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It also helps to prevent excessive tibial external rotation and femoral internal rotation medications known to cause pancreatitis purchase atomoxetine once a day. Each step at heel strike with the knee near full extension exerts tremendous force across the posterior lateral knee medicine glossary atomoxetine 40mg free shipping. The arcuate complex (posterior one third of lateral supporting structures including the lateral collateral ligament symptoms 14 days after iui discount atomoxetine 25mg line, the arcuate ligament symptoms 6 days after embryo transfer order atomoxetine 10 mg fast delivery, and the extension of the popliteus) helps to control internal rotation of the femur on the xed tibia during closed kinetic chain function (or external rotation of the tibia on the femur during open kinetic chain function symptoms right after conception purchase atomoxetine 10mg online. The posterior lateral bundle becomes more taut in extension treatment yeast purchase generic atomoxetine from india, and the anterior medial bundle becomes more taut in flexion. Its femoral and tibial attachments in the central knee joint enable it to be an ideal passive decelerator of the femur. In this location it changes its function from extensor to flexor as the knee flexes at approximately 30 degrees. Once past 30 degrees, the tendon slips behind the horizontal axis of the knee, providing force for flexion. It has attachments into the linea aspera, which are very strong and help to prevent the pivot-shift. A high Q-angle (intersection formed by lines drawn from the anterior superior iliac spine to the center of the patella and from the center of the patella to the tibial tuberosity; normally 13 degrees in males and 18 degrees in females) predisposes the patella to sublux laterally. With the addition of a loose retinaculum, patella alta, and a weak or dysplastic vastus medialis obliquus muscle, the 550 the Knee patella can easily sublux in the rst 30 degrees of knee flexion. With a flattened lateral femoral condyle, the patellofemoral joint becomes unstable, even though the patella is seated in the trochlear groove. When a person decelerates, the knee is flexed and the patella should be in the trochlear groove. If patella alta is present, the patella may not be in the groove, thus increasing stress on the patellar tendon. The supercial layer or tangential zone is composed of densely packed, elongated cells that contain 60% to 80% water. It is the thinnest articular cartilage layer and has the highest collagen content arranged at right angles to adjacent bundles and parallel to the articular surface. This layer has the greatest ability to resist shear stresses and serves to modulate the passage of large molecules between synovial fluid and articular cartilage. Next is the transitional layer with its rounded, randomly oriented chondrocytes (articular cartilage producing cells. The design of this layer reflects the transition from the shearing forces of the supercial layer and the more compressive forces of the deep articular cartilage layers. It is known for vertical columns of cells that anchor the cartilage, distribute loads, and resist compression. The calcied cartilage layer contains the tidemark layer (boundary between calcied and uncalcied cartilage. The tidemark layer is composed of a thin basophilic line of decalcied articular cartilage separating hyaline cartilage from subchondral bone. Branches of the popliteal artery split and form a genicular anastomosis composed of the superior medial and lateral genicular arteries and the inferior medial and lateral genicular arteries. The cruciate ligaments also twist upon themselves during knee flexion and extension. The weight-bearing line or mechanical axis of the femur on the tibia is normally biased slightly toward the medial side of the knee, creating a 170 to 175-degree angle between the longitudinal axis of the femur and tibia, which is opened laterally. If this alignment is altered by degenerative changes, fracture, or genetic conditions, excessive stress is placed on either the medial or the lateral tibiofemoral joint compartment. Tibial varum or femoral valgus (angle greater than 170 to 175 degrees) leads to increased medial compartment stress, whereas femoral varum or tibial valgus (angle less than 170 to 175 degrees) leads to increased lateral compartment stress. Are there differences between female and male knee joint anatomy and biomechanics No particular anatomic or biomechanic knee joint characteristic is unique to either gender. However, females tend to have a wider pelvis, greater femoral anteversion, more frequent evidence Functional Anatomy of the Knee 551 of a coxa varusgenu valgus hip and knee joint alignment with lateral tibial torsion, a greater Q angle (18 degrees versus 13 degrees), more elastic capsuloligamentous tissues, a narrower femoral notch, and smaller diameter cruciate ligaments. What is the normal amount of tibial torsion and how does the physical therapist measure it clinically Tibial torsion can be measured by having the patient sit with their knees flexed to 90 degrees over the edge of an examining table. The therapist then places the thumb of one hand over the prominence of one malleolus and the index nger of the same hand over the prominence of the other malleolus. Looking directly down over the end of the distal thigh, the therapist visualizes the axes of the knee and of the ankle. These lines are not normally parallel but instead form a 12 to 18-degree angle because of lateral tibial rotation. While both menisci are prone to injury, the medial meniscus is at greater injury risk for both isolated and combined injury in the young athlete because of its adherence to the medial collateral ligament. In addition to transverse plane rotatory knee joint loads, any direct blows to the lateral aspect of the knee while the foot is planted may lead to injury at both the medial collateral ligament and the medial meniscus. Additionally, as a result of generally greater medial compartment weight-bearing loads during gait, the medial meniscus is more prone to degenerative tears as we age. The lateral meniscus is more often injured in combination with noncontact anterior cruciate ligament injury. The popliteus musculotendinous complex functions as a kinesthetic monitor and controller of anterior-posterior lateral meniscus movementfor unlocking and internally rotating the knee joint during flexion initiation, and for balance or postural control during single-leg stance. Increased popliteus activity during tibial internal rotation with concomitant transverse plane femoral and tibial rotation lends support to the theory that it withdraws and protects the lateral meniscus, prevents forward dislocation of the femur on the tibia, and provides an equilibrium adjustment function. Popliteus activation may be most essential during movements performed in midrange knee flexion, when capsuloligamentous structures are unable to function optimally. The anatomic location, biomechanic function, muscle activation, and kinesthesia characteristics of the popliteus musculotendinous complex suggest that it warrants greater attention during the design and implementation of lower extremity injury prevention and functional rehabilitation programs. Nyland J et al: Anatomy, function, and rehabilitation of the popliteus musculotendinous complex, J Orthop Sports Phys Ther 35:165-179, 2005. Yagi M et al: Biomechanical analysis of an anatomic anterior cruciate ligament reconstruction, Am J Sports Med 30:660-666, 2002. Yasuda K et al: Anatomic reconstruction of the anteromedial and posterolateral bundles of the anterior cruciate ligament using hamstring tendon grafts, Arthroscopy 20:1015-1025, 2004. The Q-angle is measured by extending a line through the center of the patella to the anterior superior iliac spine and another line from the tibial tubercle through the center of the patella. The intersection of these two lines is the Q-angle; the normal value for this angle is 13 to 18 degrees. Men tend to have Q-angles closer to 13 degrees while women usually have Q-angles at the high end of this range. Because the Q-angle is a measure of bony alignment, it can be altered only through bony realignment surgical procedures. A measurement similar to the Q-angle, the tubercle-sulcus angle is reported to be a more accurate assessment of the quadriceps vector. The tubercle-sulcus angle is formed by a line drawn from the tibial tubercle to the center of the patella, which normally should be perpendicular to the transepicondylar axis. Excessive femoral anteversion, external tibial torsion, genu valgum, and subtalar hyperpronation can contribute to an increase in the Q-angle. When these conditions are found together, a patient is often said to have malicious or miserable malalignment syndrome. Bony factors, such as a dysplastic patella, patella alta, or a shallow intercondylar groove, can contribute to lateral tracking of the patella. Yagi M et al: Biomechanical analysis of an anatomic anterior cruciate ligament reconstruction, Am J Sports Med 30:660-666, 2002. Yasuda K et al: Anatomic reconstruction of the anteromedial and posterolateral bundles of the anterior cruciate ligament using hamstring tendon grafts, Arthroscopy 20:1015-1025, 2004. The Q-angle is measured by extending a line through the center of the patella to the anterior superior iliac spine and another line from the tibial tubercle through the center of the patella. The intersection of these two lines is the Q-angle; the normal value for this angle is 13 to 18 degrees. Men tend to have Q-angles closer to 13 degrees while women usually have Q-angles at the high end of this range. Because the Q-angle is a measure of bony alignment, it can be altered only through bony realignment surgical procedures. A measurement similar to the Q-angle, the tubercle-sulcus angle is reported to be a more accurate assessment of the quadriceps vector. The tubercle-sulcus angle is formed by a line drawn from the tibial tubercle to the center of the patella, which normally should be perpendicular to the transepicondylar axis. Excessive femoral anteversion, external tibial torsion, genu valgum, and subtalar hyperpronation can contribute to an increase in the Q-angle. When these conditions are found together, a patient is often said to have malicious or miserable malalignment syndrome. Bony factors, such as a dysplastic patella, patella alta, or a shallow intercondylar groove, can contribute to lateral tracking of the patella. Soft tissue structures, such as a tight lateral retinaculum Patellofemoral Disorders 553 A normal tubercle-sulcus angle at 90 degrees of knee flexion. A line from the tibial tubercle to the center of the patella should be perpendicular to the transepicondylar axis. Usually it is diagnosed by radiography and by determining the ratio between the length of the patellar tendon and the vertical length of the patella (Insall-Salvati ratio. The length of the patellar tendon is determined by measuring the distance between the inferior pole of the patella and the most cephalad part of the tibial tubercle. Patients with patella alta are more susceptible to patellar instability because the patella is less able to seat itself in the intercondylar groove. A simple classication scheme that helps to determine treatment was proposed by Holmes and Clancy. The four major rehabilitation categories associated with this system require the clinician to recognize instability, tension, friction, and compression disorders and the specic protocols for their appropriate treatment. Patellofemoral instability includes patients with patellar subluxation or dislocationeither recurrent or a single episode. First-time or infrequent subluxations and dislocations are treated with rehabilitation. Patients who continue to have problems after exhaustive therapy often require surgery. Most patients are treated conservatively with physical therapy, including quadriceps strengthening, lower extremity stretching, and treatment of potential contributing factors. Such patients often are treated with surgery only after an exhaustive trial of rehabilitation. General Name/Disorder Treatment Category Lateral patellar compression syndrome Compression Global patellar pressure syndrome Compression Patellar instability Instability Patellar trauma (depends on structure) Compression or friction Osteochondritis dissecans Compression Articular defect Compression or friction Suprapatellar plica Friction continued 556 the Knee continued General Name/Disorder Treatment Category Fat pad irritation Friction or compression Medial retinacular pain Friction Medial patellofemoral ligament Friction or instability Iliotibial band syndrome Friction Bursitis Friction or compression Muscle strain Tension Tendinosis/tendinitis Tension Osgood-Schlatter disease (apophysitis) Tension 12. Treatment includes stretching of the lateral retinaculum, such as medial glides and tilts. McConnell advocates quadriceps strengthening exercises with a medial glide of the patella with patellar taping. If rehabilitation is not successful, a lateral retinacular release often is performed. In lateral pressure syndrome, the tight lateral retinaculum causes a lateral tilt of the patella and may stretch the medial retinaculum. Bipartite patellas still have an intact ossication center, most commonly at the superolateral pole. An anteroposterior radiograph of the bipartite patella may be mistaken for a fracture by the inexperienced eye. A bone scan may assist the clinician in diagnosing symptomatic disruption of the bipartite patella. What is the difference between Osgood-Schlatter disease and Sinding LarsenJohansson disease Osgood-Schlatter disease is apophysitis of the tibial tubercle, and Sinding-LarsenJohansson disease is apophysitis of the distal pole of the patella. Functional shortening of the longer lower extremity may involve excessive subtalar pronation, genu valgus, forefoot abduction, and/or walking with a partially flexed knee. However, when the cartilage is not healthy, stresses are transferred to the subchondral bone, which is highly innervated. Hoffas disease (fat pad syndrome) manifests as pain and swelling of the infrapatellar fat pad, usually from direct trauma to the anterior knee. Tenderness often is present at the anteromedial and anterolateral joint lines and on either side of the patellar tendon. A large fat pad also may become entrapped between the anterior articular surfaces of the knee with forced knee extension. Treatment normally begins with protection of the anterior knee, particularly during activities where repetitive contusion may occur. Quadriceps strengthening should be performed to prevent weakness or atrophy resulting from disuse. The medial plica is a crescent-shaped, rudimentary synovial fold extending from the quadriceps tendon to around the medial femoral condyle and ending in the fat pad. The medial plica can be injured with a direct blow to the knee or through overuse activities such as repetitive squatting, running, or jumping. Contracted tissue running repetitively over the medial femoral condyle can cause pain and even erosion of the articular surface of the medial femoral condyle. Pain is aggravated by running, squatting, jumping, and prolonged sitting with the knee flexed. The most frequent clinical sign is tenderness located one ngers breadth medial to the patella. The fold is often palpable, especially when the knee is flexed and the plica is stretched across the medial femoral condyle. Techniques designed to assess the presence of plica syndrome include the stutter test, Hughstons plica test, and the mediopatellar plica test, but their sensitivity and specicity have not been studied. This injury occurs when the prepatellar bursa is subjected to blunt trauma or repetitive microtrauma over the anterior knee, often found in individuals who work on their knees (carpenters or gardeners.

To reflect that change medicine 035 buy atomoxetine amex, the axis (or center) of rotation is called the instantaneous axis (or center) of rotation medications quetiapine fumarate order atomoxetine 18 mg amex. Relative angles can be stated as either internal (included) or external (anatomic) angles section 8 medications 25mg atomoxetine mastercard. An internal angle is the angle between the longitudinal axes of the two segments comprising a joint medicine 600 mg generic atomoxetine 10mg free shipping, while the external angle is the angular displacement from the anatomic position holistic medicine order atomoxetine amex. For example medications bad for your liver purchase generic atomoxetine on-line, in the anatomic position, the internal knee angle is 180 degrees, while the external angle is 0 degrees. If this angle were decreased by 30 degrees, the internal angle would be 150 degrees while the external angle would be 30 degrees (see gure. It is important to understand the distinction between these three measures and to be consistent in their use. In observational gait analysis, for example, ankle and knee measures are usually external, relative angles while the thigh is usually an absolute angle with respect to the vertical; many motion capture systems, on the other hand, report internal angles for all three joints. A muscles force-producing (absorbing) capability is primarily determined by the: Type of muscle action (concentric, eccentric, isometric) Length of muscle (force-velocity relation) Physiologic cross-sectional area of the muscle Number of motor units within a muscle that are activated (intramuscular coordination) Rate of motor unit activation (rate-coding) Intrinsic force-generating capability of the muscle (specic tension) Contractile history of the muscle (e. Just as forces can be combined together to determine a resultant, they can also be broken into their components. The components are useful in identifying the different effects of a force on a joint. For example, a muscle force can be divided into the component that is perpendicular to the bone 16 Basic Science (causing it to rotate) and the component that is parallel to the bone (usually increasing the compressive force across a joint. Therefore in addition to causing movement at a joint, all muscle forces will affect the amount of compression at a joint. During rehabilitation of certain joint pathologies, it may be necessary to identify which therapeutic exercises will increase the force of a muscle (to strengthen it) without applying harmful compressive forces across the joint. Impulse is the area under the force-time curve, and accounts not only for the magnitude of the force but also for the duration over which the force is applied. Impulse determines the change in a bodys momentum, which is the product of mass and velocity. Applying a smaller force over a longer period of time will have the same impulse (and effect on a bodys momentum) as applying a larger force over a shorter period of time. Increasing the time of the impact, which can be accomplished by cushioned shoes and/or bending the knees when making contact with the ground, can attenuate the magnitude of an impact force, and may decrease the risk of injury. The moment of a force (moment for short), or torque, is the turning effect of a force. A force will have a tendency to rotate a body according to its magnitude, its direction, and the perpendicular distance between its line of application and the axis of rotation. Human movement occurs as a result of muscle forces producing a resultant moment about a joint axis of rotation. Even linear movement is a result of the coordinated rotation of two or more joints. Knowing that the moment is the product of the force and the moment arm, the length of the moment arm can be manipulated to increase or decrease the force required to complete a task. For example, low back injury prevention strategies are based on the premise of decreasing the moment about the low back during lifting by keeping the load as close to the spine as possible, thus reducing the moment arm of the external resistance. Similarly, flexing the elbows during abduction will decrease the moment arm about the shoulder, thus making the movement easier to perform. On the other hand, during manual muscle testing, the therapist can increase the demand on a muscle by applying the resistance as far from the axis of rotation as possible. When a study recommends a particular exercise because it produces a high net joint moment, what does that mean One of the greatest limitations in biomechanics is that we cannot, with current technology, measure muscle forces in a noninvasive way. Skeletal muscles are required to produce force, reduce (or absorb) force, or stabilize against a force. A concentric muscle action Biomechanics 17 produces forcethe muscle moment is greater than the moment of an external force, and movement occurs in the direction of the muscle moment. An eccentric muscle action reduces forcethe muscle moment is less than the moment of an external force, and movement occurs in the direction opposite of the muscle moment. The eccentric muscle action reduces the external force, and consequently decreases the acceleration caused by it. An isometric muscle action stabilizes against a forcethe muscle moment is equal and opposite to the moment created by an external force, and no movement occurs. Examining this relation reveals that greater force can be produced isometrically (when the velocity is zero) than can be produced concentrically, and greater force can be produced eccentrically than can be produced isometrically (see gure. Peak eccentric force is estimated to be between 120% and 140% of peak concentric force. Additionally, there is a negative relation between force and velocity in the concentric range, while there is a positive relation between force and velocity in the eccentric range. Yes; mechanical power is the product of the net joint moment and the angular velocity. Eccentric muscle actions are the primary means by which energy is safely absorbed by the body. Because the other tissues are not as capable of absorbing or distributing energy, energy levels can quickly exceed the tissues limits, resulting in injury. Is the denition of joint instability dened consistently throughout the clinical literature Investigators and clinicians have used at least three denitions: (1) excessive and occasionally uncontrolled range of motion resulting in frank joint dislocation; (2) small, abnormal movement in an otherwise normal range of motion that may result in pain because of impingement at the joint; and (3) a small amount of force necessary to move a joint through its range of motion (or low stiffness. Several factors combine to determine the location, severity, and type of injury, including the: Magnitude Rate Duration Frequency Variability Location D irection 23. The insensate and poorly vascularized foot, in association with connective tissue changes, is vulnerable to increases in pressure and consequently the development of pressure sores. If the body weight transmitted to the foot can be dispersed over a larger surface area of the foot, the magnitude of pressure is decreased as is the chance for ulceration. The same factors apply to a person conned to prolonged bed rest; pressure sores may develop on areas where bony prominences contact the bed. However, a certain amount of pressure applied to cartilage is normal and desirable. The degree of pressure is governed by the amount of quadriceps contraction (producing stress or force) and the amount of contact between the patella and the femur. The smaller contact area seems to have a stronger relationship to symptoms than does the increased amount of force. Depending on the tissue and its role, tissues respond quite differently, and this difference in response is called anisotropic. For example, tendon responds well to tension, not as well to shear, and not at all to compression. Human bone can handle compressive force best (such as pushing both ends of the bone toward each other), followed by tension (such as pulling both ends of the bone away from each other) and then shear forces (such as pushing the top of the bone to the right and the bottom of the bone to the left. A bending force basically subjects one side of the bone to compression, while the other side Biomechanics 19 experiences tension; therefore the side subjected to tension usually fails rst (immature bone may fail in compression rst. For torsional loading (such as twisting the top part of the bone, while holding the bottom of the bone xed), fracture patterns typically show that the bone fails as a result of shear forces, and then tension. Both determine the intensity of loading, and are quantied as force per unit area. Some scientists maintain that pressure represents the distribution of force external to a body and stress represents the distribution of force inside a body. Others maintain that pressure should be used in reference to fluids, while stress should be used in reference to solids. The tissue response to a force (or load) is deformation, which is a change in the size or shape of the tissue. Deformation is usually expressed as the quotient of the change in tissue length divided by the tissues original length, or strain. Laboratory experiments usually apply a given force (N) to a tissue of known cross-sectional area (mm2) and specied length (mm), in which the resulting deformation (mm) is measured. Can tissue responses to stress be measured in vivo, and if so, how is that accomplished For example, musculotendinous units are accessible to testing in vivo, but cartilage is not. The force, either exerted by subject (active) or caused by an apparatus (passive), is measured using a dynamometer and the deformation (here displacement) is measured using an imaging technique. Plotting the stress (force per area) on the vertical axis and the corresponding strain (deformation) on the horizontal axis produces a stress-strain (force-deformation) curve, which graphically represents the relation between the two (see gure. Several important qualities can be determined from this curve, including the tissues: Ultimate strengththe point on the curve where the tissue fails Yield point the point at which a permanent deformation occurs Elastic regionthe portion of the curve preceding the yield point Plastic regionthe portion of the curve following the yield point Stiffnessthe slope of the curve in the elastic range, also known as Youngs modulus Energy the area under the curve 30. When the force is applied to the tissue externally, does the tissue return to its original state after the force is removed At lower levels of force the tissue returns to its original form, and therefore this stage is called the elastic region. It is in the elastic region that the characteristics of the tissue are stable and therefore are used to describe the tissues with a modulus. This Youngs modulus is the change in stress over the change in strain during the elastic (or linear) range of the stress-strain testing. If the force continues to increase, it reaches a transitional pointthe yield point. The yield point is where the material changes from the elastic range to the plastic range. Beyond this yield point, permanent deformation will occur even after the load is removed. The stress-strain curve can be appreciated clinically most easily during ligamentous testing. If the injurious force did not exceed the yield point, the ligament would return to its original length with no detectable changes in joint laxity. If the injurious force exceeded the yield point but did not reach the ultimate strength of the ligament, the ligament would experience a permanent deformation that would be manifested as an increase in joint laxity. If the injurious force exceeded the ultimate strength of the ligament, the ligament would catastrophically fail and the subsequent force applied during ligamentous testing would be met with no resistance. Even if the amount of load is in the elastic range, but it is applied for a longer time, it will continue to cause a deformation. Human cartilage takes 4 to 16 hours to reach creep equilibrium, and this is why humans become slightly shorter as the day passes. Prolonged flexion of the lumbar spine results in a creep of the posterior ligaments, which decreases joint stiffness and may predispose the low back to injury. It is prudent to advise patients to allow this flexion-creep to reverse itself before performing activities that require lumbar stability. When viscoelastic tissue is loaded and then subsequently unloaded, the amount of stress is lower for a given amount of strain. This phenomenon is a consequence of the tissues viscosity, and is called hysteresis. The area between the loading and unloading curves (shaded area, see gure) is a measure of hysteresis, and represents the energy absorbed by the tissue, which is usually lost in the form of heat (although it could cause tissue damage. Repeated loadings, as well as acute and chronic stretching, increase a tendons compliance and decrease the amount of hysteresis. These changes increase the energy returned during the stretch-shortening cycle (improving performance), and can decrease the risk of injury. These changes show that stretching has benecial effects other than just improving the range of motion of a joint. The amount of force or tension that a muscle can produce varies with the length of the muscle at the time of contraction. When the bers shorten beyond resting length, the force production decreases slowly at rst, and then rapidly. This relationship can be used to help explain why surgically lengthened muscles are weak postoperatively (see gure. Discuss some factors that affect the biomechanical properties of tendons and ligaments. There are morphological, biomechanical, metabolic, and histologic differences between types of cartilage in the joints of the lower extremities. Those differences, in part, are the reason why osteoarthritis is more prominent in the knee and hip joints than in the ankle joint. With boundary lubrication, a layer of fluid prevents direct contact between two surfaces, decreasing friction. With fluid lm lubrication, the fluid between two surfaces separates the contact surfaces and distributes the loading between them. Fluid lm lubrication works by: Increased fluid pressure creating a wedge, separating two surfaces (hydrodynamic) Increased fluid pressure deforming the articular surface, creating greater contact area (elastohydrodynamic) Increased pressure on the articular cartilage, forcing fluid out onto the surface (weep) 38. Friction is a force, parallel to the contact surface, that opposes motion between two objects. The magnitude of the friction force will depend upon the material characteristics of the two contacting surfaces, and will be lower if there is relative motion between the two surfaces. A certain amount of friction between the ground and our shoes is necessary for efcient movement and to prevent slipping, but it also wears the soles of our shoes. High friction forces between the ground and the shoe increase the risk of ankle and knee injuries in sports where there is a lot of sudden turning or stopping, while repetitive friction forces to the skin can cause blisters. An obvious example would be the difference in change in volume response to resistive exercise by a muscle and a tendon. A tendon adapts to change slower than muscle because it has fewer cells (in this case, tenocytes) that are capable of facilitating adaptation. Evidence on the rate of adaptation of ligaments, cartilage, and intervertebral disks is scarce, but it is believed that they develop more slowly than muscle. It is important to realize, during rehabilitation, that a muscle will regain its strength before the other tissues of the musculoskeletal system, and therefore muscle strength alone is not a good indicator of the rehabilitation process. What happens to the strength of an intramedullary rod when its diameter is increased

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Functional Electrical Stimulation Therapeutic Neuromuscular Electrical Stimulation Repetitive stimulation is applied to paralyzed muscles to minimize atrophy and/or maintain range of motion treatment with chemicals or drugs order generic atomoxetine on-line. Iontophoresis A transdermal delivery system in which a substance bearing a charge is propelled through the skin by a low electrical current symptoms bipolar order 18mg atomoxetine fast delivery. Treatments can be provided to the extremities for 515 minutes medicine 44 159 discount atomoxetine line, or given to the trunk (neck treatment meaning purchase atomoxetine 10 mg with mastercard, back medicine in spanish atomoxetine 40 mg without a prescription, abdo men) for 1530 minutes symptoms vaginal yeast infection cheap atomoxetine on line. Massage will not affect muscle strength, mass, or rate of atrophy of denervated muscle. Severe pressure over trigger points has produced hematoma forma tion with subsequent nerve entrapment, in severe cases. Helps with desensitization, allows clearing of secretions, and improves circulation. Can be applied transverse or perpendicular to the muscle, tendon, or ligament fibers. Massage is done with the fascia-muscle in a stretched position rather than relaxed or shortened. Traction can be achieved using manual technique or with the use of a pulley system or an electrical motor ized device. To relieve symptoms of nerve root compression, 2030 of flexion optimally opens the intervertebral foramina. This position reduces lumbar lordosis, and the spine is relatively flexed, opening the intervertebral foramina. For cervical radiculopathy, traction may use 25 pounds with neck flexion described earlier. Another option may be the use of a split table, which elimi nates the lower body segment friction (Judovich, 1955. It is used for distraction when neural foram ina opening or retraction of herniated disc material is desired. Muscle shortening is produced by coordinated movement of the thin (actin) and thick (myosin) filaments within the myofibrils. During muscle contraction, increasing amount of myosin overlap is observed, and muscle shortening occurs. Contraction results in the Z lines approaching each other, shrinking of the H zone and I band. Eccentric and concentric contractions are muscle contractions that may be isokinetic or isotonic. Can be minimized by beginning with low-intensity exercise followed by regular exercise routine Muscle soreness decreases with muscle conditioning. Conditioning, Total Body Endurance Exercises, or Cardiopulmonary Endurance Exercises these types of exercise use large muscle groups to perform continuous and rhythmic exercises that provide low intensity and high repetition. This is in contrast to anaerobic fast eccentric contractions > slow eccentric contractions > isometric contractions > slow exercises, which utilize high intensity and concentric contractions. Aerobic Exercises (Endurance Exercises) Combination of cardiopulmonary endurance exercise with strengthening. More tension is developed, and more energy is absorbed into the muscle and tendon, which can lead to bone avulsion or muscletendon tears. One contraction a day at 50% of maximal strength is enough to prevent this decrease. A 26% decrease in gastrocnemius and 24% decrease in soleus muscle torque were found. In studies by Beckman (1995) and Nicholas (1976), effects of hip musculature strength and recruitment pattern were affected for several months after ankle sprain. Calcium is excreted in the urine and feces starting at 23 days after immobilization, and peaking at 37 weeks. After activity is resumed, calcium levels remain high for 3 weeks, reaching normal values at 56 weeks. After activity is resumed, loss continues for 1 week and plateaus during the second week. Below normal values are obtained at 4 weeks and returns to normal values in 6 weeks. It depends on nutrition from the synovial fluid through loading and unloading of pressure. Immobilization causes ligament strength to decrease, compliance to increase, and collagen degradation to increase. It documents the severity of disability as well as the outcomes of rehabilitation treatment as part of a uniform data system. Decreased baroreceptor sensitivity is also associated to cough and micturition syncope syndromes. These declines reflect changes in related organ systems, which are stressed by voluntary ventilation required during these tests. Chemical alteration of cartilage with a decreased ability to bear weight without causing ulceration of cartilage and eventual exposure of bone Decreased peak bone mineral density starting in mid-30s Base of stance is increased. Hyperthermia is affected by impaired sweating and aggravated by medical conditions, such as malnutrition, hypoglyce mia, and hypothyroidism; or medications, such as narcotics, ethanol, and benzodiazepines. Results have shown that memory disturbances in the elderly are related to depression rather than poor perfor mance. There are related studies that show that there is little or no aging effect in verbal ability. Older men have decreased ability to have psychogenic erections and require more intense stimulation. Erections may be partial; the force of ejaculation is decreased, with a less intense sensation of orgasm. Other reasons for decreased sexual function may include partners impotence, decreased libido, and decreased opportunities for sexual encounters. Toxicity manifests with cardiac dysrhythmias, anorexia, nausea, vomiting, abdominal pain, fatigue, depression, drowsiness, lethargy, headache, confusion, and ocular disturbances. In states of prostaglandin inhibition, the patients develop hyporeninemic hypoaldosteronism. Other causes, such as decreased cognitive function, diarrhea, and decreased sphincter tone, need to be evalu ated. Diarrhea is commonly seen in association with fecal impaction, infection, and drugs, such as laxatives, antibiotics, and digoxin toxicity. Sleep related disorders in the elderly are frequently related to depression Increased incidence of iatrogenic complicationsadverse drug interactions are usually the result of polypharmacy Emotional sequelaeanxiety and confusion are common in relation to illness, progno sis, and hospitalization. Many times patients are dependent for functional activities Social support system and discharge dispositionpatients functional abilities may be impaired. This can be added to a decrease in patients motivation, which can lead to a more difficult return to a prior living situation Deconditioning effects, as previously discussed, tend to appear earlier, are more severe, and take longer to reverse in the elderly. Falls in the commu nity are associated with decreased static balance, leg strength, and hip/ankle flexibility. Nortriptyline is less anticholinergic, has decreased sedation effect, and causes less orthostatic hypotension (which is a result of alpha-1 blockade. Agitation If medications are required, Elavil (amitriptyline) is recommended over other medications, such as benzodiazepines like Valium. Due to the fact that fat-soluble drugs tend to accumu late more in the elderly as a result of changes in metabolism and body composition, benzo diazepines accumulate with the adverse side effects, such as drowsiness. Ankle inversion injury and hypermobility: Effect on hip and ankle muscle electromyography onset latency. The mere presence of low levels of carboxyhemoglobin is not causal proof for altered neuropsychological performance. Comparison of in vivo temperatures produced by hydrotherapy, paraffin wax treatment, and Fluidotherapy. Electroacupuncture analgesia could be mediated by at least two pain-relieving mechanisms; endorphin and non-endorphin systems. Splinting vs surgery in the treatment of carpal tunnel syndrome: Arandomized controlled trial. Lumbar traction therapyElimination of physical factors that prevent lumbar stretch. Therapeutic temperature distribution produced by ultrasound as modified by dosage and volume of tissue exposed. Heating patterns produced by short wave diathermy using helical induction coil applicators. Temperature distributions in the human thigh, produced by infrared, hot pack and microwave applications. A study of thigh muscle weakness in different pathological states of the lower extremity. Cigarette smokers can benefit from rehabilitation if the role of smoking cessation is emphasized and integrated into the rehabilitation program (Celli, 2005. Classification of Functional Pulmonary Disability: Moser Classification (Corsello, 1991) 1. Muscles of Respiration Active Muscles During Inspiration the diaphragm, innervated by the phrenic nerve, is the primary muscle of respiration during inspiration. Diaphragmatic contraction increases the volume and decreases the intra-thoracic pressure in the thoracic cavity. This resulting decrease in intra-thoracic pres sure relative to atmospheric pressure results in inhalation. Active Muscles During Expiration Normally a passive process which becomes more active in certain disease states, such as emphysema Abdominal musclesprimary expiratory muscles Accessory muscles: internal intercostals Active Muscles of the Upper Airway Facilitate airway patency. Respiratory involvement is caused by failure to adequately remove secretions from the bronchioles, resulting in widespread bronchiolar obstruction and subsequent bron chiectasis, overinflation, and infection. Stiffness of the chest wall or the lung tissue itself Can be associated with variable levels of hypercapnia or hypoxia. Respiratory failure usually develops late in the disease and is the most common cause of death. If patient is > 35 years of age and quits smok ing, the rate of decline of lung function slows to the normal rate associated with aging, and some improvement in function can occur. This decreases diaphragmatic excursion and the vital capacity in the sitting position. A study by Maloney reported that in the sitting position the use of an abdominal binder improved vital capacity (Figure 93) (Maloney, 1979. The vital capacity is improved lished for determining the point at in the seated position with corset. Hypercapnia may occur as disease progresses and as vital capacity decreases (Bach, 1996. Evaluate Nutritional State Respiratory muscle weakness is associated with metabolic deficits. It indicates visceral protein depletion and is a good predic tor of rehabilitation potential. This condition increases the work of the respiratory system, particularly during weight-bearing activities. It is important to instruct the patient on how to admin ister it since > 60% use inhalers incorrectly. Use is limited by potential toxicity (Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, 2007. Caused by loss of heat, water, or both from the lungs during exercise as the result of hyperventilation. The most accepted guideline for O2 use during exercise is if the patient exhibits an exercise induced SaO2 below 90%. Different types may be used in patients with obstructive pulmonary disease and restrictive disease. Feedback of abdominal and rib cage movement is obtained through hand placement as described previously. Benefits: increased tidal volume, decreased functional residual capacity, and increase in maximum oxygen uptake Segmental breathing Obstructions, such as tumors and mucous plugs, should be cleared prior to practicing this technique. Techniques to Reduce Dyspnea and the Work of Breathing Pursed-Lip Breathing Patient inhales through the nose for a few seconds with the mouth closed, then exhales slowly for 46 seconds through pursed lips. Maintain an Adequate Airway Secretion Management Program Controlled Cough the patient assumes an upright sitting position, inhales deeply, holds the breath for sev eral seconds, contracts the abdominal muscles (bears down increasing intra-thoracic pressure), then opens the glottis and rapidly and forcefully exhales while contracting the abdominal muscles and leaning slightly forward. Secretion Mobilization Techniques (Postural Drainage, Percussion, Vibration) Indications: Sputum production > 30 mL/day Aspiration Atelectasis Moderate sputum production in debilitated patients that are unable to raise their own secretions Postural Drainage (Figure 94) Utilizes gravity-assisted positioning to improve the flow of mucous secretions out of the airways. Positions for Postural Drainage (Figure 94) A common position is the Trendelenburg or head-down posture, which can be done with the patient supine or prone, and different postural variations, such as side lying or trunk bending. Mechanical loadPressure changes related to position Upright positionabdominal contents remain in low position due to gravity; dia phragm can compress them easily. With progression from the sitting to the Trendelenburg position, the diaphragmatic work of breathing is increased (the abdominal content load increases. The diaphragm will accom modate to the increase in load by increasing its contraction. In obesity, the external load of the abdominal muscles may be greater than the muscles capacity of contraction. In neuromuscular disease, the muscles may not be able to generate tension against the abdominal content load, requiring changes in posture to assist in breathing. The weight of the pulmonary tissue also contributes to overall pressure on the most dependent alveoli. The dependent alveoli expand in size when changing from sitting to supine position, increasing ventilation at the base of the lung. Blood flowgravity dependent Maximum flow is greatest at the most gravity dependent portions of the lung. However, posterior seg ment flow will exceed anterior segment perfusion in this position. Zone 3: Pulmonary venous pressure (Ppv) exceeds alveolar pressure and fow is determined by the arterial venous pressure (Ppa) difference (PpaPpv) which is constant down this pulmonary zone.

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If one of the humeral epicondyles is fractured and displaced or a comminuted supracondylar or intracondylar fracture is present medications with aspirin buy atomoxetine with mastercard, the normal relationship muscle medications requiring central line generic 18 mg atomoxetine mastercard, these three constitute the lateral border of the pos of the two epicondyles to each other is disrupted treatment group purchase atomoxetine online now. The central portion of the pos terior forearm is occupied by the extensor digitorum Olecranon Bursa medicine kit generic atomoxetine 18mg with visa. The redundancy of the skin overlying communis and extensor carpi uinaris medicine you can give dogs 10mg atomoxetine, which originate the olecranon process facilitates the extreme amount of from a common tendon at the lateral cpicondyle and flexion possible at the elbow in treatment 1 order 40 mg atomoxetine with amex. The group of three muscles, which originates in the midfore olecranon bursa lies between the tip of the olecranon and arm, emerges between the extensor digitorum communis the overlying skin, facilitating the large amount of sliding motion that takes place between the skin and the bone. Trauma, inflammation, or infection can cause this bursa to fill with blood, synovial fluid, or pus, respectively. The presence of fluid causes the bursa to swell to the size of a Ping-Pong ball or even larger and bulge outward (Fig. In the presence of sterile inflammation, the skin overlying the bursa may be slightly warm; in the presence of infection, the skin is normally hot and erythematous. The tip of the elbow and adjacent subcutaneous bor der of the proximal ulna is the most common site for for mation of rheumatoid nodules (Fig. When present, these rubbery nodules satisfy one of the criteria for the diagnosis of rheumatoid arthritis. The muscular anatomy of the dis tal portion of the upper arm is dominated by the triceps brachii, the principal extensor of the elbow. The principal insertion of the triceps is into the proximal olecranon, although it also flares into an aponeurosis that covers the small anconeus muscle and blends into the fascia of the posterior forearm. A bulge on the lateral aspect of the pos terior elbow marks the proximal portions of the radially innervated brachioradialis and extensor carpi radialis longus muscles, which originate on the epicondylar ridge above the elbow and course distally to their insertions at Figure 3-7. Together with the extensor carpi radialis brevis S, Sledge C: Textbook of Rheumatology, 2nd ed. A, brachioradialis; B, extensor carpi radialis longus; C, extensor carpi radialis brevis; D, extensor digitorum communis; E, extensor carpi ulnaris; F, outcropping muscles of the thumb; G, subcutaneous border of the ulna. The tip Owing to the way these muscles emerge obliquely between of the olecranon is a subcutaneous prominence that the other two extensor muscle groups, they are sometimes should be visible in virtually all individuals. In leaner patients, the epicondylar ridge of the distal humerus is visible in con Ulna. The muscular contours of the posterior forearm tinuity with the lateral epicondyle. The radial head, how are completed by the ulnar portion of the flexor muscle ever, is not normally visible because it is covered by the mass, which bulges out sufficiently to constitute the extensor muscle mass. The subcutaneous border When an olecranon fracture occurs, the pull of the of the ulna is often visible as a linear furrow extending triceps muscle usually causes the proximal fragment of distally from the olecranon. The subcutaneous examined before much swelling has set in, this displace border of the ulna constitutes the dividing line between ment is detectable as a disruption in the normal trian the extensor and the flexor compartments of the forearm. There is relatively little soft tissue overly distal aspect of the upper arm to the medial epicondyie. This soft spot is also generally considered the triceps, and anterior to it lie the biceps and brachialis easiest point at which to aspirate or inject the elbow joint. Distention or fullness at the site of the normal soft spot suggests the presence of intraarticular fluid. The ulnar nerve is best identified from the causes of such a distention include hemarthrosis due to medial aspect. It courses through the posterior compart an intraarticular fracture; synovitis due to arthritis, ment of the upper arm just posterior to the intermuscu osteochondritis dissecans, or loose bodies; or infection. The ulnar nerve is virtually subcuta of the olecranon process and the prominence of the neous as it passes through the groove between the medial media] epicondyie (Fig. The medial epicondyie epicondyie and the olecranon; this groove is often called serves as the origin of the flexor-pronator muscle group. In lean individuals, the ulnar nerve A linear soft tissue ridge may be seen leading down the may actually be visible in the cubital tunnel as a linear Figure 3-10. A, olecranon process; B, medial epicondyle; C, biceps brachii; D, intermuscular septum; E, triceps; F, cubital tunnel. In patients Medial (Ulnar) Collateral Ligament overuse injuries with more subcutaneous fat, the ulnar nerve is still easily -Tenderness over the medial (ulnar) collateral palpable at this location. If ulnar neuropathy is suspected, ligament the examiner should inspect this area very closely as the -Abnormal laxity to valgus stress test patient maximally flexes and extends the elbow several (complete injuries) times. In some patients, neuropathy is secondary to Pain elicited by the milking maneuver (partial instability of the ulnar nerve in the cubital tunnel, and the injuries) nerve can be seen to pop back and forth across the medial -Associated ulnar nerve irritation at the cubital tunnel possible epicondyle as the elbow flexes and extends. The forearms are fully supinated so that the palms face forward and the elbows are fully extended. The shoulders are adducted so that the erable variation in the carrying angle among individuals, upper arms lie comfortably against the side of the chest. An average of 13 for upper extremity is not straight when the elbow is fully women and 10 for men is reported. Interestingly, the extended; instead, the forearm and hand angle away from ulnar-humeral articulation is so engineered that the car the body. This normal valgus angulation at the elbow is rying angle disappears when the elbow is flexed, and the referred to as the carrying angle. In the case of a growth disturbance, the magnitude of the deformity increases until skeletal growth is completed. This progressive valgus deformity puts abnormal tension on the ulnar nerve, which passes over the medial aspect of the elbow. Ultimately, this can lead to an insidious, progressive deterioration of ulnar nerve function with weakness and atrophy of muscles that are innervated by the ulnar nerve distal to the elbow. This condition is known as a tardy ulnar nerve palsy because the neuropathy appears tardily, sometimes years after the fracture has occurred. Trauma may also lead to a reduction or even reversal of the normal carrying angle. Such a reversal is known as cubitus varus and is sometimes called a gunstock defor mity (Fig. The most common cause of cubitus varus is malunion of a supracondylar humerus fracture that occurred in childhood. Distal to the elbow, the forearm should appear straight regardless of the position of rotation. Unexpected angulation within the forearm suggests malunion of a previous fracture or a developmental abnormality. Although the articular surfaces of the elbow participate in the mechanism that permits forearm rotation, the princi pal motions of the elbow itself are flexion and extension. Although the elbow is not a perfect hinge joint, the devi ation in the center of rotation is so minimal that, from a practical standpoint, it can be thought to function as a hinge. The center of rotation passes through the mid point of the capitellum at the anterior inferior aspect of the medial epicondyle. The average arc of motion is from 0 to 140, although 30 to 130 is thought to be sufficient for most activities of daily living. Many patients exhibit some degree of elbow hyperextension, which may meas ure as much as 30. In fact, hyperextension of the elbow is commonly accepted as one of the criteria for generalized joint laxity. In measuring flexion and extension of the elbow, the point at which the forearm is aligned with the upper arm is considered neutral, or 0. To assess active elbow extension, the patient is asked to straighten the elbow as much as possible. A general visual comparison of the two elbows can be done from the anterior perspective, but a lateral view is best for more accurately quantitating the amount of extension present (Fig. Hyperextension to 10 is common, and even more hyperextension can be found as an anatomic variant (Fig. If extension to at least 0 is not possible or if the amount of extension differs between the two elbows, the Figure 3-14. To assess passive elbow extension, the examiner grasps the upper limb above and below the elbow and gently extends the joint (Fig. While performing this maneuver, the examiner should note whether the extension stops abruptly, with a hard bony feel, or more softly, with a slight feeling of give to the end point. A hard endpoint suggests a bony block, such as might be caused by the accretion of osteophytes on the olecranon process or large loose bodies in the posterior compartment of the elbow. A softer endpoint suggests that an anterior soft tissue contracture is responsible for the loss of extension. A mild loss of extension due to such a contracture is common in the dominant elbow of athletes who throw. Posterior elbow pain produced by forceful passive extension suggests cither bony or soft tissue impingement in the olecranon fossa. Athletes who throw are subject to a condition called valgus extension overload, in which the recurrent valgus stresses that occur during throwing cause Figure 3-15. Such patients normally feel posterior elbow ily be overlooked at the elbow because the normal upright pain when their elbows are forcefully extended. If such a condition is suspected, the rupture or radial nerve injury should cause a dramatic patient should be asked to extend the elbow with the arm difference between active and passive extension of the in the overhead position to see whether full elbow exten elbow, just as quadriceps weakness can result in an exten sion against gravity is possible (Fig. To assess active elbow flexion, the examiner should ask the patient to bend both elbows as far as possi ble (Fig. The normal flexion endpoint of the elbow is softer than the normal extension endpoint because flexion is usually limited by the impingement of the flexor muscle groups of the upper arm and forearm. In patients with unusually well-developed biceps, the loss of flexion can be considerable. Loss of flexion in the presence of a firmer, bony endpoint suggests an anterior impingement due to osteophytes on the coronoid process of the ulna, ectopic calcification, or large loose bodies. To produce forearm rota tion, the curved radius rotates around the straight ulna. At its proximal end, the circular, slightly concave radial head rotates in place against the convex capitellum. This movement also occurs at the distal radial-ulnar joint and is guided by the triangular fibrocartilage and associ ated ligaments. When the forearm is fully supinated, the radius and ulna are roughly parallel to each other; when the forearm is fully pronated, the radius crosses over the ulna. Abnormalities of any of the structures involved in this complex mechanism can lead to significant loss of forearm rotation. The average amount of rotation is 70 to 80 of pronation and 85 of supination, although 50 of prona tion and 50 of supination are considered sufficient to perform most activities of daily living. Because patients often unconsciously make up for loss of forearm rotation with compensatory shoulder motion (Fig. To measure forearm rotation, the patient stands facing the examiner with elbows tucked snugly against the sides. The patient should be instructed to keep the elbows at the sides during the testing procedure. When the thumb is facing upward, the forearm is considered to be in the neutral position (Fig. To test supination, the patient is then instructed to rotate the forearms until the palms are fac ing up (Fig. The angle of rotation with respect to a vertical line is considered the amount of supination present. In a patient with 85 of supination, the plane of the palm would be almost parallel to the floor. To test pronation, the patient is then distal biceps tendon rupture, the tendon would be difficult instructed to rotate both forearms until the palms are fac to palpate and would not feel taut. The brachial artery pulse the angle between the plane of the palms and a vertical line. The nerve itself, however, cannot be distinctly iden noted, the distal biceps tendon and the associated lacertus tified by palpation. The most common site of median nerve compres the prominence of both these structures is increased by sion is the point at which the median nerve passes resisted supination or resisted elbow flexion in the between the two heads of the pronator teres muscle, a supinated position. The lacertus fibrosus is more super condition therefore referred to as pronator syndrome. This ficial and usually obscures the main portion of the ten relatively uncommon nerve compression syndrome pres don. If biceps tendinitis is suspected, the biceps tendon ents with a vague aching pain in the proximal flexor mass should be palpated carefully down toward its insertion on of the forearm that is made worse by repetitive strenuous the radius. Paresthesias in the sensory around the lateral border of the lacertus fibrosus at the distribution of the median nerve in the hand may be an level of the elbow flexion crease (Fig. To screen for pronator syndrome, should be palpable as a taut cord diving deep toward the the examiner positions the patient to test for pronation radius. In the presence of a her opposite thumb, the examiner applies firm pressure Figure 3-22. As already noted, fluid distention of the olecranon bursa is usually quite visible. Palpation of the posterior elbow previous inflammation of the bursa can be associated begins with the olecranon process (see Fig. In the with subtler findings that may be detected by gentle pal setting of acute trauma, tenderness of the olecranon, pation. By gently rubbing one or two fingers over such an especially when accompanied by swelling and ecchymo olecranon bursa, the examiner often detects ridges corre sis, suggests an olecranon fracture. This overuse olecranon apophysitis is usually associated with localized bony tenderness but very little, Ulna. Although fractures of both just superior to the olecranon process reveals a soft bones of the forearm are usually accompanied by obvious depression corresponding to the olecranon fossa of the posterior humerus. The examiner is actually palpating instability and deformity, isolated fractures of the ulna the olecranon fossa through the overlying triceps tendon. Isolated fracture of Tenderness of the distal triceps tendon suggests the pos the ulna is usually due to a direct blow and is sometimes sibility of triceps tendinitis, especially if the tenderness is called a nightstick fracture. Loose bodies in the ture, careful palpation of the subcutaneous border of the posterior compartment ot the elbow can cause tenderness ulna usually reveals localized tenderness and sometimes a in the olecranon fossa.

The content of this publication may be copied treatment 2 go purchase 40mg atomoxetine free shipping, adapted medicine to stop vomiting generic 40 mg atomoxetine, and redistributed treatment 5cm ovarian cyst purchase 10mg atomoxetine, in whole or in part medications covered by blue cross blue shield best purchase atomoxetine, provided that the material is not used for commercial purposes and that proper attribution be made medications zoloft order atomoxetine 40 mg fast delivery. All reasonable precautions have been taken by the Knowledge Management Division Knowledge Management and Information Technology Service to verify the information contained in this publication treatment nurse best 25 mg atomoxetine. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the handbook lies with the reader/user. In no event shall the Knowledge Management Division Knowledge Management and Information Technology Service be liable for damages arising from its use. Published by Knowledge Management and Information Technology Service Department of Health San Lazaro Compound, Sta. In light of the changes in disease patterns and the health sectors inability to fully provide full access to services especially among mothers, their babies, and other vulnerable groups, policymakers and program managers look to reliable mortality data to guide them in discerning areas for intervention and in crafting policies. They would need to know how Filipinos die, what they die of, whether they die prematurely or in old age. A case in point, in the past decade, the Philippines has been waging an all-out war against maternal and neonatal mortality. We need to know whether our policies and programs to reduce maternal mortality and ensure that children do not die prematurely are working. We need the evidence so that we can develop appropriate and efective intermediation and strategies. Thus, data quality depends on the accuracy and completeness of information entered in the death certifcate. A recent assessment by our civil registration and vital statistics system shows the need to capacitate personnel in-charge with accomplishing the death certifcate, particularly regarding cause of death, disease coding, and verbal autopsy. In this regard, we are glad to share this handbook on medical certifcation on the cause of death. It is a quick and easy reference for physicians especially our municipal health ofcers in accomplishing death certifcates. It provides information on the correct and proper way of certifying causes of death and accomplishing the death certifcate. This handbook represents one of our initial steps in improving the quality of mortality data. It is part of our continuing efort to strengthen the Philippine Health Information System. Better information leads to better governance, which ultimately results to healthier Filipinos! This will lead to improved classifcation in causes of death statistics, thus, ensuring more precise mortality data. The tool was adapted from the Handbook for Doctors on Cause-of-Death Certifcation of the Health Information Systems Knowledge Hub School of Population Health, the University of Queensland. It provides important information and data on the circumstances surrounding the death. The information from the death certifcate has various uses, it is used for settlement of claims, inheritance, insurance benefts as well as proof of death. The certifcate is likewise provided to the family members since it is a requirement for burial arrangement. The cause of death as certifed by a doctor is a record of an individuals death information. Being responsible for the clinical diagnosis of the cause of death, the physician plays a critical role in the cause of death certifcation. The clinical diagnosis by a physician is the basis for certifying the cause of death. When entered into a certifcate of death, it establishes the cause of death of that particular individual. The information on the death certifcate, which is coded and classifed using the International Classifcation of Diseases version 10, is entered into a database and consolidated by the Philippine Statistics Authority. It informs the policy makers and planners on the leading causes of mortality and its patterns and trends. Thus, it is of utmost importance that the countrys mortality data should be of good quality. The road to good quality data starts with the clinical diagnosis of the physician as to the cause of death. This is followed by precise manner of certifying the cause of death with immediate, antecedent, and underlying causes, entered accurately and in correct order. For the many deaths occurring in the Philippines that is not attended by a physician, the best way of ascertaining the cause of death by the local health authority is through verbal autopsy. This is done by interviewing family members who are knowledgeable as to the probable cause of death. This is the task of the local health ofcer since he or she signs the death certifcate for those not medically attended. Likewise, in the Philippines, all death certifcates have to be reviewed by the local health ofcer, medically attended or otherwise. Death Registration: Legal Mandates, Rules and Procedures xiv Death Registration: Legal Mandates, Rules, and Procedures 2 Medical Cerrtifcation of Death: Handbook for Filipino Physicians Civil Registry Law-Act No. This act mandates the registration of all facts and acts concerning the civil status of persons from birth to death, including the changes in civil status taking place therein in appropriate civil registry books. Civil registration is defned as the continuous, permanent, compulsory, and universal recording of the occurrence and characteristics of vital events pertaining to the population. If there has been no physician in attendance, it shall be issued by the mayor or the secretary of the municipality where the death occurred. The death certifcate shall be forwarded to the local civil registrar within 48 hours after death (Sec. For Muslim Filipinos, however, in accordance with Islamic law and jurisprudence, the dead body may be buried as soon as possible even without a Certifcate of Death provided that the death shall be reported by the person who performed the burial rites (or by the nearest kin) to the local health ofcer within forty-eight hours after the date of burial. Registrable Acts & Vital Events Death refers to the permanent disappearance of all evidence of life at any time after live birth has taken place, or the postnatal cessation of vital functions without capability of resuscitation. Fetal Death is death prior to the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of pregnancy; the death is indicated by the fact that after such separation the fetus does not breathe nor show any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or defnite movement of voluntary muscles. In cases when the fetus has an intra-uterine life of less than seven months, it is not deemed born if it dies within twenty-four hours after its complete delivery from the maternal womb. Except in circumstances where the place of death is not ascertained, then the place of registration is the city or municipality of usual residence of the deceased or where the deceased will be buried. Reporting of Vital Events Occurring Abroad All vital events occurring to Filipinos residing abroad (permanently or temporarily) shall be reported to the Philippine Foreign Service Establishment of the country of residence or where the vital event took place or where none is located thereat, in the Philippine Foreign Service Establishments of the country nearest the place of residence of the party concerned or where the vital event occurred. Death Certifcate and Register No human body shall be buried unless the proper death certifcate has been presented and recorded in the ofce of the local civil registrar. The surgical pathology report signed and issued by the pathologist shall serve as the Certifcate of Dismembered Body Part which may be used for burial purposes or proper disposal. Hence, document containing such body parts should not be registered since these are for burial purposes only. The practice of issuing a Certifcate of Death by the attending physician for the dismembered body part is not necessary. The certifcate is forwarded, within 48 hours after death, to the local health ofcer who will review the certifcate and afx his signature in the Reviewed By portion and direct its registration at within 30 days. Otherwise, the death should be referred to the medico-legal ofcer of the hospital or the local health ofcer who shall cause the issuance of the Certifcate of Death. For Death that Occurred in the Ambulance When a death occurs in the ambulance while the patient is being transferred to another healthcare facility, the attending physician during the transport of the patient shall accomplish the Certifcate of Death. In the absence of the local health ofcer the death should be reported to the mayor, or to any member of the Sangguniang Bayan, or to the municipal secretary who shall issue the Certifcate of Death for burial purposes. When mass death occurs and several persons die during calamities, accidents, or epidemics and the deceased cannot be identifed, the local health ofcer in the exercise of his wise discretion, may issue a corresponding number of Certifcate of Death and cause the registration of these deaths at the Ofce of the local civil registrar the certifcates must bear an annotation Body Not Identifed. The physician who completes and signs his name in the Medical Certifcate portion of the Certifcate of Death is attesting to the best of his knowledge that the person named on the certifcate died from the cause or causes of death stated. This physician, thus, becomes the certifer of death; the reported causes of death represent his best medical opinion. Entries to the Medical Certifcate must be accomplished by the physician correctly and completely before causing its registration at the Ofce of the Local Civil Registrar since there is prohibition against change or correction of entries in the Certifcate of Death without judicial order. There is violence or crime when the cause of death was due, but not limited, to the following: Stab wounds Gunshot wounds Suicide of any kind Strangulation Accident resulting to death Actual physical assault inficting injuries upon a person resulting to death Any other acts of violence upon a person resulting to death Sudden death of undetermined cause. The medico-legal ofcer of this investigative agency will accomplish and sign the Medical Certifcate portion of the Certifcate of Death. Death Registration: Legal Mandates, Rules and Procedures 11 Who Reviews the Certifcate of Death In all cases, the Medical Certifcate of death shall be reviewed and signed by the local health ofcer (Municipal/City Health Ofcer. The local civil registrar cannot deny registration except for insufciency of information. It is important that these should be mandatorily entered in the death certifcate, otherwise the document shall be considered valueless. Application for registration of death shall not be allowed if the entries in the full name of the deceased and the cause of death are not provided. Delayed Registration Registration of death beyond the 30day period shall be considered for delayed registration, and shall be accepted only if the procedures and requirements are observed and complied with. It has been completely redesigned to deliver civil registry information management in a new, more user friendly and efcient way. Death Registration: Legal Mandates, Rules and Procedures 15 Section 1 Medical Certifcation 18 Medical Cerrtifcation of Death: Handbook for Filipino Physicians Death refers to the permanent disappearance of all evidence of life at any time after live birth has taken place, or the postnatal cessation of vital functions without capabiity of resuscitation. Fetal Death is death prior to the complete expulsion or extraction from the mother of a product of conception, irrespective of the duration of pregnancy; death is indicated by the fact that after such separation, the fetus does not breathe nor show any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or defnite movement of voluntary muscles. This certifcate which was revised in January 2007 has a change in color from blue of the January 1993 version to white of the current 2007 version. Maternal Condition (if the deceased is female aged 15-49 years old), which was not present in the old form. The Medical Certifcate portion of the Certifcate of Death includes items 19b to 22 for deceased aged 8 days and above, (Fig. As certifer of death, the attending physician or local health ofcer must afx his signature in the last item, number 22. The last item also includes a Reviewed By portion where the local health ofcer will afx his signature after thorough evaluation and review of the certifcate. If the deceased died without medical attendance, the local health ofcer will afx his signature twice, one as the certifer of death and the other as the reviewer. The causes of death which must be flled out in item number 19b of the Medical Certifcate refer to all those diseases, morbid conditions or injuries which either resulted in or contributed to death and the circumstances of the accident or violence which produced any such injuries. The three lines in Part I are labeled accordingly as the Immediate cause, Antecedent cause, and Underlying cause. There is one other part in item 19b of the Medical Certifcate which must always be flled out by the certifer. Other significant conditions contributing to death: recent condition or event on the top line and going backward in time on progressively lower lines until the underlying cause is reported on the lowest line. The underlying cause of death is the disease or injury which initiated the train of morbid events leading to death, or the circumstances of the accident or violence which produced the fatal injury. It is the most important entry in the certifcate since mortality statistics is based on this underlying cause. Regardless of how many lines are flled out by the certifer with causes of death in the certifcate, the lowermost completed line in Part I, or the reported cause in line (a) when only one cause of death is reported, is always the underlying cause. Other intervening cause (or causes) of death occurring between the underlying and immediate causes is called the antecedent cause. Other significant conditions contributing to death: cause at all if only one line (immediate cause) or two lines (immediate and underlying cause) are flled out. When there is only one reported cause of death in the certifcate A 56 year old man dies from acute myocardial infarction within 3 hours of its onset. Comment: In the case sample above, acute myocardial infarction is the immediate and underlying cause at the same time. As a rule, when the certifcate has only one entry as cause of death, that entry is both the immediate cause of death and the underlying cause at the same time. When the certifcate has two causes of death, entered one each in lines (a) and (b), the entry in line (a) is the immediate cause and the one in line (b) is the underlying cause. Other significant conditions contributing to death: causes, line (a) is the immediate cause, line (b) the antecedent cause, and line (c) the underlying cause. When there are only two reported causes of death in the certifcate A 56 year old person dies from abscess of the lung, which resulted from lobar pneumonia of the left lung. Other significant conditions contributing to death: Comment: When there are only two reported causes of death as illustrated above, the frst entry which is lung abscess corresponds to the immediate cause of death, while the second reported cause which is lobar pneumonia left lung does not necessarily correspond to the antecedent cause even that word is already written to its left. As a rule, the last entry is always the underlying cause, whether there are two, three, or more reported causes of death. In the case above, lobar pneumonia left lung is the underlying cause, and we simply disregard the word antecedent cause found to its left. When there are three causes of death reported A 32 year old man dies from hypovolemic shock after sustaining multiple fractures when he was hit by a truck. Other significant conditions contributing to death: Comment: In the case sample above, the reported causes of death namely, hypovolemic shock, multiple fractures and pedestrian hit by truck, respectively corresponds to the immediate cause, antecedent cause, and underlying cause as is written on the left side of the Medical Certifcate portion of the Certifcate of Death. Note that in the Medical Certifcate, each of the lines (a), (b), and (c) has corresponding label written to its left: Immediate Cause, Antecedent Cause, and Underlying Cause, respectively. Such label of causes of death with regard to its corresponding line is true only when all three lines are completely flled out and used. Table 2 Terms that imply mode of dying rather than the cause of death Asphyxia Exhaustion Shock Asthenia Heart failure Syncope Brain failure Hepatic failure Uremia Cachexia Hepatorenal failure Vagal inhibition Cardiac arrest Kidney failure Vasovagal attack Coma Renal failure Ventricular failure Debility Respiratory arrest Source: Medical certificate of cause of death. Strengthening civil registration and vital statistics for births, deaths and causes of death: Resource Kit.

Additional information:

References:

  • http://dmd.aspetjournals.org/content/dmd/45/12/1304.full.pdf
  • https://www.gastroenterologyandhepatology.net/files/2015/03/Nassir1.pdf
  • https://www.cdc.gov/niosh/docs/2016-161/pdfs/2016-161.pdf
  • https://www.transfusionguidelines.org/document-library/documents/irradiated-blood-components/download-file/Irradiated%20blood%20components.pdf

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