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By D. Achmed. Louisiana State University at Baton Rouge. 2018.

Checkpoint 10-11 How many pairs of cranial nerves are there? The vestibulocochlear (ves-tib-u-lo-KOK-le-ar) nerve car- ries sensory impulses for hearing and equilibrium from the Checkpoint 10-12 The cranial nerves are classified as being inner ear generic nitrofurantoin 50 mg online antibiotic resistance fitness cost. This nerve was formerly called the auditory or sensory 50mg nitrofurantoin sale bacteria jersey shore, motor, or mixed. The glossopharyngeal (glos-o-fah-RIN-je-al) nerve con- tains general sensory fibers from the back of the tongue and the pharynx (throat). This nerve also contains sensory Disorders Involving the Cranial fibers for taste from the posterior third of the tongue, se- Nerves cretory fibers that supply the largest salivary gland (parotid), and motor nerve fibers to control the swallow- Destruction of optic nerve (II) fibers may result from in- ing muscles in the pharynx. Certain medications, when used in high doses over long periods, can damage the branch of the vestibu- The nervous system is one of the first systems to develop locochlear nerve responsible for hearing. By the beginning of the third week of de- Injury to a nerve that contains motor fibers causes velopment, the rudiments of the central nervous system paralysis of the muscles supplied by these fibers. Beginning with maturity, the nervous sys- lomotor nerve (III) may be damaged by certain infections tem begins to undergo changes. The brain begins to de- or various poisonous substances. Because this nerve sup- crease in size and weight due to a loss of cells, especially in plies so many muscles connected with the eye, including the cerebral cortex, accompanied by decreases in synapses the levator, which raises the eyelid, injury to it causes a and neurotransmitters. The speed of processing informa- paralysis that usually interferes with eye function. Memory di- Bell palsy is a facial paralysis caused by damage to the minishes, especially for recent events. Changes in the vas- facial nerve (VII), usually on one side of the face. This in- cular system throughout the body with a narrowing of the jury results in distortion of the face because of one-sided arteries (atherosclerosis) reduce blood flow to the brain. Degeneration of vessels increases the likelihood of stroke. Neuralgia (nu-RAL-je-ah) in general means “nerve Much individual variation is possible, however, with pain. Although age nerve is known as trigeminal neuralgia or tic douloureux might make it harder to acquire new skills, tests have (tik du-lu-RU). At first, the pain comes at relatively long shown that practice enhances skill retention. As with intervals, but as time goes on, intervals usually shorten other body systems, the nervous system has vast reserves, 10 while durations lengthen. Treatments include micro- and most elderly people are able to cope with life’s surgery and high-frequency current. Word Anatomy Medical terms are built from standardized word parts (prefixes, roots, and suffixes). Learning the meanings of these parts can help you remember words and interpret unfamiliar terms. WORD PART MEANING EXAMPLE The Brain and its Protective Structures cerebr/o brain Cerebrospinal fluid circulates around the brain and spinal cord. Imaging the Brain tom/o cut Tomography is a method for viewing sections as if cut through the body. Disorders of the Brain and Associated Structures cephal/o head Hydrocephalus is the accumulation of fluid within the brain. Cranial Nerves gloss/o tongue The hypoglossal nerve controls muscles of the tongue. Main parts—cerebrum, diencephalon, brain stem, cerebel- balance, muscle tone lum VII. Imaging—computed tomography (CT), magnetic resonance spinal cord imaging (MRI), positron emission tomography (PET) A.

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As children get to early adolescence buy nitrofurantoin 50mg amex antibiotics drugs, crutch use should be more strongly encouraged if the physical functional ability is present discount nitrofurantoin 50mg amex antibiotic resistance nature journal. There are very few young adults with CP who continue to use walkers for a significant amount of ambulation. Most individuals who use an assistive device and are functional community or full independent household ambulators will do so with crutches and not a walker. The walkers tend to be clumsy and difficult to transport. For a full-sized adult, the walker is often so wide that it does not easily fit through standard home doors. Walkers Walkers are available in a complex array of shapes and options; however, there are some basic styles that are important to consider when deciding which walker is appropriate for individuals. Even for therapists or physicians with significant experience, finding the best walker for children is still a com- bination of trial and error to see which walker these children prefer and which they can handle best. The most basic difference in walkers is they are either back- or front based. The front walker, or anterior-based walker, is pushed in front of children and the back or posterior walker is pulled along behind children. These walker styles are available in all sizes and many different frame constructs. In general, for children with CP, the posterior walker en- courages a more upright posture and may improve walking speed. The pos- terior walker is the most common design used for children in early and mid- dle childhood (Figure 6. The two exceptions are blind children and those Figure 6. Gait assistive devices have many with mental retardation who often cannot functionally use a posterior walker. The most common posterior the walker, which they cannot see, will still provide support. A develop- walker encourages children to stand more mental age of approximately 24 to 30 months is required to use a posterior upright and may increase walking speed. For children with lower cognitive ability, the front-based walker works better (Figure 6. Blind children also tend to do better with a front walker. As children get older and heavier, the posterior walkers become very wide. If individuals cannot functionally use crutches by adolescence, con- version to an anterior walker allows for a more narrow based design and is often smaller and easier to transport. The variations between the benefits of children being in a more upright position are more obvious in childhood than in adolescence. These anterior-based walkers for adolescents and adults may be fitted with articulating wheels and brakes, and some even have flip-down seats so individuals have a place to sit when stopped (see Figure 6. The standard height of walkers should be between the top of the iliac spine and the lum- bosacral junction. The standard height of the handgrips between the iliac spine and the lumbosacral junction level can be altered based on an indi- vidual child’s needs. The position of the handgrips is another optional element when ordering walkers. These handgrips may be either horizontal handgrips at the top of a standard walker height or elevated vertical handgrips. In a few children, even using a walker that allows leaning on the elbows works (Figure 6. In a population of individuals with CP who use walkers, the position of these handgrips makes no functional difference30; however, there are individual children for whom this handgrip position can make an im- portant functional difference.

The majority of the post- operative pain is resolved by 4 weeks order 50 mg nitrofurantoin amex antibiotic 375mg. If proximal hamstring lengthening was performed the physical therapist should be instructed to avoid straight leg raising stretches and long sitting unless the child is completely comfortable because postoperative sciatic nerve palsy can occur nitrofurantoin 50mg without prescription antibiotics contraindicated in pregnancy. Iliopsoas Lengthening: Over the Pelvic Brim Approach Indication This approach is another alternative to perform a myofascial lengthening of the psoas tendon. The advantage is less difficult exposure of the muscle ten- don junction in children with significant contractures; however, the difficulty is that the tendon of the psoas is on the deep and most medial aspect of the iliacus muscle. There are no specific indications to using this approach com- pared to the medial approach. The surgeon’s comfort with the specific anatomy is usually the determining factor. The incision is along the iliac crest for 5 cm extending slightly medial to the anterior superior iliac spine (Figure S3. The incision is car- ried down through the subcutaneous tissue, the fascia is opened just medial to the iliac crest, and the muscle compartment of the iliacus muscle is entered in the iliac fossa. The dissection is carried medially and posterior to the deep border of the iliacus muscle. A right-angle clamp is then passed around the deep border and the psoas tendon is delivered laterally and anteriorly. This is easiest to perform if the hip is flexed so the psoas is relaxed. Often muscle fibers of the iliacus have to be spread to locate the psoas ten- don, because the psoas tendon is covered by iliacus muscle except for the far posterior medial edge, which cannot be visualized with this approach (Figure 3. After the tendon is visualized, it is transected leaving all the surround- ing muscle fibers intact. This is a very large tendon and the entire ten- don has to be transected or no lengthening will occur. Closing the fascia, subcutaneous tissue and skin closes the wound. Caution: When doing the medial dissection to find the psoas tendon, it is im- portant to stay within the iliacus muscle compartment because the femoral nerve and artery are immediately on the anterior and medial surface of the Figure S3. It is easier to retract the femoral nerve if the hip is flexed during the dissection. Strengthening exercises and aggressive ex- tension stretching should be avoided for 6 weeks. Proximal Femoral Osteotomy Indication The proximal femoral osteotomy may be utilized for femoral shortening, providing varus, derotation, or flexion extension correction. Each of these indications for proximal femoral osteotomy is discussed in this procedure, which is all based on the placement of the chisel into the proximal femur. The incision is made longitudinally from the flare of the greater tro- chanter approximately 6 cm distal, with the larger child needing a slightly longer incision and a smaller child needing a smaller incision. The fascia latae is divided in line with the incision, extending both proximally and dis- tally longer than the incision (Figure S3. A self-retaining retractor is placed, and the vastus lateralis muscle is identified with its insertion point into the proximal femur just distal to the trochanteric apophysis. This retractor also identifies the proximal origin of the apophysis of the femur. The trochanteric bursa should be cleaned off so that good visualization is obtained of this proximal end. Electrocautery is utilized and the origin of the vastus lateralis is in- cised transversely from anterior, curved across the lateral aspect of the femur to posterior, and slightly curving distally. Care is taken to make a sharp cut with the electrocautery in this transverse cut all the way to the bone. In the midlateral aspect of the femur, the fascia of the vastus lateralis is incised from the transverse cut proximally to as far distal as possible (Figure S3. Using Cobb elevators at the distal end of this opening, subperiosteal dissection of the femur is undertaken and retractors are placed.

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Poor control severe spastic Full-height articulated AFO smaller brace with solid ankle ii proven nitrofurantoin 50 mg antibiotics for sinus infection not helping. Some control moderate spastic Half-height AFO Articulated AFO: Dorsiflexion in 2nd and 3rd rocker with muscle stretching with articulated ankle joint 5 buy 50mg nitrofurantoin amex antibiotic resistant uti in dogs. Solid ground reaction AFO (GRAFO) GRAFO: This can accommodate mild to i. Standard solid AFO with wide anterior moderate foot deformity but must have phase calf strap normal thigh-foot alignment in torsion. Active dorsiflexion and weak Anterior articulated ground reaction—Art should weigh more than 30 kg and must have Plantar flexion GRAFO near full knee extension. No foot deformity or torsional AFO: Easy to don and works well for child deformity less than 30 kg. Art GRAFO This rear-entry brace requires a normally aligned foot in both varus/valgus and torsion as well as near full knee extension. Too much knee flexion in stance phase Ground reaction AFO based on ankle control Must have passive knee extension and as noted above adequate hamstring length. Knee hyperextension in stance phase Articulated AFO set in 3°–5° of dorsiflexion Passive dorsiflexion must be possible. In these hypotonic or ataxic children, there can be a detri- ment to extending the orthotic because it makes rollover in late stance phase more difficult. Foot Orthotics Orthotics that do not control plantar flexion and dorsiflexion of the ankle are called foot orthotics. None of these orthotics has any impact on ankle plantar flexion or dorsiflexion. These orthotics are primarily used in children with hypotonia, or in middle childhood 198 Cerebral Palsy Management A B Figure 6. The solid AFO design can be modified by adding softer inside pads to protect bone protrusions or pressure areas. The supramalleolar design ex- tends above the ankle on the lateral side with the goal of controlling varus Figure 6. An orthotic design that or valgus deformity (Figure 6. The foot orthotic can have all the same uses a thinner, more flexible plastic with a design features and options that were discussed in the section on AFOs. Usu- circumferential wrap can be used for many ally, an anterior ankle strap is used; however, in some older children with good of the different designs. Its major limitation is that the thin plastic is weaker and gains ankle plantar flexion control, this is not needed. Also, the heel is typically strength by the circumferential wrapping na- posted on the side opposite the deformity. This means a lateral squaring of ture of the design. It does not work for high- the heel is added for varus deformity so the ground reaction force will tend stress environments, such as ground reaction to counteract the deformity. The opposite is done for valgus deformity, in AFOs, and can be difficult to put on and take which a post is added to the medial side of the heel. This supramalleolar foot off, especially for children just learning to orthotic design also works well with the wrap-around thin plastic design; how- dress themselves. It is more difficult for children to don the orthotic, and heavy children tend to collapse Figure 6. AFOs made for children the orthotic the same way a shoe deforms with long-term wear. There is no with spasticity need a good stable anterior ankle strap that is directed across the axis clear choice between the thin plastic wrap-around design and the solid plastic of the ankle joint. Input from the families and children should be considered is a padded anterior ankle strap that loops as well as the preference of the orthotists. Most children who need control through a D-ring fixed on the side opposite of planovalgus or varus, but have good plantar flexion and dorsiflexion con- the main deforming force (A). If the child has trol of the ankle, should be fitted with a supramalleolar orthotic (SMO).

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He presents with moderate 92 Exercising with a fever and/or acute infection fatigue of two week’s duration generic 50 mg nitrofurantoin with amex antibiotics contraindicated in pregnancy, sore throat buy 50 mg nitrofurantoin with amex antibiotics viral disease, cervical adenopathy and a palpable spleen. Should this athlete be cleared to play for this final game? Sample examination questions Multiple choice questions (answers on p 561) 1 Fever is usually associated with all of the following except: A increased sweating B decreased heart rate C increased respiration D increased susceptibility to heat injury E decreased performance 2 Acute viral hepatitis can be associated with which of the following: A hypoglycemia B altered lipid metabolism C fatigue D myalgias E all of the above 3 The most common return to play issue for the athlete with infectious mononucleosis concerns A Spleen enlargement B Encephalitis C Lympadenopathy D Airway Obstruction E Rash 93 Evidence-based Sports Medicine Summarising the evidence Recommendations for Results Level of evidence* return to activity Fever/acute infection “Neck check” criteria for return to play N/A C Modification of activity according to sport N/A C Myocarditis Prevention of development of myocarditis N/A C by restriction of activities during acute viral infection Return to play with myocarditis N/A C Hepatitis Return to play based on symptoms/ N/A C clinical condition of patient Infectious mononucleosis Return to play criteria based on time N/A C since onset of illness (3 weeks) Use of ultrasound assessment of spleen N/A C size for return to play decisions * A1: evidence from large RCTs or systematic review (including meta-analysis) A2: evidence from at least one high quality cohort A3: evidence from at least one moderate sized RCT or systematic review A4: evidence from at least one RCT B: evidence from at least one high quality study of non-randomised cohorts C: expert opinion † Arbitrarily, the following cut-off points have been used; large study size: ≥ 100 patients per intervention group; moderate study size ≥ 50 patients per intervention group. References 1 Alluisi E, Beisel W, Morgan B, Caldwell L. Effects of Sandfly fever on isometric muscular strength, endurance and recovery. Acute Infection: metabolic responses, effects on performance, interaction with exercise, and myocarditis. Does fever or myalgia indicate reduced physical performance capacity in viral infections? Effects of virus infection on physical performance in man. Respiratory tract infection and bronchial responsiveness in elite athletes and sedentary control subjects. Biochemical responses of the myocardium and red skeletal muscle to Salmonella typhirmurium infection in the rat. Metabolic effects of intracellular infections in man. Diagnosing exertional rhabdomyolysis: a brief review and a report of 2 cases. Sports and exercise during acute illness: recommending the right course for patients. Exercise in coxsackie B3 myocarditis: effects on heart lymphocyte subpopulations and the inflammatory reaction. Augmentation of the virulence of murine coxsackie virus B-3 myocardiopathy by exercise. Hypertrophic cardiomyopathy, myocarditis, and other myopericardial diseases and mitral valve prolapse. Portal venous hemodynamics in chronic liver disease: effects of posture change and exercise. The treatment of acute infectious hepatitis: controlled studies of the effects of diet, rest and physical reconditioning on the acute course of the disease and on the incidence of relapses and residual abnormalities. The effect of defined physical exercise in the early convalescence of viral hepatitis. Effects of early and vigorous exercise on recovery from infectious hepatitis. Joint Position Statement: human immunodeficiency virus and other blood borne pathogens in sports. Principles and Practice of Primary Care Sports Medicine. Philadelphia: Lipincott, Williams and Wilkins 2001;239–246. Epstein-Barr virus infections, including infectious mononucleosis. Aerobic capacity after contracting infectious mononucleosis. Infectious mononucleosis: relation of bed rest and activity to prognosis. When to resume sports after infectious mononucleosis. Spontaneous rupture of the spleen in patients with infectious mononucleosis. Hepatosplenomegaly in infectious mononucleosis, assessed by ultrasononic scanning. Infectious mononucleosis: recognizing the condition, “reactivating” the patient. Rupture of the pathologic spleen: is there a role for nonoperative therapy? IAN SHRIER Introduction Over the past 30 years, sport medicine professionals have promoted stretching as a way to decrease the risk of injury.

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