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Which of the following interventions that are likely to prevent injury were also included in the experimental group as co-interventions? A Shin guards B Supervised rehabilitation C Warm-up D Education E All or none of the above 2 With regards to the number of studies examining whether stretching outside periods of exercise prevent injury or minimise the severity of injury: A 2 found it does and 2 found it does not B 0 found it does and 2 found it does not C 2 found it does and 0 found it does not D All studies used a cohort design E All or none of the above 3 Theoretical reasons why stretching prior to exercise would not decrease injuries include all of the following EXCEPT: A Tissues that are more compliant are associated with a decreased ability to absorb energy B The compliance of active muscle is related to the compliance of muscle during normal stretches C Most injuries occur during eccentric activity of the muscle purchase 25mg atarax overnight delivery, within its normal range of motion D Overstretching a muscle is known to be a cause of muscle injury E All or none of the above Essay question 1 Discuss the evidence for and against the use of stretching immediately prior to exercise as an intervention to prevent injuries atarax 25 mg on-line. Acknowledgements The author would like to acknowledge that some of this material has been previously published in the Clinical Journal of Sport Medicine Vol 9(4): 221–227 buy atarax 10 mg with mastercard, 1999, and in the Physician and Sports Medicine Vol 28(8): 57–63, 2000. Overall, stretching before exercise does not prevent injury. Note that most studies done on recreational athletes or military personnel. According to the basic science of injury, there is no reason why elite athletes would be expected to have different results. Does stretching outside 2 RCTs (n = 300–470), weaknesses in A1 periods of exercise follow-up and differences in baseline prevent injury? One study suggested a decreased injury rate and the other only decreased severity of injury. Warming-up and stretching for improved physical performance and prevention of sports-related injuries. Biomechanical responses to repeated stretches in human hamstring muscle in vivo. Passive energy absorption by human muscle-tendon unit is unaffected by increase in intramuscular temperature. Optimal duration of static stretching exercises for improvement of coxo-femoral flexibility. Effect of duration of passive stretch on hip abduction range of motion. The effect of heat and stretching on the range of hip motion. Repeated passive stretching: acute effect on the passive muscle moment and extensibility of short hamstrings. Mechanical and physiological responses to stretching with and without preisometric contraction in human skeletal muscle. Sport stretching: effect on passive muscle stiffness of short hamstrings. Comparison of the hold-relax procedure and passive mobilization on increasing muscle length. Electromyographic investigation of muscle stretching techniques. Ipsilateral and contralateral effects of proprioceptive neuromuscular facilitation techniques on hip motion and electromyographic activity.

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During the past decade atarax 25mg with mastercard, several DAT ligands have been developed and used to assess PD and related disorders discount 10mg atarax overnight delivery. Table 2 provides a more detailed comparison of the properties of these ligands cheap atarax 10mg with mastercard. This comparison both illustrates the increasing choice of radioligands available and underscores the distinction of those ligands that enable easy quantification of the imaging signal. DAT imaging agents are cocaine analogs with nanomolar affinity at the DAT (36–41). These ligands are chemically modified to alter TABLE 2 Characteristics of SPECT Dopamine Transporter Radioligands 99m Tc- SPECT tracer [123I]b-CIT [123I]FP-CIT TRODAT [123I]Altropane Time to peak uptake Protracted, Rapid, 2–3 h Rapid, 2–3 h Rapid, 0. Nonetheless, the kinetic properties of DAT radiotracers are quite different with regard to plasma protein binding, permeability across the blood-brain barrier, binding affinity, selectivity for the dopamine transporter, and elimination. These differences are crucial to the applications of the DAT ligand for imaging (42). For example, while a given DAT tracer may distinguish PD from healthy controls based on the qualitative appearance of striatal uptake, the ability to distinguish the longitudinal changes in severity of PD may be more difficult for tracers with relatively poorer signal-to-noise properties (lower specific to nonspecific brain uptake) (Table 2). The quantitative properties of the radiotracer must be well understood to assess disease progression. Specifically, does the imaging signal provide a measure that is related to Bmax, the density of DAT, and/or the integrity of dopamine neurons? For some tracers absolute quantitation of the DAT signal may require invasive methods involving full kinetic modeling, while other DAT tracers have a pharmacokinetic profile, which simplifies the methods for signal quantification. For example, the 123 unusual binding kinetics of [ I]b-CIT, with a protracted period of stable specific radiotracer uptake in the brain and extremely slow elimination from the DAT sites in striatum, permit reproducible quantitative determination of DAT density using a simple tissue ratio method (19,43). For DAT tracers with faster washout from specific binding sites, this simple ratio technique will overestimate the density of binding sites in healthy striatum relative to PD (44), although these tracers may permit better visual discrimination of diseased from control cases. None of these tracers is commercially available as yet in North America, although one tropane derivative of 1 123 cocaine (FP-CIT, DATSCAN ) is available as a [ I]-labeled tracer in Europe. PD DIAGNOSIS ACCURACY The diagnosis of PD is currently based primarily on clinical judgment. However, the variability of disease presentation, progression, and response to medications often makes diagnosis uncertain. Prevalence studies of parkinsonism suggest a diagnostic accuracy of 80% after examination and application of clinical diagnostic criteria (48–50). Long-term clinicopatho- logical studies evaluating the diagnostic accuracy of PD demonstrate that the diagnoses most commonly mistaken for PD are progressive supranuclear Copyright 2003 by Marcel Dekker, Inc.

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Although the improvements persisted beyond 2 years after surgery cheap 10 mg atarax visa, signs of decreased efficacy were seen after 12 months buy atarax 10 mg on-line. In summary atarax 10 mg otc, DBS of the globus pallidus results in improvement of the cardinal features of PD including tremor, bradykinesia, rigidity, and gait and a marked reduction of levodopa-induced dyskinesias. The daily levodopa dosage or antiparkinsonian medication dosage is not reduced. Optimal Pallidal Electrode Location Studies of GPi stimulation have reported variable and sometimes opposite effects by using different electrode contacts (27–29). Stimulation in the dorsal GP (upper contact) significantly improved gait, akinesia, and rigidity and could induce dyskinesia when the patients were in the off-state. In contrast, stimulation of the posteroventral GP (lower contact) significantly worsened gait and akinesia. DEEP BRAIN STIMULATION OF THE SUBTHALAMIC NUCLEUS The STN has gained importance in PD. Although it is believed that subthalamic lesions induce ballism, patients who undergo subthalamotomy or subthalamic stimulation usually do not have these involuntary move- ments. Hence if the lesions extend beyond the STN, and in particular if they involve the internal segment of the globus pallidus or the pallidal fugal pathways, then no involuntary movements are seen (31). There are multiple reports of the antiparkinsonian effects of STN DBS (Table 3) (32–38). They also reported a mean reduction of 40% of antiparkinsonian medications and 83% improvement in dyskinesias. Other studies have duplicated these results with STN stimulation. All studies have consistently reported improvement in the UPDRS scores in the off-medication state. The improvement in the ADL scores ranged from 30 to 72%, and the UPDRS Motor score improvements ranged from 42 to 74% in the off-medication state (Table 3). Irrespective of the percentage of Copyright 2003 by Marcel Dekker, Inc. TABLE 3 Selected Studies of Deep Brain Stimulation of the Subthalamic Nucleus Number of Author patients Follow-up Improvement Krack et al. In other words, if the patient is evaluated 12 hours after not taking antiparkinsonian medications (off- medication state) and the evaluations are repeated after the patient has taken antiparkinsonian medications and the medications have started working (on-medication state), the percentage improvement would be similar to that seen after surgery with stimulation alone.

If children are brought to the operating room cold and dehydrated best 25 mg atarax, it is often much harder to start intravenous lines atarax 25mg overnight delivery, including increased diffi- cult1y in starting central lines and arterial line placement order atarax 10 mg fast delivery. Also, the sudden large-volume hydration and warming may make the physiology somewhat unstable even before the surgery starts. Many of these children are chroni- cally dehydrated, especially poor feeders, and often have blood pressure drops 450 Cerebral Palsy Management with the induction of anesthesia. Before children are taken to the operating room, there must be documentation of at least one blood volume of blood typed and cross-matched. This requirement usually means having six units of packed cells available with at least that much available in the blood bank for cross-matching if it should be needed later. The blood bank should also be ready to emergently prepare platelets and fresh-frozen plasma. Anesthesia and Intraoperative Preparation After children are anesthetized, the endotracheal tube must be well se- cured so that it will not dislodge. If children have a standard tracheostomy, an oral endotracheal tube is usually used to allow better securing of the tube. If children have a tracheal diversion, an endotracheal tube is inserted and se- cured with sutures at the level of the tracheal stoma. It is difficult to secure this type of tube with tape because the posterior aspect of the neck has to be prepped for the surgical field. Two large 18-gauge peripheral intravenous catheters need to be inserted if possible, and we always insert a double- lumen large-bore central venous catheter. The double-lumen central venous catheter is placed through a long tunnel in the subcutaneous tissue to de- crease the risk of infection, and in this way, it can also become the access port for providing nutrition via central venous hyperalimentation. All chil- dren should have direct intraarterial monitoring of blood pressure, which also provides a port for obtaining blood samples to continue to monitor clotting factors, hemoglobin levels, and blood chemistry. If a percutaneous arterial catheter cannot be placed, a surgical cutdown of an artery should be performed to insert a catheter. A urinary catheter is required to measure urine output, and a nasogastric tube should be inserted to decompress the stom- ach. This stomach decompression may help with bleeding by decreasing the intraabdominal pressure. Many children with CP have had multiple medical problems with frequent hospital stays, often with multiple intravenous and arterial lines. In a few children these prior multiple lines may make insertion of intravenous access and arterial lines difficult. It is important for the sur- gical team to have patience at this stage of the procedure because short cuts may lead to disasters later.

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