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Hormones The pituitary is often called the master gland because The remainder of this chapter deals with hormones and it releases hormones that affect the working of other the tissues that produce them discount 20 mg cialis soft overnight delivery erectile dysfunction at the age of 17. Refer to Figure 12-2 to lo- glands cialis soft 20 mg visa erectile dysfunction gabapentin, such as the thyroid, gonads (ovaries and testes), cate each of the endocrine glands as you study them. These Pancreatic releasing hormones travel to the ante- islets rior pituitary by way of a special type of circulatory pathway called a portal system. By this circulatory “detour,” Ovaries some of the blood that leaves the hy- Testes pothalamus travels to capillaries in the anterior pituitary before returning to the heart. As the blood circulates through the capillaries, it delivers the hormones that stimulate the release of anterior pituitary secretions. Hypo- thalamic releasing hormones are indi- cated with the abbreviation RH added to an abbreviation for the name of the Figure 12-2 The endocrine glands. For example, the 248 CHAPTER TWELVE Table 12•1 The Endocrine Glands and Their Hormones GLAND HORMONE PRINCIPAL FUNCTIONS Anterior pituitary GH (growth hormone) Promotes growth of all body tissues TSH (thyroid-stimulating hormone) Stimulates thyroid gland to produce thyroid hormones ACTH (adrenocorticotropic hormone) Stimulates adrenal cortex to produce cortical hor- mones; aids in protecting body in stress situations (injury, pain) PRL (prolactin) Stimulates secretion of milk by mammary glands FSH (follicle-stimulating hormone) Stimulates growth and hormone activity of ovarian follicles; stimulates growth of testes; promotes development of sperm cells LH (luteinizing hormone); ICSH (interstitial Causes development of corpus luteum at site of cell-stimulating hormone) in males ruptured ovarian follicle in female; stimulates secretion of testosterone in male Posterior pituitary ADH (antidiuretic hormone) Promotes reabsorption of water in kidney tubules; at high concentration stimulates constriction of blood vessels Oxytocin Causes contraction of uterine muscle; causes ejection of milk from mammary glands Thyroid Thyroxine (T4) and triiodothyronine(T3) Increases metabolic rate, influencing both physical and mental activities; required for normal growth Calcitonin Decreases calcium level in blood Parathyroids Parathyroid hormone (PTH) Regulates exchange of calcium between blood and bones; increases calcium level in blood Adrenal medulla Epinephrine and norephinephrine Increases blood pressure and heart rate; activates cells influenced by sympathetic nervous system plus many not affected by sympathetic nerves Adrenal cortex Cortisol (95% of glucocorticoids) Aids in metabolism of carbohydrates, proteins, and fats; active during stress Aldosterone (95% of mineralocorticoids) Aids in regulating electrolytes and water balance Sex hormones May influence secondary sexual characteristics Pancreatic islets Insulin Needed for transport of glucose into cells; required for cellular metabolism of foods, especially glucose; decreases blood sugar levels Glucagon Stimulates liver to release glucose, thereby increasing blood sugar levels Testes Testosterone Stimulates growth and development of sexual organs (testes, penis) plus development of secondary sexual characteristics, such as hair growth on body and face and deepening of voice; stimulates maturation of sperm cells Ovaries Estrogens (e. In- uretic hormone, or ADH, and oxytocin) are actually pro- hibiting hormones suppress both growth hormone, duced in the hypothalamus and stored in the posterior pi- which stimulates growth and metabolism, and prolactin, tuitary. Their release is controlled by nerve impulses that which stimulates milk production in the mammary travel over pathways (tracts) between the hypothalamus glands. These inhibiting hormones are abbreviated GH- and the posterior pituitary. THE ENDOCRINE SYSTEM: GLANDS AND HORMONES 249 Table 12•2 Disorders Associated with Endocrine Dysfunction HORMONE EFFECTS OF HYPERSECRETION EFFECTS OF HYPOSECRETION Growth hormone Gigantism (children), acromegaly (adults) Dwarfism (children) Antidiuretic hormone Syndrome of inappropriate antidiuretic Diabetes insipidus hormone (SIADH) Aldosterone Aldosteronism Addison disease Cortisol Cushing syndrome Addison disease Thyroid hormone Graves disease, thyrotoxicosis Infantile hypothyroidism (cretinism) in chil- dren; myxedema in adults Insulin Hypoglycemia Diabetes mellitus Parathyroid hormone Bone degeneration Tetany (muscle spasms) Internal-external stimuli Neurotransmitters Hypothalamus 12 Releasing hormones secreted ADH Oxytocin Infundibulum Portal system Posterior pituitary Hormones feed back to anterior pituitary Anterior pituitary and hypothalamus Breast Oxytocin Thyroid TSH ADH Uterus Thyroid hormones ACTH Adrenal Kidney PRL FSH Ovary FSH GH Adrenocorticosteroids LH LH (ICSH) Estrogen Corpus Breast luteum Testes Bone and Progesterone soft tissues Testosterone Figure 12-3 The hypothalamus, pituitary gland, and target tissues. Arrows indicate the hormones’ target issues and feedback pathways. ZOOMING IN What two structures does the infundibulum connect? Large amounts of this hormone cause contraction of smooth muscle in blood vessel walls and raise blood pressure. Hormones of the Anterior Lobe Inadequate amounts of ADH cause excessive water loss and result in a disorder called diabetes insipidus. This ◗ Growth hormone (GH), or somatotropin (so-mah-to- type of diabetes should not be confused with diabetes TRO-pin), acts directly on most body tissues, promot- mellitus, which is due to inadequate amounts of in- ing protein manufacture that is essential for growth. GH causes increase in size and height to occur in youth, ◗ Oxytocin (ok-se-TO-sin) causes contractions of the before the closure of the epiphyses of long bones. A uterus and triggers milk ejection from the breasts. It also stimulates the liver to Box 12-1 offers information on melanocyte-stimulating release fatty acids for energy in time of stress. Tumors of the Pituitary The effects of pituitary tu- ◗ Follicle-stimulating hormone (FSH) stimulates the devel- mors depend on the cell types in the excess tissue. Some opment of eggs in the ovaries and sperm cells in the testes. A person who develops ovulation in females and sex hormone secretion in both such a tumor in childhood will grow to an abnormally tall males and females; in males, the hormone is sometimes stature, a condition called gigantism (ji-GAN-tizm) (see called interstitial cell–stimulating hormone (ICSH). Although people with this condition are large, they are usually very weak. FSH and LH are classified as gonadotropins (gon-ah- If the GH-producing cells become overactive in the do-TRO-pinz), hormones that act on the gonads to regu- adult, a disorder known as acromegaly (ak-ro-MEG-ah- late growth, development, and function of the reproduc- le) develops. In acromegaly, the bones of the face, hands, tive systems in both males and females. The fingers resemble a spatula, and the face takes on a coarse appearance: the nose widens, the Hormones of the Posterior Lobe lower jaw protrudes, and the forehead bones may bulge. Box 12-1 A Closer Look Melanocyte-Stimulating Hormone: More Than a Tan? In Addison disease, the pitu- lating melanocytes to manufacture the pigment melanin. In hu- itary tries to compensate for decreased glucocorticoid levels mans, though, MSH levels are usually so low that its role as a by increasing POMC production. The resulting increased lev- primary regulator of skin pigmentation and hair color is ques- els of ACTH and MSH appear to cause the blotchy skin pig- tionable. Recent research suggests that MSH is probably more im- MSH’s roles in the rest of the body include helping the brain portant as a neurotransmitter in the brain than as a hormone to regulate food intake, fertility, and even the immune re- in the rest of the body.

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One of the problems of this expanded role of pediatric therapists is that many therapists do not believe they have the training needed to take on this role order cialis soft 20mg mastercard erectile dysfunction drugs free trial. Most phys- ical therapy training programs are at the master’s degree level generic cialis soft 20 mg with visa erectile dysfunction can cause pregnancy; however, the amount of training in pediatrics is minimal in many programs where there is a much greater allure to sports medicine and other adult rehabilitation di- rections. This experience mirrors what happens in orthopaedic training. Currently, there are a few well-developed specialty training programs for pe- diatric therapists, and none as well organized as the fellowship programs in pediatric orthopaedics. The trend to standardize this pediatric training is moving ahead and should train therapists who are much better equipped to take on the role in which they are currently expected to function. Many of these protocols have high regional concentrations of use, often in the area in which the sys- tem was initially developed and popularized. The same theories of therapy are widely used among both occupational and physical therapy. Neurodevelopmental Treatment Approach (NDT): Bobath Technique The NDT treatment approach was developed in England in the 1940s and 1950s by Dr. Bobath based on their understanding of neurologic development and experience gained in treating children. Based on the hierarchical concept of under- standing development, this approach focused first on correcting abnormal tone through the use of range-of-motion exercises, encouraging normal mo- tor patterns, and positioning. Second, abnormal primitive reflexes are ad- dressed through the use of extinction by repeated stimulation. Another ex- ample is neck flexion as the child is falling backward to prevent the head from hitting. Altering sensory input by careful handling and positioning is also an important aspect to achieving the first three goals. By having the child experience only normal movements, the brain will gradually remember the normal movements and forget the ab- normal postures used by the immature brain. The requirement of very early treatment, under the theory that the more immature the brain is, the more it can be influenced to develop normally, is also stressed in NDT therapy. Another important aspect of this treatment is the insistence that the parents learn, and at all times apply, these correct handling techniques. In the earlier years of the technique, there was great focus on idealized movements, such as the perfect way to come to a sitting position from lying; however, focus has more recently been on functional patterns that work for the child. The outcome of research has largely failed to show the benefits proposed by the founders of NDT techniques. Compared with other therapy techniques, or no therapy, there are few significant specific functional gains from the NDT approach. Despite the marginal evidence for direct benefit, NDT still has a widespread use, with some ther- apists maintaining the missionary zeal of avoiding specific movements in a child, such as extensor posturing. These therapists also focus on the children having correct crawling before they can stand or walk, and having them walk correctly with a walker before they can walk independently. This kind of missionary rigidity is inappropriate, and parents can be informed that they do not need to feel guilty when things do not happen exactly as the therapist requests. Because the objective data supporting the efficacy of NDT treat- ment are marginal, there is very little role for enforcing these concepts rigidly, although they may be perfectly legitimate techniques to help teach children correct movement. Therapy, Education, and Other Treatment Modalities 155 Sensory Motor Treatment Approach: The Rood Technique The sensory motor treatment approach was developed by Margaret Rood in the United States during the 1950s. Rood was trained as a physical and occupational therapist. This approach uses the same hierarchical under- standing of neuromotor developmen, and was developed in approximately the same time period, as the NDT protocols. The sensory motor technique depends heavily on tactile stimulation to facilitate movement. The overall goal of sensory motor therapy is to activate the movements at an autonomic level similar to how postural responses in normal individuals are activated. This activation requires superimposing mobility as produced by basic mus- cle responses onto stability, which is produced by tonic muscle responses.

Also 20 mg cialis soft overnight delivery erectile dysfunction pump, these flexion contractures are much more amenable to stretching out in young children order cialis soft 20mg on line erectile dysfunction doctors in alexandria va. Gait 267 joints are very sensitive to abnormal joint reaction forces. These abnormal forces may cause substantial abnormalities in the development of the joints and, in some cases, lead to joint dislocation. Joint dislocation is a prominent problem at the hip and is a lesser problem in the other joints. The specific joint problems are addressed in the sections devoted to those joints. Children with spastic CP have a tendency to have short muscles, which translates into decreased joint range of motion. The decreased range of motion subsequently leads to fixed joint contractures, even when there are no structural joint deformities. Joint Motor Mechanics Often, the mechanics of a single joint are based on the specifics of the in- volved joint; however, the only active way to move a joint is by the muscle attached to that joint. These muscle–tendon units attach in the bone and work by creating a moment through a moment arm. An excellent example of this is the knee, where the hamstring muscles attach to the tibia by being posterior to the joint’s center of motion. A moment arm is created and a ten- sion force is applied to create a moment that may cause motion. The mo- ment created is called the strength of the hamstring in clinical scenarios (Figure 7. The amount of strength, or joint moment, that is created in- cludes the percent of the muscle’s contraction, the cross-sectional area of the muscle, the position of the muscle fiber length on the Blix curve, the direc- tion and velocity of the change in the muscle fiber, and the moment arm of the muscle. Another variable is muscle fiber configuration with the degree of pennation of the fibers to the line of action of the muscle. In the hamstring muscles, this variable is of no significance because of a very low pennation angle. Some of these variables can be actively altered, and others are struc- tural variables. The variables that can be actively altered are the percent of muscle firing, the moment arm length, the position on the Blix curve, and the velocity of length change. The variables with the structural characteristics that can change over time are the diameter of the muscle through muscle Figure 7. To understand the force-gener- ating ability of the muscle, it is very impor- tant to understand the concept of stable ver- sus changing moment arms. An example is the quadriceps, which has a relatively con- sistent moment arm length independent of the joint position. The hamstrings, on the other hand, have a moment arm that is very dependent on joint position with the moment arm being very short at knee extension and very long at full knee flexion. Thus, the im- pact of a hamstring contracture very quickly becomes more significant as the degree of knee flexion increases. Single-Joint Muscles From the perspective of the central program generator, muscle activation that crosses a single joint requires consideration of the impact of at least three variables, including the percent of motor units to activate, the current length of the fiber that will define the moment arm and the Blix curve location, and the velocity of muscle fiber shortening. The system also has to consider its longer-term organization caused by structural alterations. From the treatment perspective, the major alterations are made in the structural variable. A major element in the clinical assessment of children is trying to understand if these structural changes are positive to the function of the joint and the whole- body motor system or if this structural change is now part of the pathology of the impairment that is increasing the disability. The intellectual under- standing of muscles that cross single joints, such as the short head of the biceps femoris, is relatively easy. The force generated is easily modeled, lead- ing to a clear understanding of the effects; however, in children with CP, these single joint crossing muscles cause far fewer problems than the muscles that cross multiple joints. Multiple-Joint Muscles Multiple-joint muscles, such as the rectus femoris and the gastrocnemius, comprise most of the problematic muscles.

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