belly is altered when the mus- such contractions have long been a matter of dis- cle contracts and the tendon stiffens, and thirdly, the pute, and the manoeuvre is important in the clin- contraction may not be associated with a sufficient ical examination. It was previously thought that per- increase in drive to offset these effects. Indeed, if formance of the Jendrassik manoeuvre potentiated thecontractionisareflexcontractiontothevibration tendonjerksinuninvolvednon-contractingmuscles (tonic vibration reflex, TVR), unloading is the rule, in duetowidespreadactivationofdynamic motoneu- human subjects (Burke et al. Similarly, the reflex potentiation accompany- (Clark, Matthews & Muir, 1981). These problems are ing other alerting stimuli, such as a warning cue, has even greater if overt movement occurs at the joint, been attributed to the same mechanism. However, because movement can displace the vibrator and attractive as it may be, this hypothesis is seriously because the responses of different endings are not flawed for a number of reasons. For (i) It is based on the belief that the H reflex is not example, the response of primary endings is maxi- potentiated to the same extent by the reinforcement malduringthestretchingphaseofpassiveoscillating manoeuvre. The effects of alternating passive movements on the spindle response to vibration. The response increases more gradually through subharmonics during the stretching phase to 1:2. With shortening, the response gradually decreases again through subharmonics. If a mechanism was responsible Increased spindle discharge for the reflex reinforcement, one would expect the during contraction effects on spindle activity to be large, not small, not restricted to a few afferents, and one would expect Evidence for activation of γ motoneurones all studies to have no difficulty demonstrating this When movement is prevented so that contractions same finding. Panel (b ) plots the size sure block experiments suggest that this increase in of the muscle afferent volley from soleus against the spindle discharge is mediated, at least in part, by the intensity of tendon percussion. The round symbols activation of motoneurones (Burke, Hagbarth & represent data when the subject was at rest and the Skuse,1979). Theunloadingreflexprovidesevidence triangles when the subject performed the Jendrassik that muscle afferent feedback (presumably mainly manoeuvre. There is no difference in the relation- of spindle origin) contributes to the maintenance ships. However, the manoeuvres were effective re- of motor firing during a tonic isometric contrac- inforcing manoeuvres because a tendon jerk tion. When a muscle is pulling against a fixed resis- occurred (filled symbols) with weaker percussion tancethatsuddenlygivesway,asilentperiodappears and a lesser afferent volley. Panel (c ) plots, for the in the EMG of the contracting muscle at a latency same data, the size of the reflex response against the appropriate for the withdrawal of Ia afferent support intensity of the afferent volley. Jendrassikmanoeuvre(triangles),thereflexresponse Thus, overall the fusimotor-driven inflow from pri- was obtained at lower threshold than at rest (circles) maryandsecondaryendingsduringavoluntarycon- and was larger for any given size of afferent volley. Decreased presynaptic inhibition of Ia terminals has been suggested (Zehr & Stein, 1999), but, if any- Spindle acceleration after the onset of EMG thing,presynapticinhibitionofIaterminalstosoleus motoneurones is slightly increased at the onset of With brisk phasic contractions, the increase in spin- abrisk ECR contraction (Meunier & Morin, 1989; dle discharge follows the appearance of EMG in the Chapter8,p. Teethclenchinghasbeenreported contracting muscle by up to 50 ms (Vallbo, 1971), to enhance the H reflexes of both soleus and tibialis evidence that is inconsistent with the follow-up anterior (as might be expected for a reinforcement length servo hypothesis (Merton, 1951, 1953; see manoeuvre) but also to decrease peroneal-induced Matthews, 1972). Attempts to produce consistent reciprocalIainhibitionofthesoleusHreflex(Takada spindle activation in advance of EMG by, e.

Hence buy discount proscar 5mg on-line prostate cancer 1cd 10, the formula Zhen Wu Tang Jia Wei (True Warrior Decoction with Added Flavors) was prescribed which was com- posed of: Fu Ling (Poria) proscar 5 mg fast delivery prostate cancer with metastasis, Bai Shao (Radix Paeoniae Albae), and Bai Zhu (Rhizoma Atractylodis Macrocephalae), 9g each, blast-fried Fu Zi (Radix Lateralis Praeparatus Aconiti Carmichaeli), 6g, Sheng Jiang (uncooked Rhizoma Zingiberis), 3 slices, Dang Shen (Radix Codonopsitis), 12g, and Sang Piao Xiao (Ootheca Mantidis), 4. One packet of these medicinals was administered each day, and initially three packets were given. Case 4:4 The patient was an eight year-old male little boy whose initial visit occurred on June 19, 1997. This boy had had enuresis 1-2 times nightly since infancy and had gone for only short periods of time without enuresis. His signs and symptoms included a fatigued essence spirit, an emaciated body, a bright, white facial complexion, frequent catching cold, sweating on exertion, a poor appetite, bowel movements after eating, a pale tongue with thin, white fur, and a vacuous, weak, forceless pulse. For these purposes, the doctor selected Bu Zhong Yi Qi Tang (Supplement the Center & Boost the Qi Decoction) plus Suo Quan Wan (Reduce the Stream Pills) with additions and subtractions: Huang Qi (Radix Astragali), 10g, Dang Shen (Radix Codonopsitis), 8g, Bai Zhu (Rhizoma Atractylodis Macrocephaleae), 8g, Chen Pi (Pericarpium Citri Reticulatae), 5g, Sheng Ma (Rhizoma Cimicifugae), 1g, Chai Hu (Radix Bupleuri), 3g, Dang Gui (Radix Angelicae Sinensis), 6g, Yi Zhi Ren (Fructus Alpiniae Oxyphyllae), 8g, Fu Pen Zi (Fructus Rubi), 5g, mix-fried Gan Cao (Radix Glycyrrhizae), 3g, Shi Chang Pu (Rhizoma Acori Tatarinowii) and stir-fried Mai Ya (Fructus Germinatus Hordei), 6g each. Therefore, the doctor decided to add Shan Yao (Radix Dioscoreae) to the above formula for 10 more days. The doctor prescribed 20 more packets of the current formula, after which time, the case was cured, and there was no recurrence in the first six months after treatment. Case 5:5 The next case is that of a 12 year-old boy who was first seen on March 15, 1980. Since the winter of 1977, the patient commonly had enuresis in the evening. The child had already taken medici- nals to supplement the kidneys and secure and astringe and also took the formula Bu Shen Gou Rou Tang (Supplement the Kidneys Dog Meat Decoction) but had obtained no results. The latter for- mula contained Gou Qi Zi (Fructus Lycii), Rou Gui (Cortex Cinnamomi), and Shu Di (cooked Radix Rehmanniae) with Gou Rou (dog meat). There was also a bright, lusterless complexion, a pale tongue with thin, white fur, and a deep, fine pulse. For this, Gan Jiang Ling Zhu Tang Jian (Licorice, Ginger, Poria & Representative Case Histories 189 Atractylodes Decoction with Additions and Subtractions) plus Suo Quan Wan (Reduce the Stream Pills) was prescribed with addi- tions and subtractions: Pao Jiang (blast-fried Rhizoma Zingiberis), Bai Zhu (Rhizoma Atractylodis Macrocephalae), Shan Yao (Radix Dioscoreae), and Fu Ling (Poria), 10g each, Yi Zhi Ren (Fructus Alpiniae Oxyphyllae), mix-fried Gan Cao (Radix Glycyrrhizae), and Wu Yao (Radix Linderae), 8g each. The child was asked to restrict the amount of water he drank after midday. Case 6:6 The patient in this case history was a 14 year-old female who was first examined on May 17, 1984. She had already taken upbearing, contracting, and astringing medicinals with no results. Her tongue was pale with thin, white fur, and her pulse was soggy and moderate (or slightly slow). Based on these signs and symptoms, her Chinese medical pattern was categorized as spleen-kidney vacuity cold with inability to trans- form qi. The formula prescribed was Ma Huang Fu Zi Gan Cao Tang (Ephedra, Aconite & Licorice Decoction) which was com- posed of: Ma Huang (Herba Ephedrae), 12g, Fu Zi (Radix Lateralis Praeparatus Aconiti Carmichaeli), 12g, and Gan Cao (Radix Glycyrrhizae), 6g. After taking only two packets of these medici- nals, the young woman did not have enuresis for four nights. After continuing to take the medicine for another five packets, the enuresis did not return even on follow-up after one year. Case 7:7 This case is of an eight year-old boy who was initially seen on January 7, 1984. For more than three years, the child had had enuresis 1-2 times every night. The child had already taken medic- inals to fortify the spleen and boost the kidneys, secure, astringe, and reduce urination as well as acupuncture and moxibustion all with no success. The tongue fur was thin and white, and his pulse was moderate (or slightly slow). The doctor used Ge 190 Treating Pediatric Bed-wetting with Acupuncture & Chinese Medicine Gen Tang (Puerariae Decoction). The formula prescribed consisted of: Ge Gen (Radix Puerariae), 10g, Ma Huang (Herba Ephedrae), 4g, Gui Zhi (Ramulus Cinnamomi), mix-fried Gan Cao (Radix Glycyrrhizae), and Bai Shao (Radix Paeoniae Albae), 6g each, Sheng Jiang (uncooked Rhizoma Zingiberis), 2g, and Da Zao (Fructus Jujubae), 7 pieces. After nine packets of these medici- nals, the enuresis was completely cured and did not return.

Agreement is especially important also get at the responsibilities of each member since the team buy generic proscar 5mg prostate cancer questions to ask doctor, not the patient and family of the team order proscar 5mg otc mens health positions. This decision is individual leadership must be taken to manage often made under some pressure by the health the medical, neurophysiologic, functional, cog- care insurer to halt services that are not med- nitive, psychologic, social, educational, and vo- ically necessary. Studies of inpatient stroke rehabilitation sup- port the approach primarily as an efficient means to organize services for patients with PHYSICIANS functional disabilities. Sample Patient Satisfaction Questions for Inpatient Rehabilitation Answered on a Likert Scale 1. Did the program enable you to take better care of yourself and train the family in your care? He had his ataxic patients, primary care doctor the indications for med- many with tabes dorsalis, practice upper ex- ications, measures for secondary prevention of tremity coordination and walking tasks and in- complications, management of risk factors for corporated parallel bars into gait training. His recurrence or exacerbation of the disease, and methods gained adherents in the United the type and duration of rehabilitative inter- States9 and led to the first hospital gymnasium ventions. In a study of disagreements between at the Salpétrière in Paris, the most famous physicians and patients about their encounters, neurology department of its day. Physiatrists evolved from the need for so that patients can obtain equipment, services, a rehabilitation discipline after World War II and pertinent disability reports. Thus, cilitators of the team, especially on an inpatient from their roots in syphilis, polio, and war- service. Here, the physician leads a weekly related trauma, neurologists and physiatrists are team conference that reviews the progress of most likely to participate with an inpatient team. The conference allows the team Physicians are especially responsible for antic- to share notes and thoughts about each patient ipating and managing the medical complica- and to solve lingering problems. A physician tions and rehabilitation needs of their patients leader articulates, mobilizes, and persuades the (see Chapter 8). In addition, physicians who patient, family, and team of therapists toward specialize in neurologic rehabilitation educate goals that they come to share. Team meetings and journal clubs with pain and disability and the present degree may be used to discuss new and relevant re- of disability. These issues include interference impairments will affect rehabilitation potential. Is in- functional activities, physical fitness, mood, somnia associated with anxiety or depression, and lifestyle. These elements will impact reha- a noisy roommate, and pain at rest or with cer- bilitation care and goal-setting. Although neuroimaging point to a urinary tract infection, phlebitis or studies cannot themselves predict impairments aspiration, as well as caloric and fluid intake, and prognosis, tests such as computerized to- short-term therapy goals, how the patient and mography (CT) and magnetic resonance imag- family are coping with unexpected burdens, ing (MRI) offer useful insights. During daily rounds, the physician that reveals an old, silent lacuna in the right encourages patients to spend more time out of basis pontis, however, offers insight into the bed, reiterates specific exercises for improving cause of a pseudobulbar palsy and alters the endurance, motor control, and skills that can prognosis. Families and people with neurologic dis- pably tender musculoligamentous tissue cause eases are quick to check for experimental and pain or limit movement? Does a medication or alternative treatments on the Internet and in episodic orthostatic hypotension lessen atten- articles. The physician needs to put animal re- tion span and endurance for exercise? Is hy- search results, ongoing clinical trials, uncon- ponatremia or anemia having negative clinical trolled use of substances that include much consequences? Does a muscle group show in- hype by the seller, and alternative medicine ap- creased paresis with a few repetitive contrac- proaches into perspective. Nor does the com- problems related only to the cerebral injury, or pulsive clinician ever disregard the insights of does a metabolic abnormality, a medication or, the rest of the team. A modest decline in at- in an older person, an underlying dementia tention span or exercise tolerance noted by the 218 Common Practices Across Disorders speech therapist or occupational therapist may should insist on definable interventions. If one mean, for example, incipient sepsis, a new approach is not working, a different approach metabolic complication, or side effects of a can then be defined and tested. A few minutes of assessment and measures of success, such as changes in the explanation prevents lost opportunities to un- time needed to eat a meal or walk 50 feet, help cover unrecognized problems and misunder- label success beyond nonparametirc tools that standings. Vigilance is necessary in regard to are used to define levels of independence (see identifying inpatient and outpatient medical Chapter 7). System For Medical Rehabilitation14 helps put During outpatient care, physicians must de- features of the recovery of impairments and dis- velop their skills at counseling about matters abilities into perspective. This information such as exercise13 and specific directions about stimulates collective deliberations that may build home practice paradigms for motor and cogni- a consensus toward alternative solutions and the tive retraining.

These disorders may include infections generic 5 mg proscar free shipping prostate oncology 2020, liver dis- arette smoke can precipitate or aggravate asthma and ease discount 5 mg proscar with amex mens health april 2013, accidental injuries, and psychiatric problems of upper respiratory disorders in children. These disorders may be caused by • Inform smokers with nonsmoking spouses or other mem- other factors, of course, and are nonspecific. Nursing Diagnoses Evaluation • Ineffective Coping related to reliance on alcohol or other • Observe for improved behavior (eg, less impulsiveness, drugs improved judgment and thought processes, commits no • Risk for Injury: Adverse effects of abused drug(s) injury to self or others). CHAPTER 15 SUBSTANCE ABUSE DISORDERS 249 Efforts to change attitudes and decrease demand Nursing Notes: Apply Your Knowledge for drugs can be made through education and coun- seling about such topics as drug effects and nondrug ways to handle the stresses and problems of daily life. She tells you she has tried to quit smoking many times be- fore but this time she is determined. She went to her physician for drinking alcoholic beverages and taking mind-altering a prescription for the patch and she even bought some nicotine drugs. Initially, conscious, voluntary choices are made gum at the drug store in case the cravings get really bad. Since This period varies somewhat, but drug dependence de- you are an RN, as well as the mother of a friend, what advice can velops in most instances only after prolonged use. When mind-altering drugs are prescribed for a legiti- mate reason, the client must use them in prescribed doses and preferably for a short time. Physicians can help prevent drug abuse by prescribing PRINCIPLES OF THERAPY drugs appropriately, prescribing mind-altering drugs in limited amounts and for limited periods, using nondrug Prevention of Alcohol measures when they are likely to be effective, educat- and Other Drug Abuse ing clients about the drugs prescribed for them, partic- ipating in drug education programs, and recognizing, Use measures to prevent substance abuse. Although there are as early as possible, clients who are abusing or are difficulties in trying to prevent conditions for which causes likely to abuse drugs. Nurses can help prevent drug abuse by administering individual measures may be helpful: drugs appropriately, using nondrug measures when pos- 1. Decrease the supply or availability of commonly sible, teaching clients about drugs prescribed for them, abused drugs. Most efforts at prevention have tried to and participating in drug education programs. For example, laws desig- resources for information and educational materials nate certain drugs as illegal and provide penalties for include the following: possession or use of these drugs. Other laws regulate National Institute on Drug Abuse circumstances in which legal drugs, such as opioid 6001 Executive Blvd analgesics and barbiturates, may be used. Also, laws Bethesda, MD 20892-9561 regulate the sale of alcoholic beverages. Many current attitudes seem to Information (NCADI) promote drug use, misuse, and abuse, including: Center for Substance Abuse Prevention a. The belief that a drug is available for every mental 5600 Fishers Lane and physical discomfort and should be taken in pref- Rockwall II erence to tolerating even minor discomfort. Conse- Rockville, MD 20857 quently, society has a permissive attitude toward Phone: (301) 443-0365 taking drugs, and this attitude is probably perpetuated E-Mail: nnadal@samhsa. Parents can help prevent drug abuse in their children by there are many appropriate uses of drugs, and clients minimizing their own use of drugs and by avoiding certainly should not be denied their benefits. Children are more likely to ficulties emerge when there is excessive reliance on use illegal drugs if their parents have a generally per- drugs as chemical solutions to problems that are not missive attitude about drug taking, if either parent amenable to chemical solutions. Pregnant women should avoid alcohol, nicotine, and by alcoholic beverages of some kind. The apparently prevalent view that drug abuse refers effects on the fetus. The acceptance and use of illegal drugs in certain subgroups of the population. This is especially Treatment measures for alcohol and other drug abuse are not prevalent in high school and college students. Even people who have been institutionalized 250 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM and achieved a drug-free state for prolonged periods are apt chanical ventilation. Removal of some drugs can be to resume their drug-taking behavior when released from the hastened by hemodialysis. Treatment of substance abuse may be complicated by holics Anonymous and Narcotics Anonymous, have been the presence of other disorders. For example, depres- more successful than health professionals in dealing with sion is common and may require antidepressant drug drug abuse. As a general rule, treatment depends on the type, ex- tent, and duration of drug-taking behavior and the particular Review and Application Exercises situation for which treatment is needed.