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+{"id": "article-100024_0", "title": "Chronic Total Occlusion of the Coronary Artery -- Continuing Education Activity", "content": "Chronic total occlusion (CTO) lesions are diagnosed in patients who are undergoing coronary angiography as part of the evaluation of ischemic heart disease, cardiomyopathy, or valvular heart disease. CTO revascularization has not shown benefit in rates of all-cause mortality, myocardial infarction, stroke, and repeat revascularization and is commonly performed to improve a patient's quality of life by reducing their angina symptoms. This activity reviews the evaluation and treatment of chronic total occlusion of the coronary artery and highlights the role of the interprofessional team in evaluating and treating this condition.", "contents": "Chronic Total Occlusion of the Coronary Artery -- Continuing Education Activity. Chronic total occlusion (CTO) lesions are diagnosed in patients who are undergoing coronary angiography as part of the evaluation of ischemic heart disease, cardiomyopathy, or valvular heart disease. CTO revascularization has not shown benefit in rates of all-cause mortality, myocardial infarction, stroke, and repeat revascularization and is commonly performed to improve a patient's quality of life by reducing their angina symptoms. This activity reviews the evaluation and treatment of chronic total occlusion of the coronary artery and highlights the role of the interprofessional team in evaluating and treating this condition."}
+{"id": "article-100024_1", "title": "Chronic Total Occlusion of the Coronary Artery -- Continuing Education Activity", "content": "Objectives: Describe the histopathology of a chronic total occlusion (CTO) lesion. Review the risk factors for developing chronic total occlusion (CTO) lesions. Outline the typical presentation of a patient with chronic total occlusion (CTO) lesions. Explain the importance of improving care coordination amongst the interprofessional team( primary care physician, cardiologist, and interventionist) to enhance the delivery of care for patients with chronic total occlusion (CTO). Access free multiple choice questions on this topic.", "contents": "Chronic Total Occlusion of the Coronary Artery -- Continuing Education Activity. Objectives: Describe the histopathology of a chronic total occlusion (CTO) lesion. Review the risk factors for developing chronic total occlusion (CTO) lesions. Outline the typical presentation of a patient with chronic total occlusion (CTO) lesions. Explain the importance of improving care coordination amongst the interprofessional team( primary care physician, cardiologist, and interventionist) to enhance the delivery of care for patients with chronic total occlusion (CTO). Access free multiple choice questions on this topic."}
+{"id": "article-100024_2", "title": "Chronic Total Occlusion of the Coronary Artery -- Introduction", "content": "A coronary chronic total occlusion (CTO) is defined as 100% occlusion of a coronary artery for a duration of greater than or equal to 3 months based on angiographic evidence. The TIMI (thrombolysis in myocardial infarction) flow grading system is a scoring classification from 0-3 referring to the levels of coronary blood flow assessed during coronary angiography. The TIMI flow grading system is as below [1] : TIMI 0 flow (no perfusion-complete occlusion) - the absence of any forward flow beyond a coronary occlusion. TIMI 1 flow (penetration without perfusion) - faint forward flow beyond the occlusion, associated with an incomplete filling of the distal coronary bed. TIMI 2 flow (partial reperfusion) - delayed forward flow with complete filling of the distal coronary bed. TIMI 3 flow (full perfusion) - normal flow, which fills the distal coronary bed.", "contents": "Chronic Total Occlusion of the Coronary Artery -- Introduction. A coronary chronic total occlusion (CTO) is defined as 100% occlusion of a coronary artery for a duration of greater than or equal to 3 months based on angiographic evidence. The TIMI (thrombolysis in myocardial infarction) flow grading system is a scoring classification from 0-3 referring to the levels of coronary blood flow assessed during coronary angiography. The TIMI flow grading system is as below [1] : TIMI 0 flow (no perfusion-complete occlusion) - the absence of any forward flow beyond a coronary occlusion. TIMI 1 flow (penetration without perfusion) - faint forward flow beyond the occlusion, associated with an incomplete filling of the distal coronary bed. TIMI 2 flow (partial reperfusion) - delayed forward flow with complete filling of the distal coronary bed. TIMI 3 flow (full perfusion) - normal flow, which fills the distal coronary bed."}
+{"id": "article-100024_3", "title": "Chronic Total Occlusion of the Coronary Artery -- Introduction", "content": "A \"true\" CTO is defined as 100% occlusion of a coronary artery with TIMI 0 flow; whereas a \"functional\" CTO is defined as severely stenotic, yet, less than a 100% occlusion of the coronary artery with TIMI 1 flow for a duration of greater than or equal to 3 months based on angiographic evidence. [2] Moreover, it is difficult to identify the exact period over which a CTO lesion is present in the absence of serial angiograms. Therefore, it is mostly estimated based on available clinical information related to the timing of the event that caused the occlusion, for example, prior myocardial infarction or sudden change in anginal symptoms with electrocardiogram changes consistent with the location of the occlusion. However, in many patients, the age of the CTO cannot be determined with confidence.", "contents": "Chronic Total Occlusion of the Coronary Artery -- Introduction. A \"true\" CTO is defined as 100% occlusion of a coronary artery with TIMI 0 flow; whereas a \"functional\" CTO is defined as severely stenotic, yet, less than a 100% occlusion of the coronary artery with TIMI 1 flow for a duration of greater than or equal to 3 months based on angiographic evidence. [2] Moreover, it is difficult to identify the exact period over which a CTO lesion is present in the absence of serial angiograms. Therefore, it is mostly estimated based on available clinical information related to the timing of the event that caused the occlusion, for example, prior myocardial infarction or sudden change in anginal symptoms with electrocardiogram changes consistent with the location of the occlusion. However, in many patients, the age of the CTO cannot be determined with confidence."}
+{"id": "article-100024_4", "title": "Chronic Total Occlusion of the Coronary Artery -- Etiology", "content": "Risk factors for CTO lesion in patients are as below [3] : Known coronary artery disease or history of myocardial infarction Excessive tobacco use High LDL cholesterol, low HDL cholesterol Diabetes Sedentary lifestyle Hypertension Family history of premature disease End-stage kidney disease Obesity Postmenopausal women", "contents": "Chronic Total Occlusion of the Coronary Artery -- Etiology. Risk factors for CTO lesion in patients are as below [3] : Known coronary artery disease or history of myocardial infarction Excessive tobacco use High LDL cholesterol, low HDL cholesterol Diabetes Sedentary lifestyle Hypertension Family history of premature disease End-stage kidney disease Obesity Postmenopausal women"}
+{"id": "article-100024_5", "title": "Chronic Total Occlusion of the Coronary Artery -- Epidemiology", "content": "CTO lesions are found in approximately one-quarter to one-third of patients undergoing diagnostic coronary angiography. The true prevalence, however, in the general population is unknown due to a subset of patients with CTO lesions being asymptomatic or minimally symptomatic and never undergoing diagnostic coronary angiography. Patients with a history of coronary artery bypass graft surgery are found to have CTOs of their native vessels more frequently (50% to 55%). In comparison, patients presenting with ST-elevation myocardial infarction (STEMI) are less likely to have a CTO (9%\u00a0to 11%). [4] [5]", "contents": "Chronic Total Occlusion of the Coronary Artery -- Epidemiology. CTO lesions are found in approximately one-quarter to one-third of patients undergoing diagnostic coronary angiography. The true prevalence, however, in the general population is unknown due to a subset of patients with CTO lesions being asymptomatic or minimally symptomatic and never undergoing diagnostic coronary angiography. Patients with a history of coronary artery bypass graft surgery are found to have CTOs of their native vessels more frequently (50% to 55%). In comparison, patients presenting with ST-elevation myocardial infarction (STEMI) are less likely to have a CTO (9%\u00a0to 11%). [4] [5]"}
+{"id": "article-100024_6", "title": "Chronic Total Occlusion of the Coronary Artery -- Epidemiology", "content": "Data from the National Heart, Lung, and Blood Institute (1997\u20131999) Dynamic Registry showed that CTO lesions are most common in the right coronary artery and least common in the left circumflex artery. Older patients are more likely to have at least one CTO lesion with 37% prevalence in patients under the age of \u00a065 years, 40% in patients between the ages of 65\u00a0to 79 years, and 41% in those patients who are older than 85 years. [6]", "contents": "Chronic Total Occlusion of the Coronary Artery -- Epidemiology. Data from the National Heart, Lung, and Blood Institute (1997\u20131999) Dynamic Registry showed that CTO lesions are most common in the right coronary artery and least common in the left circumflex artery. Older patients are more likely to have at least one CTO lesion with 37% prevalence in patients under the age of \u00a065 years, 40% in patients between the ages of 65\u00a0to 79 years, and 41% in those patients who are older than 85 years. [6]"}
+{"id": "article-100024_7", "title": "Chronic Total Occlusion of the Coronary Artery -- Pathophysiology", "content": "Pathogenesis of coronary artery disease, which can progress to CTO lesions, has multiple contributing factors, which include upregulation of the immunologic and inflammatory markers (cytokines, leukocytes, high sensitivity C-reactive protein),\u00a0 endothelial dysfunction, and cholesterol accumulation. Most commonly, it starts with the collection of smooth muscle cells within the intima, and this progresses to macrophages accumulating in the intima leading to pathologic intimal thickening and progression of lesions. [7] [8]", "contents": "Chronic Total Occlusion of the Coronary Artery -- Pathophysiology. Pathogenesis of coronary artery disease, which can progress to CTO lesions, has multiple contributing factors, which include upregulation of the immunologic and inflammatory markers (cytokines, leukocytes, high sensitivity C-reactive protein),\u00a0 endothelial dysfunction, and cholesterol accumulation. Most commonly, it starts with the collection of smooth muscle cells within the intima, and this progresses to macrophages accumulating in the intima leading to pathologic intimal thickening and progression of lesions. [7] [8]"}
+{"id": "article-100024_8", "title": "Chronic Total Occlusion of the Coronary Artery -- Histopathology", "content": "Histopathological attributes of a CTO lesion commonly consist of calcium, lipids (both intracellular and extracellular), smooth muscle cells, an extracellular matrix, and neovascularization. Occlusions typically have a dense concentration of collagen-rich fibrous tissue at the proximal and distal ends contributing to a columnar lesion of calcified, resistant fibrous tissue surrounding a softer core of organized thrombus and lipids. Lesion classification is as soft, hard, or a mixture of both. Soft plaques are more frequent in occlusions less than 12 months of age and consist of cholesterol-laden cells and foam cells. Hard plaques are more prevalent in occlusions that are older than 12 months of age and are characterized by dense fibrous tissue with fibrocalcific regions without neovascular channels. [9]", "contents": "Chronic Total Occlusion of the Coronary Artery -- Histopathology. Histopathological attributes of a CTO lesion commonly consist of calcium, lipids (both intracellular and extracellular), smooth muscle cells, an extracellular matrix, and neovascularization. Occlusions typically have a dense concentration of collagen-rich fibrous tissue at the proximal and distal ends contributing to a columnar lesion of calcified, resistant fibrous tissue surrounding a softer core of organized thrombus and lipids. Lesion classification is as soft, hard, or a mixture of both. Soft plaques are more frequent in occlusions less than 12 months of age and consist of cholesterol-laden cells and foam cells. Hard plaques are more prevalent in occlusions that are older than 12 months of age and are characterized by dense fibrous tissue with fibrocalcific regions without neovascular channels. [9]"}
+{"id": "article-100024_9", "title": "Chronic Total Occlusion of the Coronary Artery -- History and Physical", "content": "CTO lesions are diagnosed in patients who are undergoing coronary angiography as part of the evaluation of ischemic heart disease, cardiomyopathy, or valvular heart disease. Patients with ischemic heart disease generally present with typical chest pain symptoms (stable or unstable angina), atypical chest pain, NSTEMI, or STEMI. In contrast, patients with different types of cardiomyopathies or valvular heart disease may present with a variety of symptoms, including decompensated congestive heart failure. Therefore, during history taking in patients suspected of having ischemic heart disease, it is essential to have them describe and subjectively quantify their symptoms.", "contents": "Chronic Total Occlusion of the Coronary Artery -- History and Physical. CTO lesions are diagnosed in patients who are undergoing coronary angiography as part of the evaluation of ischemic heart disease, cardiomyopathy, or valvular heart disease. Patients with ischemic heart disease generally present with typical chest pain symptoms (stable or unstable angina), atypical chest pain, NSTEMI, or STEMI. In contrast, patients with different types of cardiomyopathies or valvular heart disease may present with a variety of symptoms, including decompensated congestive heart failure. Therefore, during history taking in patients suspected of having ischemic heart disease, it is essential to have them describe and subjectively quantify their symptoms."}
+{"id": "article-100024_10", "title": "Chronic Total Occlusion of the Coronary Artery -- History and Physical", "content": "The history should also include risk factors for cardiovascular disease (diabetes, tobacco abuse, hypertension, hyperlipidemia) and non-cardiac causes of the patient's symptoms, including pulmonary embolism, aortic dissection, pneumothorax, esophageal rupture or perforating peptic ulcer. Physical examination in these patients should include complete auscultation of the heart and lung sounds together with assessment for heart failure signs including jugular venous distention, Kussmaul sign, hepatojugular reflex, ascites, and peripheral edema.", "contents": "Chronic Total Occlusion of the Coronary Artery -- History and Physical. The history should also include risk factors for cardiovascular disease (diabetes, tobacco abuse, hypertension, hyperlipidemia) and non-cardiac causes of the patient's symptoms, including pulmonary embolism, aortic dissection, pneumothorax, esophageal rupture or perforating peptic ulcer. Physical examination in these patients should include complete auscultation of the heart and lung sounds together with assessment for heart failure signs including jugular venous distention, Kussmaul sign, hepatojugular reflex, ascites, and peripheral edema."}
+{"id": "article-100024_11", "title": "Chronic Total Occlusion of the Coronary Artery -- Evaluation", "content": "A significant component of an assessment for a patient who presents with signs and symptoms of ischemic heart disease is history and physical exam. These should include vital signs (respiratory rate, blood pressure, temperature, and heart rate), review of the patient's medication list, and an electrocardiogram. During their evaluation, the patient should have an assessment for any underlying or comorbid valvular heart disease or heart failure.", "contents": "Chronic Total Occlusion of the Coronary Artery -- Evaluation. A significant component of an assessment for a patient who presents with signs and symptoms of ischemic heart disease is history and physical exam. These should include vital signs (respiratory rate, blood pressure, temperature, and heart rate), review of the patient's medication list, and an electrocardiogram. During their evaluation, the patient should have an assessment for any underlying or comorbid valvular heart disease or heart failure."}
+{"id": "article-100024_12", "title": "Chronic Total Occlusion of the Coronary Artery -- Evaluation", "content": "A healthcare provider should consider thyroid function testing, pulmonary function testing, routine blood work, including cardiac enzymes, chest X-ray, and echocardiography as part of their initial evaluation. If the initial assessment and evaluation are performed on an urgent basis, intravenous access should be obtained and, if no contraindication exists, the patient should be administered aspirin (162 to 325 mg) and nitrates. If available, patients should be placed on a cardiac monitor and should be assessed with pulse oximetry for the need for supplemental oxygen.", "contents": "Chronic Total Occlusion of the Coronary Artery -- Evaluation. A healthcare provider should consider thyroid function testing, pulmonary function testing, routine blood work, including cardiac enzymes, chest X-ray, and echocardiography as part of their initial evaluation. If the initial assessment and evaluation are performed on an urgent basis, intravenous access should be obtained and, if no contraindication exists, the patient should be administered aspirin (162 to 325 mg) and nitrates. If available, patients should be placed on a cardiac monitor and should be assessed with pulse oximetry for the need for supplemental oxygen."}
+{"id": "article-100024_13", "title": "Chronic Total Occlusion of the Coronary Artery -- Treatment / Management", "content": "CTO revascularization has not shown to benefit rates of all-cause mortality, myocardial infarction, stroke, or repeat revascularization; however, it has shown to significantly improve patients' quality of life and reduce symptoms of angina. [10] [11] [12] Nuclear medicine stress test or myocardial viability studies are also used in conjunction with symptoms to objectively demonstrate areas of ischemia or viability supplied by the CTO vessel. Based on current guidelines, patients with single-vessel CTO lesions should undergo coronary artery bypass surgery if they have left main artery disease, proximal LAD disease which supplies a viable anterior wall, or three-vessel disease in a patient with insulin-dependent diabetes, severe left ventricular dysfunction, or chronic kidney disease. [13]", "contents": "Chronic Total Occlusion of the Coronary Artery -- Treatment / Management. CTO revascularization has not shown to benefit rates of all-cause mortality, myocardial infarction, stroke, or repeat revascularization; however, it has shown to significantly improve patients' quality of life and reduce symptoms of angina. [10] [11] [12] Nuclear medicine stress test or myocardial viability studies are also used in conjunction with symptoms to objectively demonstrate areas of ischemia or viability supplied by the CTO vessel. Based on current guidelines, patients with single-vessel CTO lesions should undergo coronary artery bypass surgery if they have left main artery disease, proximal LAD disease which supplies a viable anterior wall, or three-vessel disease in a patient with insulin-dependent diabetes, severe left ventricular dysfunction, or chronic kidney disease. [13]"}
+{"id": "article-100024_14", "title": "Chronic Total Occlusion of the Coronary Artery -- Treatment / Management", "content": "In patients who meet the indication for a CTO PCI, informed consent is necessary before the procedure after an extensive discussion about the risks and benefits of CTO PCI for the patient. Due to the challenging nature of the CTO lesions, a successful outcome for PCI in these lesions is when the procedure obtains TIMI-3 flow, and there is less than 50% of residual stenosis in the vessel.", "contents": "Chronic Total Occlusion of the Coronary Artery -- Treatment / Management. In patients who meet the indication for a CTO PCI, informed consent is necessary before the procedure after an extensive discussion about the risks and benefits of CTO PCI for the patient. Due to the challenging nature of the CTO lesions, a successful outcome for PCI in these lesions is when the procedure obtains TIMI-3 flow, and there is less than 50% of residual stenosis in the vessel."}
+{"id": "article-100024_15", "title": "Chronic Total Occlusion of the Coronary Artery -- Treatment / Management", "content": "Multiple scoring systems are available to operators to predict technical success in CTO lesions. One of the most commonly used scoring systems is the J-CTO score, developed using the Chronic Total Occlusion Registry in Japan. A J-CTO score is used to predict the probability of crossing the CTO lesion within 30 minutes, and is inclusive of five independent factors; blunt stump appearance of the proximal cap of the occlusion, occlusion length greater than or equal to 20 mm, calcification detected within the CTO segment, the presence of a greater than 45-degree bend within the CTO segment, and prior failed PCI attempt of the CTO lesion. Each of these independent factors carries 1 point in the J-CTO score; zero is considered easy, a score of one is deemed to be intermediate, two rates as difficult, and greater than or equal to three is considered very difficult, with the probability of crossing within 30 minutes found to be 88%, 67%, 42%, and 10% respectively. [14]", "contents": "Chronic Total Occlusion of the Coronary Artery -- Treatment / Management. Multiple scoring systems are available to operators to predict technical success in CTO lesions. One of the most commonly used scoring systems is the J-CTO score, developed using the Chronic Total Occlusion Registry in Japan. A J-CTO score is used to predict the probability of crossing the CTO lesion within 30 minutes, and is inclusive of five independent factors; blunt stump appearance of the proximal cap of the occlusion, occlusion length greater than or equal to 20 mm, calcification detected within the CTO segment, the presence of a greater than 45-degree bend within the CTO segment, and prior failed PCI attempt of the CTO lesion. Each of these independent factors carries 1 point in the J-CTO score; zero is considered easy, a score of one is deemed to be intermediate, two rates as difficult, and greater than or equal to three is considered very difficult, with the probability of crossing within 30 minutes found to be 88%, 67%, 42%, and 10% respectively. [14]"}
+{"id": "article-100024_16", "title": "Chronic Total Occlusion of the Coronary Artery -- Treatment / Management", "content": "Another commonly used score to predict the technical success of CTO PCI is the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO) score. This predictor uses four independent factors to assess the CTO lesion, which includes CTO lesion proximal cap ambiguity, moderate/severe tortuosity of the CTO vessel, Circumflex artery CTO, and the absence of interventional collaterals. Each of these factors carries one point and correlates with technical success. \u00a0A PROGRESS-CTO score of 0 is associated with 91% technical success, a score of 1 correlates with 74%, a score of 2 is 57% percent, and a score of \u22653 is less than 4.3%. [15]", "contents": "Chronic Total Occlusion of the Coronary Artery -- Treatment / Management. Another commonly used score to predict the technical success of CTO PCI is the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO) score. This predictor uses four independent factors to assess the CTO lesion, which includes CTO lesion proximal cap ambiguity, moderate/severe tortuosity of the CTO vessel, Circumflex artery CTO, and the absence of interventional collaterals. Each of these factors carries one point and correlates with technical success. \u00a0A PROGRESS-CTO score of 0 is associated with 91% technical success, a score of 1 correlates with 74%, a score of 2 is 57% percent, and a score of \u22653 is less than 4.3%. [15]"}
+{"id": "article-100024_17", "title": "Chronic Total Occlusion of the Coronary Artery -- Differential Diagnosis", "content": "STEMI NSTEMI Pulmonary embolism Aortic dissection Pneumothorax Esophageal rupture Perforating peptic ulcer disease", "contents": "Chronic Total Occlusion of the Coronary Artery -- Differential Diagnosis. STEMI NSTEMI Pulmonary embolism Aortic dissection Pneumothorax Esophageal rupture Perforating peptic ulcer disease"}
+{"id": "article-100024_18", "title": "Chronic Total Occlusion of the Coronary Artery -- Prognosis", "content": "In addition to causing symptoms, CTOs have correlations with a worse overall prognosis, with higher rates of death and non-fatal adverse cardiovascular events in several populations. Patients with CTOs tend to be older and have more comorbidities and more significant impairment of left ventricular function. Furthermore, patients with non-revascularized CTOs have higher mortality and a higher risk of major adverse cardiovascular events in comparison to patients with multivessel coronary artery disease who are completely revascularized. [16] [17]", "contents": "Chronic Total Occlusion of the Coronary Artery -- Prognosis. In addition to causing symptoms, CTOs have correlations with a worse overall prognosis, with higher rates of death and non-fatal adverse cardiovascular events in several populations. Patients with CTOs tend to be older and have more comorbidities and more significant impairment of left ventricular function. Furthermore, patients with non-revascularized CTOs have higher mortality and a higher risk of major adverse cardiovascular events in comparison to patients with multivessel coronary artery disease who are completely revascularized. [16] [17]"}
+{"id": "article-100024_19", "title": "Chronic Total Occlusion of the Coronary Artery -- Complications", "content": "Percutaneous coronary intervention (PCI) of a CTO lesion on average requires more fluoroscopy time, higher contrast volume, and carries a lower success rate compared to non-CTO PCI\u2019s. CTO PCIs also have a higher complication rate than non-CTO PCIs with major complications, including myocardial infarction, stroke, vessel perforation, and death. However, vascular access site complications during CTO PCI occur at a similar frequency as routine PCI; these include poorly controlled bleeding, hematoma, acute thrombosis, distal embolization, retroperitoneal hemorrhage, dissection of the access artery, arteriovenous fistula, and pseudoaneurysm. Other potentially serious complications include ventricular tachyarrhythmias, bradycardia, allergic reactions, atheroembolism, and contrast nephropathy. [18] [19] [20] [21] [22] [23]", "contents": "Chronic Total Occlusion of the Coronary Artery -- Complications. Percutaneous coronary intervention (PCI) of a CTO lesion on average requires more fluoroscopy time, higher contrast volume, and carries a lower success rate compared to non-CTO PCI\u2019s. CTO PCIs also have a higher complication rate than non-CTO PCIs with major complications, including myocardial infarction, stroke, vessel perforation, and death. However, vascular access site complications during CTO PCI occur at a similar frequency as routine PCI; these include poorly controlled bleeding, hematoma, acute thrombosis, distal embolization, retroperitoneal hemorrhage, dissection of the access artery, arteriovenous fistula, and pseudoaneurysm. Other potentially serious complications include ventricular tachyarrhythmias, bradycardia, allergic reactions, atheroembolism, and contrast nephropathy. [18] [19] [20] [21] [22] [23]"}
+{"id": "article-100024_20", "title": "Chronic Total Occlusion of the Coronary Artery -- Complications", "content": "Data analysis of the National Cardiovascular Data Registry-Cath PCI Registry in the United States showed higher in-hospital major adverse cardiovascular event frequency (1.6 versus 0.8 percent; p<0.001) which included mortality (0.4 % versus 0.3%; p<0.001), stroke (0.1% versus 0.1 %; p = 0.045), tamponade (0.3% versus 0.1%; p<0.001), MI (2.7% versus 1.9 %; p<0.001), and urgent CABG surgery (0.8% versus 0.4%; p<0.001) in 22,365 patients who underwent CTO PCI compared with 572,145 patients who underwent non-CTO PCI. CTO PCIs also had lower procedural success rate (59% vs. 96%, p < 0.001) in this registry. [24]", "contents": "Chronic Total Occlusion of the Coronary Artery -- Complications. Data analysis of the National Cardiovascular Data Registry-Cath PCI Registry in the United States showed higher in-hospital major adverse cardiovascular event frequency (1.6 versus 0.8 percent; p<0.001) which included mortality (0.4 % versus 0.3%; p<0.001), stroke (0.1% versus 0.1 %; p = 0.045), tamponade (0.3% versus 0.1%; p<0.001), MI (2.7% versus 1.9 %; p<0.001), and urgent CABG surgery (0.8% versus 0.4%; p<0.001) in 22,365 patients who underwent CTO PCI compared with 572,145 patients who underwent non-CTO PCI. CTO PCIs also had lower procedural success rate (59% vs. 96%, p < 0.001) in this registry. [24]"}
+{"id": "article-100024_21", "title": "Chronic Total Occlusion of the Coronary Artery -- Complications", "content": "Another multicenter registry (OPEN-CTO) from 12 CTO-PCI centers of 1,000 consecutive patients undergoing CTO PCI evaluated success rates, complication rates, and health status benefits at one month. \u00a0CTO PCIs showed a success rate of 86%, with an in-hospital mortality of 0.9%, 1-month mortality of 1.3%. 4.8% of the patients had coronary perforations requiring treatment. Additionally, major adverse cardiovascular events were 7%, myocardial infarction 2.6%, acute kidney injury 0.7%, and stroke 0%. [12]", "contents": "Chronic Total Occlusion of the Coronary Artery -- Complications. Another multicenter registry (OPEN-CTO) from 12 CTO-PCI centers of 1,000 consecutive patients undergoing CTO PCI evaluated success rates, complication rates, and health status benefits at one month. \u00a0CTO PCIs showed a success rate of 86%, with an in-hospital mortality of 0.9%, 1-month mortality of 1.3%. 4.8% of the patients had coronary perforations requiring treatment. Additionally, major adverse cardiovascular events were 7%, myocardial infarction 2.6%, acute kidney injury 0.7%, and stroke 0%. [12]"}
+{"id": "article-100024_22", "title": "Chronic Total Occlusion of the Coronary Artery -- Deterrence and Patient Education", "content": "Patient education should include resources such as videos and pamphlets. Teaching should focus on risk factor reduction and lifestyle modification such as smoking cessation, blood pressure management based on guidelines, screening for new-onset diabetes, and exercise as tolerated.", "contents": "Chronic Total Occlusion of the Coronary Artery -- Deterrence and Patient Education. Patient education should include resources such as videos and pamphlets. Teaching should focus on risk factor reduction and lifestyle modification such as smoking cessation, blood pressure management based on guidelines, screening for new-onset diabetes, and exercise as tolerated."}
+{"id": "article-100024_23", "title": "Chronic Total Occlusion of the Coronary Artery -- Enhancing Healthcare Team Outcomes", "content": "Educating patients at risk for\u00a0coronary artery disease\u00a0and making a closed-loop communication between them and their cardiologist for primary and secondary prevention can further\u00a0improve the management of patients at risk of these CTO lesions. Collaboration with shared decision making (between primary care physician, cardiologist, and interventionist) and communication\u00a0are\u00a0vital\u00a0elements for good outcomes in patients with coronary artery disease and CTO lesions.", "contents": "Chronic Total Occlusion of the Coronary Artery -- Enhancing Healthcare Team Outcomes. Educating patients at risk for\u00a0coronary artery disease\u00a0and making a closed-loop communication between them and their cardiologist for primary and secondary prevention can further\u00a0improve the management of patients at risk of these CTO lesions. Collaboration with shared decision making (between primary care physician, cardiologist, and interventionist) and communication\u00a0are\u00a0vital\u00a0elements for good outcomes in patients with coronary artery disease and CTO lesions."}
+{"id": "article-100024_24", "title": "Chronic Total Occlusion of the Coronary Artery -- Enhancing Healthcare Team Outcomes", "content": "The interprofessional team care provided to the patient must use an integrated care pathway combined with an evidence-based approach to evaluating CTO lesions. The earlier angiographic and demographic predictors of failure to revascularize are identified in CTO lesions; the better is the prognosis and outcome.", "contents": "Chronic Total Occlusion of the Coronary Artery -- Enhancing Healthcare Team Outcomes. The interprofessional team care provided to the patient must use an integrated care pathway combined with an evidence-based approach to evaluating CTO lesions. The earlier angiographic and demographic predictors of failure to revascularize are identified in CTO lesions; the better is the prognosis and outcome."}
+{"id": "article-100024_25", "title": "Chronic Total Occlusion of the Coronary Artery -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Chronic Total Occlusion of the Coronary Artery -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

statpearls/chunk/article-100131.jsonl

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+{"id": "article-100131_0", "title": "Cardiopulmonary Arrest in Adults -- Continuing Education Activity", "content": "Cardiopulmonary arrest is the cessation of adequate heart function and respiration and results in death without reversal. Often this condition is found in patients with coronary artery disease. This activity reviews the management and prevention of cardiopulmonary arrest and highlights the role of the interprofessional team in treating patients with this condition.", "contents": "Cardiopulmonary Arrest in Adults -- Continuing Education Activity. Cardiopulmonary arrest is the cessation of adequate heart function and respiration and results in death without reversal. Often this condition is found in patients with coronary artery disease. This activity reviews the management and prevention of cardiopulmonary arrest and highlights the role of the interprofessional team in treating patients with this condition."}
+{"id": "article-100131_1", "title": "Cardiopulmonary Arrest in Adults -- Continuing Education Activity", "content": "Objectives: Outline the typical presentation of a patient who suffers from cardiopulmonary arrest. Summarize the epidemiology of cardiac arrest in the U.S. Summarize the causes of cardiopulmonary arrest. Access free multiple choice questions on this topic.", "contents": "Cardiopulmonary Arrest in Adults -- Continuing Education Activity. Objectives: Outline the typical presentation of a patient who suffers from cardiopulmonary arrest. Summarize the epidemiology of cardiac arrest in the U.S. Summarize the causes of cardiopulmonary arrest. Access free multiple choice questions on this topic."}
+{"id": "article-100131_2", "title": "Cardiopulmonary Arrest in Adults -- Introduction", "content": "Cardiopulmonary arrest (CPA) is the cessation of effective ventilation and circulation. It is also known as cardiac arrest or circulatory arrest. In adults, it is most likely to be caused by a primary cardiac event. The most common electrical mechanism which is responsible for 50\u00a0to 80% of\u00a0cardiopulmonary\u00a0arrest is ventricular fibrillation (VF).\u00a0While, 20^% to 30% which represents the less common causes of dysrhythmias involve\u00a0Pulseless electrical activity (PEA), and asystole. Pulseless sustained ventricular tachycardia (VT) is a less common mechanism.\u00a0This condition could progress to sudden death if it not treated promptly. Nevertheless, a\u00a0cardiopulmonary arrest (CPA) could be\u00a0reversed by cardiopulmonary resuscitation\u00a0and/or cardioversion or defibrillation, or cardiac pacing. [1]", "contents": "Cardiopulmonary Arrest in Adults -- Introduction. Cardiopulmonary arrest (CPA) is the cessation of effective ventilation and circulation. It is also known as cardiac arrest or circulatory arrest. In adults, it is most likely to be caused by a primary cardiac event. The most common electrical mechanism which is responsible for 50\u00a0to 80% of\u00a0cardiopulmonary\u00a0arrest is ventricular fibrillation (VF).\u00a0While, 20^% to 30% which represents the less common causes of dysrhythmias involve\u00a0Pulseless electrical activity (PEA), and asystole. Pulseless sustained ventricular tachycardia (VT) is a less common mechanism.\u00a0This condition could progress to sudden death if it not treated promptly. Nevertheless, a\u00a0cardiopulmonary arrest (CPA) could be\u00a0reversed by cardiopulmonary resuscitation\u00a0and/or cardioversion or defibrillation, or cardiac pacing. [1]"}
+{"id": "article-100131_3", "title": "Cardiopulmonary Arrest in Adults -- Introduction", "content": "The American Heart Association's AHA periodically releases updates and recommendations\u00a0for adult basic life support (BLS) and the quality of cardiopulmonary resuscitation\u00a0(CPR) on adults.\u00a0Despite the causes, early induction of cardiopulmonary resuscitation\u00a0(CPR) along with cardiac monitoring will determine which pulseless arrest pathway one has to follow. Evidence suggests that more than 400000 people die of cardiopulmonary arrest in the U.S every year. [2] They may or may not have been diagnosed with cardiopulmonary\u00a0disease.", "contents": "Cardiopulmonary Arrest in Adults -- Introduction. The American Heart Association's AHA periodically releases updates and recommendations\u00a0for adult basic life support (BLS) and the quality of cardiopulmonary resuscitation\u00a0(CPR) on adults.\u00a0Despite the causes, early induction of cardiopulmonary resuscitation\u00a0(CPR) along with cardiac monitoring will determine which pulseless arrest pathway one has to follow. Evidence suggests that more than 400000 people die of cardiopulmonary arrest in the U.S every year. [2] They may or may not have been diagnosed with cardiopulmonary\u00a0disease."}
+{"id": "article-100131_4", "title": "Cardiopulmonary Arrest in Adults -- Etiology", "content": "There are various causes for cardiopulmonary\u00a0arrest in adults which varies by age\u00a0and population. However, patients diagnosed with cardiac disease are more susceptible to having\u00a0a cardiac arrest. Furthermore, it can be\u00a0classified into\u00a0different categories, which include cardiac, respiratory, and traumatic causes. But 75%\u00a0of cardiac arrest incidents\u00a0are believed to be due to coronary artery diseases. [2]", "contents": "Cardiopulmonary Arrest in Adults -- Etiology. There are various causes for cardiopulmonary\u00a0arrest in adults which varies by age\u00a0and population. However, patients diagnosed with cardiac disease are more susceptible to having\u00a0a cardiac arrest. Furthermore, it can be\u00a0classified into\u00a0different categories, which include cardiac, respiratory, and traumatic causes. But 75%\u00a0of cardiac arrest incidents\u00a0are believed to be due to coronary artery diseases. [2]"}
+{"id": "article-100131_5", "title": "Cardiopulmonary Arrest in Adults -- Etiology -- Coronary Artery Disease", "content": "Coronary artery abnormalities: Anomalous coronary artery anatomy. Acute lesions (platelet aggregation,\u00a0plaque fissuring, acute thrombosis). Chronic atherosclerosis. coronary artery spasm Myocardial Infarction: Acute Healed", "contents": "Cardiopulmonary Arrest in Adults -- Etiology -- Coronary Artery Disease. Coronary artery abnormalities: Anomalous coronary artery anatomy. Acute lesions (platelet aggregation,\u00a0plaque fissuring, acute thrombosis). Chronic atherosclerosis. coronary artery spasm Myocardial Infarction: Acute Healed"}
+{"id": "article-100131_6", "title": "Cardiopulmonary Arrest in Adults -- Etiology -- Myocardial Hypertrophy", "content": "Secondary Hypertrophic cardiomyopathy Nonobstructive Obstructive", "contents": "Cardiopulmonary Arrest in Adults -- Etiology -- Myocardial Hypertrophy. Secondary Hypertrophic cardiomyopathy Nonobstructive Obstructive"}
+{"id": "article-100131_7", "title": "Cardiopulmonary Arrest in Adults -- Etiology -- Infiltrative and Inflammatory Disorders", "content": "Infiltrative diseases Noninfectious inflammatory diseases Myocarditis", "contents": "Cardiopulmonary Arrest in Adults -- Etiology -- Infiltrative and Inflammatory Disorders. Infiltrative diseases Noninfectious inflammatory diseases Myocarditis"}
+{"id": "article-100131_8", "title": "Cardiopulmonary Arrest in Adults -- Etiology -- Inherited Disorders", "content": "Early repolarization syndrome. Brugada syndrome Short QT syndrome. Long QT syndrome. Catecholaminergic polymorphic\u00a0ventricular tachycardia", "contents": "Cardiopulmonary Arrest in Adults -- Etiology -- Inherited Disorders. Early repolarization syndrome. Brugada syndrome Short QT syndrome. Long QT syndrome. Catecholaminergic polymorphic\u00a0ventricular tachycardia"}
+{"id": "article-100131_9", "title": "Cardiopulmonary Arrest in Adults -- Etiology -- Heart Failure", "content": "Ejection fraction less than 35% [3]", "contents": "Cardiopulmonary Arrest in Adults -- Etiology -- Heart Failure. Ejection fraction less than 35% [3]"}
+{"id": "article-100131_10", "title": "Cardiopulmonary Arrest in Adults -- Etiology -- Congenital disease", "content": "Tetralogy of Fallot", "contents": "Cardiopulmonary Arrest in Adults -- Etiology -- Congenital disease. Tetralogy of Fallot"}
+{"id": "article-100131_11", "title": "Cardiopulmonary Arrest in Adults -- Etiology -- Respiratory Causes", "content": "Airway obstruction: Bronchospasm due to (pulmonary edema, pulmonary hemorrhage, and pneumonia) Severe asthma or Chronic Obstructive Pulmonary Disease (COPD). Pulmonary Embolism Respiratory Muscle Weakness: due to spinal cord injury.", "contents": "Cardiopulmonary Arrest in Adults -- Etiology -- Respiratory Causes. Airway obstruction: Bronchospasm due to (pulmonary edema, pulmonary hemorrhage, and pneumonia) Severe asthma or Chronic Obstructive Pulmonary Disease (COPD). Pulmonary Embolism Respiratory Muscle Weakness: due to spinal cord injury."}
+{"id": "article-100131_12", "title": "Cardiopulmonary Arrest in Adults -- Etiology -- Traumatic Causes", "content": "Overall, the prevalence of cardiac causes is around 50% to 60%. Whilst, the second most common cause that is respiratory insufficiency is around 15% to 40%. [4]", "contents": "Cardiopulmonary Arrest in Adults -- Etiology -- Traumatic Causes. Overall, the prevalence of cardiac causes is around 50% to 60%. Whilst, the second most common cause that is respiratory insufficiency is around 15% to 40%. [4]"}
+{"id": "article-100131_13", "title": "Cardiopulmonary Arrest in Adults -- Epidemiology", "content": "Cardiac arrest is divided into out-hospital cardiac arrest\u00a0(OHCA) and in-hospital cardiac arrest\u00a0(IHCA). However, the incidence of cardiopulmonary arrest worldwide is not well described. In the U.S, more than\u00a0290,000 IHCA occur in adults annually,\u00a0whilst 326,000 cases of OHCA among adults occur yearly.\u00a0Half of these are unwitnessed. [4] [5]", "contents": "Cardiopulmonary Arrest in Adults -- Epidemiology. Cardiac arrest is divided into out-hospital cardiac arrest\u00a0(OHCA) and in-hospital cardiac arrest\u00a0(IHCA). However, the incidence of cardiopulmonary arrest worldwide is not well described. In the U.S, more than\u00a0290,000 IHCA occur in adults annually,\u00a0whilst 326,000 cases of OHCA among adults occur yearly.\u00a0Half of these are unwitnessed. [4] [5]"}
+{"id": "article-100131_14", "title": "Cardiopulmonary Arrest in Adults -- Epidemiology", "content": "Men and women in\u00a0middle-age have different susceptibilities to cardiopulmonary arrest; however, the sex differences decrease with increasing\u00a0age. The difference in risk for cardiopulmonary\u00a0arrest collateral\u00a0the variations in age-related risks for other features\u00a0of coronary heart disease (CHD) between males and\u00a0females. As the gender gap for signs of coronary heart disease closes in the 6th\u00a0to 8th\u00a0decades, the excess risk of arrest\u00a0in males progressively narrows. In spite of the lower incidence among younger women, CHD risk factors such as diabetes (DM), cigarette smoking, hyperlipidemia, and hypertension (HTN) are very highly influential.", "contents": "Cardiopulmonary Arrest in Adults -- Epidemiology. Men and women in\u00a0middle-age have different susceptibilities to cardiopulmonary arrest; however, the sex differences decrease with increasing\u00a0age. The difference in risk for cardiopulmonary\u00a0arrest collateral\u00a0the variations in age-related risks for other features\u00a0of coronary heart disease (CHD) between males and\u00a0females. As the gender gap for signs of coronary heart disease closes in the 6th\u00a0to 8th\u00a0decades, the excess risk of arrest\u00a0in males progressively narrows. In spite of the lower incidence among younger women, CHD risk factors such as diabetes (DM), cigarette smoking, hyperlipidemia, and hypertension (HTN) are very highly influential."}
+{"id": "article-100131_15", "title": "Cardiopulmonary Arrest in Adults -- Pathophysiology", "content": "Data from postmortem examinations of cardiopulmonary arrest and sudden cardiac death (SCD) victims correlate with the clinical observations on the prevalence of coronary artery disease as the major structural etiologic factor. Higher than 80% of victims have pathologic findings of coronary artery disease. The pathologic description often involves a combination of extensive atherosclerosis of the coronary arteries along with\u00a0unstable coronary artery lesions, which include various permutations of fissured, eroded, or ruptured plaques; and/or thrombosis. As many as seventy percent\u00a0of men who die suddenly have preexisting healed myocardial infarctions, whereas only twenty percent\u00a0have recent acute MIs, in spite of\u00a0the prevalence of thrombi and unstable plaques. [6]", "contents": "Cardiopulmonary Arrest in Adults -- Pathophysiology. Data from postmortem examinations of cardiopulmonary arrest and sudden cardiac death (SCD) victims correlate with the clinical observations on the prevalence of coronary artery disease as the major structural etiologic factor. Higher than 80% of victims have pathologic findings of coronary artery disease. The pathologic description often involves a combination of extensive atherosclerosis of the coronary arteries along with\u00a0unstable coronary artery lesions, which include various permutations of fissured, eroded, or ruptured plaques; and/or thrombosis. As many as seventy percent\u00a0of men who die suddenly have preexisting healed myocardial infarctions, whereas only twenty percent\u00a0have recent acute MIs, in spite of\u00a0the prevalence of thrombi and unstable plaques. [6]"}
+{"id": "article-100131_16", "title": "Cardiopulmonary Arrest in Adults -- History and Physical", "content": "In numerous patients, warning signs and symptoms may precede a cardiac arrest. Nevertheless, these features are\u00a0ignored and unrecognized several times because those who survive after experiencing cardiopulmonary arrest, many of them suffer from amnesia while those patients who suffered cardiopulmonary arrest but survived and remember the event reveals that the most common sign was palpitations, shortness of breath,\u00a0nausea, and chest pain.", "contents": "Cardiopulmonary Arrest in Adults -- History and Physical. In numerous patients, warning signs and symptoms may precede a cardiac arrest. Nevertheless, these features are\u00a0ignored and unrecognized several times because those who survive after experiencing cardiopulmonary arrest, many of them suffer from amnesia while those patients who suffered cardiopulmonary arrest but survived and remember the event reveals that the most common sign was palpitations, shortness of breath,\u00a0nausea, and chest pain."}
+{"id": "article-100131_17", "title": "Cardiopulmonary Arrest in Adults -- History and Physical", "content": "Clinicians examing cardiopulmonary arrest should start\u00a0head-to-toe assessment immediately which will help to formulate the plan of management. The physical examination will help to diagnose the cardiopulmonary\u00a0arrest as well as provide the most important information regarding the possible cause and the prognosis. While, the history will help to delineate at\u00a0what time the event took place, what the victim\u00a0was doing, and the involvement of drugs.\u00a0In many cases, the gold standard\u00a0for diagnosing the cardiopulmonary\u00a0arrest is the loss\u00a0of carotid pulse,\u00a0But, many studies have shown that the rescuers often make a mistake while checking the carotid pulse, whether they are laypersons or the healthcare professionals. [7]", "contents": "Cardiopulmonary Arrest in Adults -- History and Physical. Clinicians examing cardiopulmonary arrest should start\u00a0head-to-toe assessment immediately which will help to formulate the plan of management. The physical examination will help to diagnose the cardiopulmonary\u00a0arrest as well as provide the most important information regarding the possible cause and the prognosis. While, the history will help to delineate at\u00a0what time the event took place, what the victim\u00a0was doing, and the involvement of drugs.\u00a0In many cases, the gold standard\u00a0for diagnosing the cardiopulmonary\u00a0arrest is the loss\u00a0of carotid pulse,\u00a0But, many studies have shown that the rescuers often make a mistake while checking the carotid pulse, whether they are laypersons or the healthcare professionals. [7]"}
+{"id": "article-100131_18", "title": "Cardiopulmonary Arrest in Adults -- Evaluation", "content": "Cardiopulmonary resuscitation should not be interrupted for doing blood or radiological investigation. However, point of care testing, like blood glucose or serum potassium may be done if it doesn't\u00a0interfere with cardiopulmonary resuscitation efforts. Point of care ultrasound can also be used to evaluate the activity of the heart during cardiopulmonary resuscitation which has proved beneficial in many studies. [8]", "contents": "Cardiopulmonary Arrest in Adults -- Evaluation. Cardiopulmonary resuscitation should not be interrupted for doing blood or radiological investigation. However, point of care testing, like blood glucose or serum potassium may be done if it doesn't\u00a0interfere with cardiopulmonary resuscitation efforts. Point of care ultrasound can also be used to evaluate the activity of the heart during cardiopulmonary resuscitation which has proved beneficial in many studies. [8]"}
+{"id": "article-100131_19", "title": "Cardiopulmonary Arrest in Adults -- Treatment / Management", "content": "Five stages in the management of the patient with confirmed cardiopulmonary arrest are: Initial evaluation plus Basic Life Support Defibrillation Advanced Life Support Post-resuscitation care Long-term management", "contents": "Cardiopulmonary Arrest in Adults -- Treatment / Management. Five stages in the management of the patient with confirmed cardiopulmonary arrest are: Initial evaluation plus Basic Life Support Defibrillation Advanced Life Support Post-resuscitation care Long-term management"}
+{"id": "article-100131_20", "title": "Cardiopulmonary Arrest in Adults -- Treatment / Management", "content": "Once the diagnosis of cardiopulmonary arrest is confirmed, then basic life support (BLS) and\u00a0defibrillation can be carried out by the public, physicians, paramedical personnel, trained laypersons, and nurses. There is an increasing\u00a0demand for specialized skills such as Advanced Life Support (ALS), post-resuscitation care, and long-term management of post cardiopulmonary arrest patients. The cardiopulmonary arrest could be reversed by two main interventions, i.e., early CPR\u00a0and early Automated external defibrillation (AED). The first\u00a0step involves recognition of the cardiopulmonary\u00a0arrest\u00a0and the\u00a0BLS\u00a0measures. If defibrillation is available for public use, then it\u00a0should be activated and used if needed. Next, advanced life support (ALS) measures are used, involving\u00a0IV/IO\u00a0medication administration. If\u00a0spontaneous circulation returns, then the case\u00a0will undergo post-resuscitation care along with\u00a0subsequent long-term management. The identification of a cardiopulmonary\u00a0arrest victim includes ensuring that the patient is unresponsive, pulseless, and having abnormal breathing. Once the patient\u00a0is identified, immediate CPR and activation of the Emergency Medical Services (EMS) should be done promptly. Nowadays, public access to defibrillation has been adding another layer of response.", "contents": "Cardiopulmonary Arrest in Adults -- Treatment / Management. Once the diagnosis of cardiopulmonary arrest is confirmed, then basic life support (BLS) and\u00a0defibrillation can be carried out by the public, physicians, paramedical personnel, trained laypersons, and nurses. There is an increasing\u00a0demand for specialized skills such as Advanced Life Support (ALS), post-resuscitation care, and long-term management of post cardiopulmonary arrest patients. The cardiopulmonary arrest could be reversed by two main interventions, i.e., early CPR\u00a0and early Automated external defibrillation (AED). The first\u00a0step involves recognition of the cardiopulmonary\u00a0arrest\u00a0and the\u00a0BLS\u00a0measures. If defibrillation is available for public use, then it\u00a0should be activated and used if needed. Next, advanced life support (ALS) measures are used, involving\u00a0IV/IO\u00a0medication administration. If\u00a0spontaneous circulation returns, then the case\u00a0will undergo post-resuscitation care along with\u00a0subsequent long-term management. The identification of a cardiopulmonary\u00a0arrest victim includes ensuring that the patient is unresponsive, pulseless, and having abnormal breathing. Once the patient\u00a0is identified, immediate CPR and activation of the Emergency Medical Services (EMS) should be done promptly. Nowadays, public access to defibrillation has been adding another layer of response."}
+{"id": "article-100131_21", "title": "Cardiopulmonary Arrest in Adults -- Treatment / Management -- Initial Evaluation\u00a0and\u00a0BLS", "content": "Confirming cardiopulmonary arrest need careful examination of the patient's level of consciousness, skin color, breathing movement, and arterial pulse either in the carotid or femoral artery. Just after confirming the arrest, the immediate responsibility of the rescuer is to call Emergency Medical Services and start CPR.", "contents": "Cardiopulmonary Arrest in Adults -- Treatment / Management -- Initial Evaluation\u00a0and\u00a0BLS. Confirming cardiopulmonary arrest need careful examination of the patient's level of consciousness, skin color, breathing movement, and arterial pulse either in the carotid or femoral artery. Just after confirming the arrest, the immediate responsibility of the rescuer is to call Emergency Medical Services and start CPR."}
+{"id": "article-100131_22", "title": "Cardiopulmonary Arrest in Adults -- Treatment / Management -- Initial Evaluation\u00a0and\u00a0BLS", "content": "It is essential to diagnose the signs of aspirations of a foreign body in the respiratory tract, which includes severe stridor, dyspnea, suprasternal and intercostal retractions. It is recommended to do the Heimlich maneuver if we are suspecting aspiration.", "contents": "Cardiopulmonary Arrest in Adults -- Treatment / Management -- Initial Evaluation\u00a0and\u00a0BLS. It is essential to diagnose the signs of aspirations of a foreign body in the respiratory tract, which includes severe stridor, dyspnea, suprasternal and intercostal retractions. It is recommended to do the Heimlich maneuver if we are suspecting aspiration."}
+{"id": "article-100131_23", "title": "Cardiopulmonary Arrest in Adults -- Treatment / Management -- Initial Evaluation\u00a0and\u00a0BLS", "content": "Maintaining a patent airway is necessary for successful cardiopulmonary resuscitation. Maneuvers like chin lift, head tilt, and jaw thrust can be used to keep the airway patent. Any visible foreign bodies like displaced dentures should be removed from the oropharynx. Ventilatory aids like oropharyngeal airway (OPA) and the nasopharyngeal airway (NPA) may be used if the rescuer is experiencing difficulty in ventilating the patient. [9] [10] The AHA guideline suggested certain recommendation for doing high-quality CPR: [11] Compression should start within 10 seconds of diagnosing cardiopulmonary arrest. Two breaths to be given after 30 compressions. Excessive ventilation should be avoided. Every effort should be made to reduce the interruption while changing the rescuer or while checking the rhythm. The rate of compression should be between 100\u00a0to 120 per minute The depth of compression should be between 2\u00a0to 2.4 inches for adults. Adequate time should be given for chest recoil", "contents": "Cardiopulmonary Arrest in Adults -- Treatment / Management -- Initial Evaluation\u00a0and\u00a0BLS. Maintaining a patent airway is necessary for successful cardiopulmonary resuscitation. Maneuvers like chin lift, head tilt, and jaw thrust can be used to keep the airway patent. Any visible foreign bodies like displaced dentures should be removed from the oropharynx. Ventilatory aids like oropharyngeal airway (OPA) and the nasopharyngeal airway (NPA) may be used if the rescuer is experiencing difficulty in ventilating the patient. [9] [10] The AHA guideline suggested certain recommendation for doing high-quality CPR: [11] Compression should start within 10 seconds of diagnosing cardiopulmonary arrest. Two breaths to be given after 30 compressions. Excessive ventilation should be avoided. Every effort should be made to reduce the interruption while changing the rescuer or while checking the rhythm. The rate of compression should be between 100\u00a0to 120 per minute The depth of compression should be between 2\u00a0to 2.4 inches for adults. Adequate time should be given for chest recoil"}
+{"id": "article-100131_24", "title": "Cardiopulmonary Arrest in Adults -- Treatment / Management -- Automated External Defibrillation", "content": "The AEDs are\u00a0easily handled via nonconventional responders, for instance:\u00a0ambulance drivers, police officers,\u00a0firefighters, security guards, and laypersons. Recent\u00a0studies have suggested\u00a0that AED use via nonconventional responders could\u00a0improve the survival rates of cardiopulmonary\u00a0arrest as the arrival of the ALS team takes time, and early defibrillation by non-conventional responders will not only reduce the time for defibrillation but will also improve patient outcome.", "contents": "Cardiopulmonary Arrest in Adults -- Treatment / Management -- Automated External Defibrillation. The AEDs are\u00a0easily handled via nonconventional responders, for instance:\u00a0ambulance drivers, police officers,\u00a0firefighters, security guards, and laypersons. Recent\u00a0studies have suggested\u00a0that AED use via nonconventional responders could\u00a0improve the survival rates of cardiopulmonary\u00a0arrest as the arrival of the ALS team takes time, and early defibrillation by non-conventional responders will not only reduce the time for defibrillation but will also improve patient outcome."}
+{"id": "article-100131_25", "title": "Cardiopulmonary Arrest in Adults -- Treatment / Management -- Advanced Cardiac Life Support", "content": "Providers can use basic life support along with advanced airway aid and medication like epinephrine and amiodarone for CPR. The advanced airway may include supraglottic airway devices and endotracheal tubes. ACLS team has the further advantage of cardiac rhythm interpretation and using defibrillation when indicated.", "contents": "Cardiopulmonary Arrest in Adults -- Treatment / Management -- Advanced Cardiac Life Support. Providers can use basic life support along with advanced airway aid and medication like epinephrine and amiodarone for CPR. The advanced airway may include supraglottic airway devices and endotracheal tubes. ACLS team has the further advantage of cardiac rhythm interpretation and using defibrillation when indicated."}
+{"id": "article-100131_26", "title": "Cardiopulmonary Arrest in Adults -- Treatment / Management -- Advanced Cardiac Life Support", "content": "ADVANCED CARDIAC LIFE SUPPORT  (ACLS) is designed to deliver adequate ventilation, stabilize the blood pressure along with the\u00a0cardiac output,\u00a0control cardiac arrhythmias, and restore organ perfusion. Maneuvers needed to accomplish these goals include- Defibrillation and pacing. Endotracheal tube intubation and mechanical ventilation Intravenous line insertion. The rapidity by\u00a0which defibrillation is performed is an essential element for improving patient outcomes. The AHA guideline suggested certain recommendation for defibrillation-", "contents": "Cardiopulmonary Arrest in Adults -- Treatment / Management -- Advanced Cardiac Life Support. ADVANCED CARDIAC LIFE SUPPORT  (ACLS) is designed to deliver adequate ventilation, stabilize the blood pressure along with the\u00a0cardiac output,\u00a0control cardiac arrhythmias, and restore organ perfusion. Maneuvers needed to accomplish these goals include- Defibrillation and pacing. Endotracheal tube intubation and mechanical ventilation Intravenous line insertion. The rapidity by\u00a0which defibrillation is performed is an essential element for improving patient outcomes. The AHA guideline suggested certain recommendation for defibrillation-"}
+{"id": "article-100131_27", "title": "Cardiopulmonary Arrest in Adults -- Treatment / Management -- Advanced Cardiac Life Support", "content": "Cardiopulmonary resuscitation should be carried out whilst\u00a0the AED\u00a0is being charged Immediate early defibrillation should be given preference over intubation and intravenous line insertion A defibrillator with a biphasic waveform is preferred over monophasic. Manufacturers recommended energy dose should be used for the first shock. If this is not mentioned, then the maximum dose should be used for defibrillation. Fixed versus escalating energy for subsequent shock should depend on manufacturers' recommendations. If the machine has the capability to escalate the energy, then higher energy should be used for a subsequent shock. A single shock strategy should be preferred to stacked shock.", "contents": "Cardiopulmonary Arrest in Adults -- Treatment / Management -- Advanced Cardiac Life Support. Cardiopulmonary resuscitation should be carried out whilst\u00a0the AED\u00a0is being charged Immediate early defibrillation should be given preference over intubation and intravenous line insertion A defibrillator with a biphasic waveform is preferred over monophasic. Manufacturers recommended energy dose should be used for the first shock. If this is not mentioned, then the maximum dose should be used for defibrillation. Fixed versus escalating energy for subsequent shock should depend on manufacturers' recommendations. If the machine has the capability to escalate the energy, then higher energy should be used for a subsequent shock. A single shock strategy should be preferred to stacked shock."}
+{"id": "article-100131_28", "title": "Cardiopulmonary Arrest in Adults -- Treatment / Management -- Advanced Cardiac Life Support", "content": "After failed defibrillation, epinephrine, 1mg I/V, should be\u00a0given. Furthermore, the dose of this drug\u00a0may be repeated after periods of three to five\u00a0minutes. Additionally, vasopressin has been recommended\u00a0as an alternative. [12]", "contents": "Cardiopulmonary Arrest in Adults -- Treatment / Management -- Advanced Cardiac Life Support. After failed defibrillation, epinephrine, 1mg I/V, should be\u00a0given. Furthermore, the dose of this drug\u00a0may be repeated after periods of three to five\u00a0minutes. Additionally, vasopressin has been recommended\u00a0as an alternative. [12]"}
+{"id": "article-100131_29", "title": "Cardiopulmonary Arrest in Adults -- Treatment / Management -- Advanced Cardiac Life Support", "content": "After 2 or 3 failed attempts, immediate intubation and arterial blood gas analysis should be carried out. Those patients who still remain acidotic even after intubation and successful defibrillation should be given 1 new/ kg of NaHCO3 initially, and further 50 percent of the dose may be repeated after 10 minutes.", "contents": "Cardiopulmonary Arrest in Adults -- Treatment / Management -- Advanced Cardiac Life Support. After 2 or 3 failed attempts, immediate intubation and arterial blood gas analysis should be carried out. Those patients who still remain acidotic even after intubation and successful defibrillation should be given 1 new/ kg of NaHCO3 initially, and further 50 percent of the dose may be repeated after 10 minutes."}
+{"id": "article-100131_30", "title": "Cardiopulmonary Arrest in Adults -- Treatment / Management -- Advanced Cardiac Life Support", "content": "Antiarrhythmic therapy with amiodarone may be started after recurrent electrical instability and failed defibrillation. 150 mg amiodarone should be given over 10 minutes, followed by 1 mg/ hr for 6 hours and 0.5 mg/ hour for the next 18 hours. Procainamide is rarely used nowadays. Calcium gluconate is not considered safe, and its use is only reserved for patients having hyperkalemia or have taken a lethal dose of calcium channel blocker. [13]", "contents": "Cardiopulmonary Arrest in Adults -- Treatment / Management -- Advanced Cardiac Life Support. Antiarrhythmic therapy with amiodarone may be started after recurrent electrical instability and failed defibrillation. 150 mg amiodarone should be given over 10 minutes, followed by 1 mg/ hr for 6 hours and 0.5 mg/ hour for the next 18 hours. Procainamide is rarely used nowadays. Calcium gluconate is not considered safe, and its use is only reserved for patients having hyperkalemia or have taken a lethal dose of calcium channel blocker. [13]"}
+{"id": "article-100131_31", "title": "Cardiopulmonary Arrest in Adults -- Treatment / Management -- Postresucitation Care", "content": "This phase starts with the successful return of spontaneous circulation. Generally, the Primary ventricular fibrillation after acute myocardial infarction( AMI)\u00a0 are highly responsive to treatment and are readily controlled while in secondary ventricular fibrillation after AMI, resuscitative efforts are usually less successful, and those patients who are resuscitated successfully, the rate of recurrence of VF is very high. Patient outcome is determined by hemodynamic stability. Asystole, bradyarrhythmias, and PEA are commonly seen in hemodynamically unstable patients. [14]", "contents": "Cardiopulmonary Arrest in Adults -- Treatment / Management -- Postresucitation Care. This phase starts with the successful return of spontaneous circulation. Generally, the Primary ventricular fibrillation after acute myocardial infarction( AMI)\u00a0 are highly responsive to treatment and are readily controlled while in secondary ventricular fibrillation after AMI, resuscitative efforts are usually less successful, and those patients who are resuscitated successfully, the rate of recurrence of VF is very high. Patient outcome is determined by hemodynamic stability. Asystole, bradyarrhythmias, and PEA are commonly seen in hemodynamically unstable patients. [14]"}
+{"id": "article-100131_32", "title": "Cardiopulmonary Arrest in Adults -- Treatment / Management -- Postresucitation Care", "content": "The outcomes and the clinical picture after In-hospital cardiopulmonary arrest (IHCA) associated with the noncardiac diseases are very poor, and in some successfully resuscitated cases, the post-resuscitation course is controlled by the nature of the underlying illness. Patients with cancer, central nervous system disease, renal\u00a0failure have a survival rate of less than ten percent\u00a0after IHCA.", "contents": "Cardiopulmonary Arrest in Adults -- Treatment / Management -- Postresucitation Care. The outcomes and the clinical picture after In-hospital cardiopulmonary arrest (IHCA) associated with the noncardiac diseases are very poor, and in some successfully resuscitated cases, the post-resuscitation course is controlled by the nature of the underlying illness. Patients with cancer, central nervous system disease, renal\u00a0failure have a survival rate of less than ten percent\u00a0after IHCA."}
+{"id": "article-100131_33", "title": "Cardiopulmonary Arrest in Adults -- Treatment / Management -- Long-Term Management After The Survival Of OHCA", "content": "Patients who survive cardiopulmonary\u00a0arrest without irreversible damage to the brain must undergo proper investigation in order to know the etiology and definite intervention so that such episodes can be prevented in the future.", "contents": "Cardiopulmonary Arrest in Adults -- Treatment / Management -- Long-Term Management After The Survival Of OHCA. Patients who survive cardiopulmonary\u00a0arrest without irreversible damage to the brain must undergo proper investigation in order to know the etiology and definite intervention so that such episodes can be prevented in the future."}
+{"id": "article-100131_34", "title": "Cardiopulmonary Arrest in Adults -- Treatment / Management -- Long-Term Management After The Survival Of OHCA", "content": "Patients with cardiopulmonary arrest due to myocardial ischemia should be managed by surgical, pharmacological ( anti ischemia therapy), and radiological intervention so that long term survival can be improved.", "contents": "Cardiopulmonary Arrest in Adults -- Treatment / Management -- Long-Term Management After The Survival Of OHCA. Patients with cardiopulmonary arrest due to myocardial ischemia should be managed by surgical, pharmacological ( anti ischemia therapy), and radiological intervention so that long term survival can be improved."}
+{"id": "article-100131_35", "title": "Cardiopulmonary Arrest in Adults -- Treatment / Management -- Long-Term Management After The Survival Of OHCA", "content": "Survivors of cardiopulmonary\u00a0arrest due to diseases, like hypertrophic cardiomyopathies, rare inherited disorders, right ventricular dysplasia, catecholaminergic polymorphic VT, Brugada syndrome, and long QT syndrome, are the candidates for Implantable cardioverter-defibrillator (ICD).", "contents": "Cardiopulmonary Arrest in Adults -- Treatment / Management -- Long-Term Management After The Survival Of OHCA. Survivors of cardiopulmonary\u00a0arrest due to diseases, like hypertrophic cardiomyopathies, rare inherited disorders, right ventricular dysplasia, catecholaminergic polymorphic VT, Brugada syndrome, and long QT syndrome, are the candidates for Implantable cardioverter-defibrillator (ICD)."}
+{"id": "article-100131_36", "title": "Cardiopulmonary Arrest in Adults -- Differential Diagnosis", "content": "Patients with cardiopulmonary arrest will be pulseless and unresponsive. But there are certain conditions having clinical manifestations similar to cardiopulmonary arrest. It includes syncope, seizure, and overdose of certain medications like opioids. [1] We should try to recognize and treat reversible causes of cardiopulmonary arrest commonly referred to as Hs and Ts. It includes- Hypovolemia Hypoxia Hypothermia Hypo/hyperkalemia Acidosis Tension pneumothorax Toxic overdose of drugs Thromboembolism/pulmonary embolism Thrombus/acute myocardial infarction Cardiac tamponade", "contents": "Cardiopulmonary Arrest in Adults -- Differential Diagnosis. Patients with cardiopulmonary arrest will be pulseless and unresponsive. But there are certain conditions having clinical manifestations similar to cardiopulmonary arrest. It includes syncope, seizure, and overdose of certain medications like opioids. [1] We should try to recognize and treat reversible causes of cardiopulmonary arrest commonly referred to as Hs and Ts. It includes- Hypovolemia Hypoxia Hypothermia Hypo/hyperkalemia Acidosis Tension pneumothorax Toxic overdose of drugs Thromboembolism/pulmonary embolism Thrombus/acute myocardial infarction Cardiac tamponade"}
+{"id": "article-100131_37", "title": "Cardiopulmonary Arrest in Adults -- Prognosis", "content": "Witnessed cardiopulmonary\u00a0arrest along with\u00a0immediate CPR and defibrillation have better patient survival and outcome. [15] Healthy and young patients are more likely to obtain the return of spontaneous circulation as compared to elderly patients with known co-morbidities such as IHD.", "contents": "Cardiopulmonary Arrest in Adults -- Prognosis. Witnessed cardiopulmonary\u00a0arrest along with\u00a0immediate CPR and defibrillation have better patient survival and outcome. [15] Healthy and young patients are more likely to obtain the return of spontaneous circulation as compared to elderly patients with known co-morbidities such as IHD."}
+{"id": "article-100131_38", "title": "Cardiopulmonary Arrest in Adults -- Complications", "content": "Various complications can occur during cardiopulmonary resuscitation. AED failure is the\u00a0most common complication. Other complications include the inability to obtain venous access, rib fracture, pneumothorax, pneumomediastinum, hemothorax, lung laceration, pulmonary hemorrhage, injury to the major vessel, and cardiac tamponade.", "contents": "Cardiopulmonary Arrest in Adults -- Complications. Various complications can occur during cardiopulmonary resuscitation. AED failure is the\u00a0most common complication. Other complications include the inability to obtain venous access, rib fracture, pneumothorax, pneumomediastinum, hemothorax, lung laceration, pulmonary hemorrhage, injury to the major vessel, and cardiac tamponade."}
+{"id": "article-100131_39", "title": "Cardiopulmonary Arrest in Adults -- Deterrence and Patient Education", "content": "Most of the cardiopulmonary arrest occur outside hospitals. Immediate cardiopulmonary resuscitation and defibrillation are the two main intervention which has shown to improve patient outcomes. [16] [17] Hence, even laypersons with adequate CPR skills and training can save lives. But, sometimes even the trained person hesitate to start CPR\u00a0because of a lack\u00a0of confidence and cardiac arrest recognition. [18] This points to the need for improving their skills and confidence by organizing regular training sessions and workshops.", "contents": "Cardiopulmonary Arrest in Adults -- Deterrence and Patient Education. Most of the cardiopulmonary arrest occur outside hospitals. Immediate cardiopulmonary resuscitation and defibrillation are the two main intervention which has shown to improve patient outcomes. [16] [17] Hence, even laypersons with adequate CPR skills and training can save lives. But, sometimes even the trained person hesitate to start CPR\u00a0because of a lack\u00a0of confidence and cardiac arrest recognition. [18] This points to the need for improving their skills and confidence by organizing regular training sessions and workshops."}
+{"id": "article-100131_40", "title": "Cardiopulmonary Arrest in Adults -- Enhancing Healthcare Team Outcomes", "content": "The vast majority of patients who experience cardiopulmonary arrest are known cases of coronary artery disease. Cardiopulmonary arrest in such patients can be prevented by reducing the progression of the disease by altering modifiable risk factors and regular medication. In addition,\u00a0healthcare professionals should educate the patient about the advantages of a\u00a0healthy diet,\u00a0regular exercise, effective treatment of dyslipidemia, hypertension (HTN), diabetes\u00a0(DM), and smoking cessation. Finally, it is the responsibility of healthcare professionals to be well versed with the basic principles and clinical skills needed for effective cardiopulmonary resuscitation. [19]", "contents": "Cardiopulmonary Arrest in Adults -- Enhancing Healthcare Team Outcomes. The vast majority of patients who experience cardiopulmonary arrest are known cases of coronary artery disease. Cardiopulmonary arrest in such patients can be prevented by reducing the progression of the disease by altering modifiable risk factors and regular medication. In addition,\u00a0healthcare professionals should educate the patient about the advantages of a\u00a0healthy diet,\u00a0regular exercise, effective treatment of dyslipidemia, hypertension (HTN), diabetes\u00a0(DM), and smoking cessation. Finally, it is the responsibility of healthcare professionals to be well versed with the basic principles and clinical skills needed for effective cardiopulmonary resuscitation. [19]"}
+{"id": "article-100131_41", "title": "Cardiopulmonary Arrest in Adults -- Review Questions", "content": "Access free multiple choice questions on this topic. Click here for a simplified version. Comment on this article.", "contents": "Cardiopulmonary Arrest in Adults -- Review Questions. Access free multiple choice questions on this topic. Click here for a simplified version. Comment on this article."}

statpearls/chunk/article-100318.jsonl

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+{"id": "article-100318_0", "title": "Amantadine Keratopathy -- Continuing Education Activity", "content": "Amantadine keratopathy is a rare dose-dependent disease process in which the drug amantadine causes damage to corneal endothelial cells through unknown mechanisms. Damage to the endothelium can ultimately lead to severe corneal edema with decreased visual acuity. Edema is typically reversible with discontinuation of the drug, but irreversible cases requiring corneal transplants have been reported. This activity describes the evaluation and management of amantadine keratopathy and highlights the role of the interprofessional team in improving care for patients with this condition.", "contents": "Amantadine Keratopathy -- Continuing Education Activity. Amantadine keratopathy is a rare dose-dependent disease process in which the drug amantadine causes damage to corneal endothelial cells through unknown mechanisms. Damage to the endothelium can ultimately lead to severe corneal edema with decreased visual acuity. Edema is typically reversible with discontinuation of the drug, but irreversible cases requiring corneal transplants have been reported. This activity describes the evaluation and management of amantadine keratopathy and highlights the role of the interprofessional team in improving care for patients with this condition."}
+{"id": "article-100318_1", "title": "Amantadine Keratopathy -- Continuing Education Activity", "content": "Objectives: Review the pathophysiology of amantadine keratopathy. Explain the risk factors for developing amantadine keratopathy. Identify the treatment options available for amantadine keratopathy. Describe the importance of collaboration and communication among the interprofessional team to advance the care of amantadine keratopathy and to improve outcomes for patients with this condition. Access free multiple choice questions on this topic.", "contents": "Amantadine Keratopathy -- Continuing Education Activity. Objectives: Review the pathophysiology of amantadine keratopathy. Explain the risk factors for developing amantadine keratopathy. Identify the treatment options available for amantadine keratopathy. Describe the importance of collaboration and communication among the interprofessional team to advance the care of amantadine keratopathy and to improve outcomes for patients with this condition. Access free multiple choice questions on this topic."}
+{"id": "article-100318_2", "title": "Amantadine Keratopathy -- Introduction", "content": "Amantadine was originally discovered as an anti-viral to treat influenza in the 1950s. In the late 1960s, it was discovered to be useful in treating tremors and dyskinesia associated with Parkinson's disease and began to be widely used for this purpose. Today amantadine is prescribed for some chronic neurodegenerative and neurocognitive diseases. The mechanism of action of amantadine is largely unknown. Amantadine keratopathy is a term used to describe corneal edema and subsequent decrease in visual acuity that is assumed to be caused by the drug. Corneal edema typically resolves with discontinuation of the drug, although cases requiring corneal transplants have been reported.", "contents": "Amantadine Keratopathy -- Introduction. Amantadine was originally discovered as an anti-viral to treat influenza in the 1950s. In the late 1960s, it was discovered to be useful in treating tremors and dyskinesia associated with Parkinson's disease and began to be widely used for this purpose. Today amantadine is prescribed for some chronic neurodegenerative and neurocognitive diseases. The mechanism of action of amantadine is largely unknown. Amantadine keratopathy is a term used to describe corneal edema and subsequent decrease in visual acuity that is assumed to be caused by the drug. Corneal edema typically resolves with discontinuation of the drug, although cases requiring corneal transplants have been reported."}
+{"id": "article-100318_3", "title": "Amantadine Keratopathy -- Etiology", "content": "The acute onset of corneal edema with amantadine treatment and the resolution with discontinuation of the drug shows a causal relationship. [1] [2] [3] [4] Studies show that amantadine keratopathy occurs in a cumulative and dose-dependent manner. [5] [6] There is a negative correlation between the duration of treatment and endothelial cell density (ECD). [1] The greatest relative risk of corneal edema is seen in patients who are given a high dose for a short period (2000 mg within 30 days RR=2.38). [6] A 4000 mg cumulative dose prescribed within 30 days led to a 3-fold increased risk in corneal edema. [6] Amantadine could act synergistically with other medications that are toxic to the cornea, increasing the risk for corneal edema and permanent damage in these patients. [2] [7]", "contents": "Amantadine Keratopathy -- Etiology. The acute onset of corneal edema with amantadine treatment and the resolution with discontinuation of the drug shows a causal relationship. [1] [2] [3] [4] Studies show that amantadine keratopathy occurs in a cumulative and dose-dependent manner. [5] [6] There is a negative correlation between the duration of treatment and endothelial cell density (ECD). [1] The greatest relative risk of corneal edema is seen in patients who are given a high dose for a short period (2000 mg within 30 days RR=2.38). [6] A 4000 mg cumulative dose prescribed within 30 days led to a 3-fold increased risk in corneal edema. [6] Amantadine could act synergistically with other medications that are toxic to the cornea, increasing the risk for corneal edema and permanent damage in these patients. [2] [7]"}
+{"id": "article-100318_4", "title": "Amantadine Keratopathy -- Etiology", "content": "Although ECD is not a highly reliable marker of clinical outcomes, patients with decreased baseline ECD may be at increased risk of amantadine keratopathy. ECD decreases linearly throughout one's lifetime, and the standard deviation of ECD increases in later decades of life. [8] [9] A study of corneas from a large cornea donor database showed that prevalence of ECD <2000 was substantially increased in the eyes of patients >75 years old (odds ratio (OR)=24.6), eyes 65-74 years old (OR=17.8), and eyes with a previous history of cataract surgery (OR=4.8). [9]", "contents": "Amantadine Keratopathy -- Etiology. Although ECD is not a highly reliable marker of clinical outcomes, patients with decreased baseline ECD may be at increased risk of amantadine keratopathy. ECD decreases linearly throughout one's lifetime, and the standard deviation of ECD increases in later decades of life. [8] [9] A study of corneas from a large cornea donor database showed that prevalence of ECD <2000 was substantially increased in the eyes of patients >75 years old (odds ratio (OR)=24.6), eyes 65-74 years old (OR=17.8), and eyes with a previous history of cataract surgery (OR=4.8). [9]"}
+{"id": "article-100318_5", "title": "Amantadine Keratopathy -- Epidemiology", "content": "The incidence and prevalence of amantadine keratopathy in the general population are not known as the majority of studies exclude patients with ocular comorbidities (e.g., glaucoma, prior history of corneal edema) where amantadine keratopathy may have an increased prevalence. Amantadine keratopathy has an equal preponderance in males and females. [6] [10] In a phase IV post-marketing surveillance study, the 2-year relative risk (RR) of developing corneal edema or Fuchs dystrophy in patients prescribed amantadine is 1.79 when compared to the general population. Over this period, 36 (0.27%) of the 13,137 patients receiving amantadine (99% of whom received a prescription of 100 mg BID) were diagnosed with Fuchs dystrophy or corneal edema. [10]", "contents": "Amantadine Keratopathy -- Epidemiology. The incidence and prevalence of amantadine keratopathy in the general population are not known as the majority of studies exclude patients with ocular comorbidities (e.g., glaucoma, prior history of corneal edema) where amantadine keratopathy may have an increased prevalence. Amantadine keratopathy has an equal preponderance in males and females. [6] [10] In a phase IV post-marketing surveillance study, the 2-year relative risk (RR) of developing corneal edema or Fuchs dystrophy in patients prescribed amantadine is 1.79 when compared to the general population. Over this period, 36 (0.27%) of the 13,137 patients receiving amantadine (99% of whom received a prescription of 100 mg BID) were diagnosed with Fuchs dystrophy or corneal edema. [10]"}
+{"id": "article-100318_6", "title": "Amantadine Keratopathy -- Epidemiology", "content": "There is an increased incidence of amantadine keratopathy within months of treatment initiation, but cases have been reported as late as 6 years after starting therapy, so the relative risk is likely greater than this. [6] [10] [11] The largest retrospective cohort study conducted on amantadine keratopathy showed that patients prescribed amantadine for Parkinson's disease specifically have an increased risk of developing amantadine keratopathy when compared to individuals taking amantadine for other reasons (RR=1.97). [6] This increased risk is likely due to long term treatment. The same study calculates a RR of 1.97 over a 15-year period for Parkinson's patients on amantadine when compared to healthy controls not taking amantadine. [6]", "contents": "Amantadine Keratopathy -- Epidemiology. There is an increased incidence of amantadine keratopathy within months of treatment initiation, but cases have been reported as late as 6 years after starting therapy, so the relative risk is likely greater than this. [6] [10] [11] The largest retrospective cohort study conducted on amantadine keratopathy showed that patients prescribed amantadine for Parkinson's disease specifically have an increased risk of developing amantadine keratopathy when compared to individuals taking amantadine for other reasons (RR=1.97). [6] This increased risk is likely due to long term treatment. The same study calculates a RR of 1.97 over a 15-year period for Parkinson's patients on amantadine when compared to healthy controls not taking amantadine. [6]"}
+{"id": "article-100318_7", "title": "Amantadine Keratopathy -- Pathophysiology", "content": "Amantadine causes permanent damage to the corneal endothelium and a decrease in corneal endothelial cell density by unknown mechanisms. [4] [11] [12] Bovine cornea cell cultures showed no signs of corneal endothelial cell apoptosis, although the duration of incubation may not have been sufficient to induce such a change. [13] Corneal endothelial cells are located in a monolayer posterior to Descemet's membrane and the stroma. These cells function to dehydrate and thus maintain the clarity of the cornea via sodium-potassium adenosine triphosphatase (Na/K\u00a0ATPase) pumps. Loss of corneal endothelium led to edema and blurred vision at a cell density of about 500 cells/mm. Corneal edema in amantadine keratopathy frequently causes loss of visual acuity to 20/200 or hand motion. [2] [3] [4] [11] [12]", "contents": "Amantadine Keratopathy -- Pathophysiology. Amantadine causes permanent damage to the corneal endothelium and a decrease in corneal endothelial cell density by unknown mechanisms. [4] [11] [12] Bovine cornea cell cultures showed no signs of corneal endothelial cell apoptosis, although the duration of incubation may not have been sufficient to induce such a change. [13] Corneal endothelial cells are located in a monolayer posterior to Descemet's membrane and the stroma. These cells function to dehydrate and thus maintain the clarity of the cornea via sodium-potassium adenosine triphosphatase (Na/K\u00a0ATPase) pumps. Loss of corneal endothelium led to edema and blurred vision at a cell density of about 500 cells/mm. Corneal edema in amantadine keratopathy frequently causes loss of visual acuity to 20/200 or hand motion. [2] [3] [4] [11] [12]"}
+{"id": "article-100318_8", "title": "Amantadine Keratopathy -- Pathophysiology", "content": "Because damage to the corneal endothelium is permanent, edema may persist even after discontinuation of the drug, and a corneal transplant may be\u00a0necessary to restore vision. [12] The primary action of amantadine as a neurologic drug is through an indirect increase in extracellular dopamine by non-competitive inhibition of NMDA receptors. Recent case reports of corneal edema with a similar clinical picture have been attributed to memantine, a drug with similar structure and mechanism of action. [14] Amantadine also has several off-target effects that may contribute to corneal edema. [13] [15] In a study on bovine cornea cultures, amantadine was shown to inhibit K channels similar to the effect of the K channel blocker clotrimazole. Cells in cultures showed an increase in area and cell volume consistent with edema, and gap junctions between cells were disrupted. [13]", "contents": "Amantadine Keratopathy -- Pathophysiology. Because damage to the corneal endothelium is permanent, edema may persist even after discontinuation of the drug, and a corneal transplant may be\u00a0necessary to restore vision. [12] The primary action of amantadine as a neurologic drug is through an indirect increase in extracellular dopamine by non-competitive inhibition of NMDA receptors. Recent case reports of corneal edema with a similar clinical picture have been attributed to memantine, a drug with similar structure and mechanism of action. [14] Amantadine also has several off-target effects that may contribute to corneal edema. [13] [15] In a study on bovine cornea cultures, amantadine was shown to inhibit K channels similar to the effect of the K channel blocker clotrimazole. Cells in cultures showed an increase in area and cell volume consistent with edema, and gap junctions between cells were disrupted. [13]"}
+{"id": "article-100318_9", "title": "Amantadine Keratopathy -- Pathophysiology", "content": "Another recent case study showed that the dopaminergic agonists ropinirole, methylphenidate, and resiniferatoxin induced corneal edema with a similar clinical presentation to amantadine keratopathy. [15] Dopamine D1 receptors (DRD1) have been found on corneal endothelial cells, and dopamine sensitivity has been linked to decreased corneal transparency. Based on these studies, it is likely that acute corneal edema in amantadine keratopathy occurs secondary to interactions with multiple corneal endothelial cell receptors that ultimately disrupt intracellular fluid osmolarity and corneal endothelial cell organization. Damage to the endothelium has been measured by different parameters, including a decrease in endothelial cell density (ECD), a decrease in cell hexagonality (CH), and an increase in the coefficient of variation (CoV). [1] [4] [5]", "contents": "Amantadine Keratopathy -- Pathophysiology. Another recent case study showed that the dopaminergic agonists ropinirole, methylphenidate, and resiniferatoxin induced corneal edema with a similar clinical presentation to amantadine keratopathy. [15] Dopamine D1 receptors (DRD1) have been found on corneal endothelial cells, and dopamine sensitivity has been linked to decreased corneal transparency. Based on these studies, it is likely that acute corneal edema in amantadine keratopathy occurs secondary to interactions with multiple corneal endothelial cell receptors that ultimately disrupt intracellular fluid osmolarity and corneal endothelial cell organization. Damage to the endothelium has been measured by different parameters, including a decrease in endothelial cell density (ECD), a decrease in cell hexagonality (CH), and an increase in the coefficient of variation (CoV). [1] [4] [5]"}
+{"id": "article-100318_10", "title": "Amantadine Keratopathy -- Pathophysiology", "content": "Endothelial cell size variation (CoV) demonstrates that some endothelial cells are enlarging to fill gaps and compensate for the loss of surrounding endothelial cells. The percentage of hexagonal cells decreases in response to chemical, mechanical, or hypoxic stress. These parameters are frequently used as markers of endothelial cell viability and pre-operative risk in patients with intrinsic disease of corneal endothelium such as Fuchs endothelial corneal dystrophy (FECD). Corneal endothelium damage may be present in eyes without corneal edema or decreased visual acuity in patients on amantadine therapy. [1] [5] Regardless of whether or not keratopathy develops, endothelial cells do not regenerate after amantadine toxicity occurs. [4] [5] [11] It is likely that amantadine keratopathy occurs in a dose-dependent fashion, with significant variation among individuals in the concentration of amantadine that is ultimately present in the aqueous, even when the prescribed dose of amantadine is the same. [4] [6]", "contents": "Amantadine Keratopathy -- Pathophysiology. Endothelial cell size variation (CoV) demonstrates that some endothelial cells are enlarging to fill gaps and compensate for the loss of surrounding endothelial cells. The percentage of hexagonal cells decreases in response to chemical, mechanical, or hypoxic stress. These parameters are frequently used as markers of endothelial cell viability and pre-operative risk in patients with intrinsic disease of corneal endothelium such as Fuchs endothelial corneal dystrophy (FECD). Corneal endothelium damage may be present in eyes without corneal edema or decreased visual acuity in patients on amantadine therapy. [1] [5] Regardless of whether or not keratopathy develops, endothelial cells do not regenerate after amantadine toxicity occurs. [4] [5] [11] It is likely that amantadine keratopathy occurs in a dose-dependent fashion, with significant variation among individuals in the concentration of amantadine that is ultimately present in the aqueous, even when the prescribed dose of amantadine is the same. [4] [6]"}
+{"id": "article-100318_11", "title": "Amantadine Keratopathy -- History and Physical", "content": "In almost all case reports of amantadine keratopathy, the patient describes a sudden onset of painless, bilateral blurring of vision with progressive worsening in the following months. Many patients have a visual acuity of 20/200 or worse at the time of presentation to an ophthalmologist. This history in patients with no past ocular disease, and negative family history of ocular disease, should prompt an extensive workup of medical history and medication exposure. If a patient is taking amantadine, the duration and dosage of treatment should be determined to stratify the patient's risk of amantadine keratopathy. It is important to consider undiagnosed ocular pathologies that may be contributing to visual loss, as amantadine keratopathy is a very rare diagnosis with a nonspecific presentation.", "contents": "Amantadine Keratopathy -- History and Physical. In almost all case reports of amantadine keratopathy, the patient describes a sudden onset of painless, bilateral blurring of vision with progressive worsening in the following months. Many patients have a visual acuity of 20/200 or worse at the time of presentation to an ophthalmologist. This history in patients with no past ocular disease, and negative family history of ocular disease, should prompt an extensive workup of medical history and medication exposure. If a patient is taking amantadine, the duration and dosage of treatment should be determined to stratify the patient's risk of amantadine keratopathy. It is important to consider undiagnosed ocular pathologies that may be contributing to visual loss, as amantadine keratopathy is a very rare diagnosis with a nonspecific presentation."}
+{"id": "article-100318_12", "title": "Amantadine Keratopathy -- History and Physical", "content": "In a patient with vision loss taking amantadine, possible comorbid ocular pathologies should be ruled out by extensive slit lamp examination of the anterior segment, retina, and optic nerve. Slit-lamp examination of the cornea shows diffuse stromal edema with Descemet's folds and absent guttae. Microcystic epithelial edema and loosened epithelia have also been described.", "contents": "Amantadine Keratopathy -- History and Physical. In a patient with vision loss taking amantadine, possible comorbid ocular pathologies should be ruled out by extensive slit lamp examination of the anterior segment, retina, and optic nerve. Slit-lamp examination of the cornea shows diffuse stromal edema with Descemet's folds and absent guttae. Microcystic epithelial edema and loosened epithelia have also been described."}
+{"id": "article-100318_13", "title": "Amantadine Keratopathy -- Evaluation", "content": "Further studies, such as pachymetry, can be used to confirm the presence of corneal edema, monitor disease progression and resolution with discontinuation of amantadine. Specular microscopy studies can be performed to assess the extent of endothelial damage and ECD.", "contents": "Amantadine Keratopathy -- Evaluation. Further studies, such as pachymetry, can be used to confirm the presence of corneal edema, monitor disease progression and resolution with discontinuation of amantadine. Specular microscopy studies can be performed to assess the extent of endothelial damage and ECD."}
+{"id": "article-100318_14", "title": "Amantadine Keratopathy -- Treatment / Management", "content": "The majority of reported cases of amantadine keratopathy have shown complete resolution of corneal edema and visual acuity with discontinuation of amantadine. [2] [3] [4] [11] There have been a few reported cases where corneal edema did not resolve after discontinuation of amantadine. [7] [12] In these cases, visual acuity returned to normal following corneal transplant surgery. It is also possible that comorbid corneal pathologies may have caused further damage to the cornea, preventing the resolution of the disease even with discontinuation of therapy. [16] A more recent case report showed that a patient with a history of amantadine keratopathy was able to continue using the drug with topical steroids without recurrence of edema or a decrease in endothelial cell density. [17] Although topical steroids have not been shown to decrease corneal edema, they could be useful as a prophylactic measure in susceptible individuals.", "contents": "Amantadine Keratopathy -- Treatment / Management. The majority of reported cases of amantadine keratopathy have shown complete resolution of corneal edema and visual acuity with discontinuation of amantadine. [2] [3] [4] [11] There have been a few reported cases where corneal edema did not resolve after discontinuation of amantadine. [7] [12] In these cases, visual acuity returned to normal following corneal transplant surgery. It is also possible that comorbid corneal pathologies may have caused further damage to the cornea, preventing the resolution of the disease even with discontinuation of therapy. [16] A more recent case report showed that a patient with a history of amantadine keratopathy was able to continue using the drug with topical steroids without recurrence of edema or a decrease in endothelial cell density. [17] Although topical steroids have not been shown to decrease corneal edema, they could be useful as a prophylactic measure in susceptible individuals."}
+{"id": "article-100318_15", "title": "Amantadine Keratopathy -- Treatment / Management", "content": "Currently, there is little to no evidence to stratify a patient\u2019s risk of developing amantadine keratopathy. Decreased vision following initiation of treatment should undoubtedly prompt a referral to an ophthalmologist by the prescribing neurologist. Patients with a history of ocular trauma, ocular surgery, corneal or anterior segment disease, and possibly those of a certain age may necessitate a consultation by a corneal specialist prior to initiation of amantadine therapy. However, further research is needed to elucidate guidelines for such practice. Increased corneal backscatter on slit-lamp examination and CCT have been shown to have weak predictive value in the prognosis of FECD. [18] [19] It is unlikely that these data points would be helpful for ophthalmologists in evaluating patients before initiating amantadine therapy. Newer forms of analysis of the cornea, including Scheimpflug tomography, show significant promise in predicting the need for future interventions in FECD prior to the loss of visual acuity. [18] Scheimpflug tomography could be an effective screening method for amantadine keratopathy, although no research has been conducted on this topic.", "contents": "Amantadine Keratopathy -- Treatment / Management. Currently, there is little to no evidence to stratify a patient\u2019s risk of developing amantadine keratopathy. Decreased vision following initiation of treatment should undoubtedly prompt a referral to an ophthalmologist by the prescribing neurologist. Patients with a history of ocular trauma, ocular surgery, corneal or anterior segment disease, and possibly those of a certain age may necessitate a consultation by a corneal specialist prior to initiation of amantadine therapy. However, further research is needed to elucidate guidelines for such practice. Increased corneal backscatter on slit-lamp examination and CCT have been shown to have weak predictive value in the prognosis of FECD. [18] [19] It is unlikely that these data points would be helpful for ophthalmologists in evaluating patients before initiating amantadine therapy. Newer forms of analysis of the cornea, including Scheimpflug tomography, show significant promise in predicting the need for future interventions in FECD prior to the loss of visual acuity. [18] Scheimpflug tomography could be an effective screening method for amantadine keratopathy, although no research has been conducted on this topic."}
+{"id": "article-100318_16", "title": "Amantadine Keratopathy -- Differential Diagnosis", "content": "Fuchs endothelial dystrophy (FECD): Fuchs endothelial dystrophy has the most similar pathophysiology and presentation to amantadine keratopathy. Differentiating features include the presence of guttata on slit-lamp examination and persistence following discontinuation of amantadine.", "contents": "Amantadine Keratopathy -- Differential Diagnosis. Fuchs endothelial dystrophy (FECD): Fuchs endothelial dystrophy has the most similar pathophysiology and presentation to amantadine keratopathy. Differentiating features include the presence of guttata on slit-lamp examination and persistence following discontinuation of amantadine."}
+{"id": "article-100318_17", "title": "Amantadine Keratopathy -- Differential Diagnosis", "content": "Band keratopathy: Calcium deposition in the anterior stroma can look similar to the stomal edema associated with amantadine keratopathy, and the epidemiology is similar due to the age-related progression and association with chronic disease. Patients will generally have a sub-acute or chronic progression of corneal opacification as opposed to that in amantadine keratopathy, and there is an increased association with ocular comorbidities. Like FECD, band keratopathy will not resolve with discontinuation of amantadine.", "contents": "Amantadine Keratopathy -- Differential Diagnosis. Band keratopathy: Calcium deposition in the anterior stroma can look similar to the stomal edema associated with amantadine keratopathy, and the epidemiology is similar due to the age-related progression and association with chronic disease. Patients will generally have a sub-acute or chronic progression of corneal opacification as opposed to that in amantadine keratopathy, and there is an increased association with ocular comorbidities. Like FECD, band keratopathy will not resolve with discontinuation of amantadine."}
+{"id": "article-100318_18", "title": "Amantadine Keratopathy -- Prognosis", "content": "The majority of reported cases have shown a complete resolution of corneal edema and return of visual acuity to baseline upon discontinuation of amantadine, especially in those with no prior ocular history. In patients with an already decreased endothelial cell density, corneal transplant or Descemet membrane endothelial keratoplasty may be indicated.", "contents": "Amantadine Keratopathy -- Prognosis. The majority of reported cases have shown a complete resolution of corneal edema and return of visual acuity to baseline upon discontinuation of amantadine, especially in those with no prior ocular history. In patients with an already decreased endothelial cell density, corneal transplant or Descemet membrane endothelial keratoplasty may be indicated."}
+{"id": "article-100318_19", "title": "Amantadine Keratopathy -- Complications", "content": "Misdiagnosis could lead to unnecessary surgeries and medical interventions as well as significant distress for patients who fail to improve. Because amantadine keratopathy causes permanent damage to the corneal endothelium, failure to recognize this disease or individuals who are susceptible could lead to permanent loss of vision.", "contents": "Amantadine Keratopathy -- Complications. Misdiagnosis could lead to unnecessary surgeries and medical interventions as well as significant distress for patients who fail to improve. Because amantadine keratopathy causes permanent damage to the corneal endothelium, failure to recognize this disease or individuals who are susceptible could lead to permanent loss of vision."}
+{"id": "article-100318_20", "title": "Amantadine Keratopathy -- Deterrence and Patient Education", "content": "Amantadine keratopathy is swelling of the cornea secondary to damage of cells responsible for keeping the cornea deturgescent and transparent. Although the damage is irreversible, the swelling usually resolves with discontinuation of the drug. If symptoms that were previously controlled with amantadine therapy worsen with discontinuation, the neurologist and ophthalmologist need to discuss how to optimize the patient's therapy.", "contents": "Amantadine Keratopathy -- Deterrence and Patient Education. Amantadine keratopathy is swelling of the cornea secondary to damage of cells responsible for keeping the cornea deturgescent and transparent. Although the damage is irreversible, the swelling usually resolves with discontinuation of the drug. If symptoms that were previously controlled with amantadine therapy worsen with discontinuation, the neurologist and ophthalmologist need to discuss how to optimize the patient's therapy."}
+{"id": "article-100318_21", "title": "Amantadine Keratopathy -- Enhancing Healthcare Team Outcomes", "content": "Greater awareness of keratopathy as an adverse effect of amantadine therapy is needed by the interprofessional team that cares for patients with neurodegenerative or neurocognitive disorders. This team includes neurologists, ophthalmologists, and primary care\u00a0clinicians. Ophthalmologists should understand the pathophysiology of amantadine keratopathy and the irreversible damage to corneal endothelium associated with it. Because medications prescribed by neurodegenerative and neurocognitive disease specialists have an extensive profile of adverse reactions, increased diligence in the review of medications may be necessary for these patients. Nurses and\u00a0pharmacists can help in identifying this disease by extensively screening patients' past medical history and medications list. The prevalence, risk factors, and complications of amantadine keratopathy remain largely unknown and serve as a possible topic of future research.", "contents": "Amantadine Keratopathy -- Enhancing Healthcare Team Outcomes. Greater awareness of keratopathy as an adverse effect of amantadine therapy is needed by the interprofessional team that cares for patients with neurodegenerative or neurocognitive disorders. This team includes neurologists, ophthalmologists, and primary care\u00a0clinicians. Ophthalmologists should understand the pathophysiology of amantadine keratopathy and the irreversible damage to corneal endothelium associated with it. Because medications prescribed by neurodegenerative and neurocognitive disease specialists have an extensive profile of adverse reactions, increased diligence in the review of medications may be necessary for these patients. Nurses and\u00a0pharmacists can help in identifying this disease by extensively screening patients' past medical history and medications list. The prevalence, risk factors, and complications of amantadine keratopathy remain largely unknown and serve as a possible topic of future research."}
+{"id": "article-100318_22", "title": "Amantadine Keratopathy -- Review Questions", "content": "Access free multiple choice questions on this topic. Click here for a simplified version. Comment on this article.", "contents": "Amantadine Keratopathy -- Review Questions. Access free multiple choice questions on this topic. Click here for a simplified version. Comment on this article."}

statpearls/chunk/article-100323.jsonl

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+{"id": "article-100323_0", "title": "Stable Angina -- Continuing Education Activity", "content": "Angina affects 10 million people in the United States. Providers must be able to differentiate between stable angina and other causes of chest pain to care for their patients appropriately. The recognition and appropriate management of stable angina is critical in reducing the risks of future myocardial infarction. This activity highlights an interprofessional team's diagnosis, evaluation, and management of stable angina.", "contents": "Stable Angina -- Continuing Education Activity. Angina affects 10 million people in the United States. Providers must be able to differentiate between stable angina and other causes of chest pain to care for their patients appropriately. The recognition and appropriate management of stable angina is critical in reducing the risks of future myocardial infarction. This activity highlights an interprofessional team's diagnosis, evaluation, and management of stable angina."}
+{"id": "article-100323_1", "title": "Stable Angina -- Continuing Education Activity", "content": "Objectives: Identify and appropriately diagnose stable angina. Determine the\u00a0pathophysiology behind myocardial ischemia to assist in treatment options. Identify and manage risk factors to decrease mortality risk with coronary heart disease. Communicate\u00a0the importance of utilizing an interdisciplinary approach with individuals who have stable angina and multiple comorbidities in order to optimize outcomes. Access free multiple choice questions on this topic.", "contents": "Stable Angina -- Continuing Education Activity. Objectives: Identify and appropriately diagnose stable angina. Determine the\u00a0pathophysiology behind myocardial ischemia to assist in treatment options. Identify and manage risk factors to decrease mortality risk with coronary heart disease. Communicate\u00a0the importance of utilizing an interdisciplinary approach with individuals who have stable angina and multiple comorbidities in order to optimize outcomes. Access free multiple choice questions on this topic."}
+{"id": "article-100323_2", "title": "Stable Angina -- Introduction", "content": "Stable angina, also known as typical angina or angina pectoris, is a symptom of myocardial ischemia. Stable angina is characterized by chest discomfort or anginal equivalent that is provoked with exertion and alleviated at rest or with nitroglycerin. This is often\u00a01 of the first manifestations or warning signs of underlying coronary disease. Angina affects 10 million people in the United States (US); given this, it is important to recognize the signs and symptoms and appropriately risk stratify and manage these individuals. [1]", "contents": "Stable Angina -- Introduction. Stable angina, also known as typical angina or angina pectoris, is a symptom of myocardial ischemia. Stable angina is characterized by chest discomfort or anginal equivalent that is provoked with exertion and alleviated at rest or with nitroglycerin. This is often\u00a01 of the first manifestations or warning signs of underlying coronary disease. Angina affects 10 million people in the United States (US); given this, it is important to recognize the signs and symptoms and appropriately risk stratify and manage these individuals. [1]"}
+{"id": "article-100323_3", "title": "Stable Angina -- Etiology", "content": "The mechanism behind stable angina is the result of a supply-demand mismatch. The myocardial oxygen demand transiently exceeds the myocardial oxygen supply, often leading to symptoms. Several factors contribute to stable angina; the most common etiology is coronary artery stenosis. This is further discussed below in the section titled \u2018Pathophysiology.\u2019 [2]", "contents": "Stable Angina -- Etiology. The mechanism behind stable angina is the result of a supply-demand mismatch. The myocardial oxygen demand transiently exceeds the myocardial oxygen supply, often leading to symptoms. Several factors contribute to stable angina; the most common etiology is coronary artery stenosis. This is further discussed below in the section titled \u2018Pathophysiology.\u2019 [2]"}
+{"id": "article-100323_4", "title": "Stable Angina -- Epidemiology", "content": "Coronary\u00a0heart disease impacts over 17 million\u00a0adults\u00a0in the United States. Of the\u00a017 million Americans affected, 55% of those are male. It contributes to over 500,000 deaths each year in the US. At age 40 years, the lifetime risk of developing coronary disease is estimated at 49% for men and 32% for women. The\u00a0incidence\u00a0of coronary events\u00a0increases\u00a0with age, although the male predominance of these events gradually narrows with advancing age. [3] Coronary\u00a0heart\u00a0disease/ischemic heart disease is not unique to the US; it is the leading cause of death in adults from low, middle, and high-income countries. [4]", "contents": "Stable Angina -- Epidemiology. Coronary\u00a0heart disease impacts over 17 million\u00a0adults\u00a0in the United States. Of the\u00a017 million Americans affected, 55% of those are male. It contributes to over 500,000 deaths each year in the US. At age 40 years, the lifetime risk of developing coronary disease is estimated at 49% for men and 32% for women. The\u00a0incidence\u00a0of coronary events\u00a0increases\u00a0with age, although the male predominance of these events gradually narrows with advancing age. [3] Coronary\u00a0heart\u00a0disease/ischemic heart disease is not unique to the US; it is the leading cause of death in adults from low, middle, and high-income countries. [4]"}
+{"id": "article-100323_5", "title": "Stable Angina -- Epidemiology", "content": "Coronary\u00a0heart disease can also cause significant debility. This debility can manifest in several ways,\u00a01 of which is angina. Angina affects over 10 million people in the US, with over 500,000 new cases diagnosed each year. [1] [3]", "contents": "Stable Angina -- Epidemiology. Coronary\u00a0heart disease can also cause significant debility. This debility can manifest in several ways,\u00a01 of which is angina. Angina affects over 10 million people in the US, with over 500,000 new cases diagnosed each year. [1] [3]"}
+{"id": "article-100323_6", "title": "Stable Angina -- Pathophysiology", "content": "Simply put, angina results from an imbalance between the myocardial oxygen supply and the myocardial oxygen demand. Understanding the factors that contribute to each of these measures is important.", "contents": "Stable Angina -- Pathophysiology. Simply put, angina results from an imbalance between the myocardial oxygen supply and the myocardial oxygen demand. Understanding the factors that contribute to each of these measures is important."}
+{"id": "article-100323_7", "title": "Stable Angina -- Pathophysiology", "content": "Endothelial cells line the coronary arteries, regulate vascular tone, and prevent intravascular thrombosis. Any disruption in these\u00a02 functions can lead to coronary\u00a0heart disease. Multiple mechanisms can result in injury or impairment of the endothelial lining. These mechanisms include, but are not limited to, stress, hypertension, hypercholesterolemia, viruses, bacteria, and immune complexes. Endothelial injury triggers an immune response, leading to fibrous tissue formation. Smooth muscle remodeling/fibrous caps can lead to coronary artery stenosis or even acute coronary syndrome.", "contents": "Stable Angina -- Pathophysiology. Endothelial cells line the coronary arteries, regulate vascular tone, and prevent intravascular thrombosis. Any disruption in these\u00a02 functions can lead to coronary\u00a0heart disease. Multiple mechanisms can result in injury or impairment of the endothelial lining. These mechanisms include, but are not limited to, stress, hypertension, hypercholesterolemia, viruses, bacteria, and immune complexes. Endothelial injury triggers an immune response, leading to fibrous tissue formation. Smooth muscle remodeling/fibrous caps can lead to coronary artery stenosis or even acute coronary syndrome."}
+{"id": "article-100323_8", "title": "Stable Angina -- Pathophysiology", "content": "Coronary artery stenosis is the most common cause of myocardial ischemia. During increased myocardial oxygen demand, the stenosis prevents adequate myocardial oxygen supply. Four main factors contribute to oxygen demand: heart rate, systolic blood pressure, myocardial wall tension, and myocardial contractility. In states of increased demand such as illness, stress, and exercise \u2013 we rely on the body\u2019s ability to up-regulate myocardial oxygen supply appropriately.", "contents": "Stable Angina -- Pathophysiology. Coronary artery stenosis is the most common cause of myocardial ischemia. During increased myocardial oxygen demand, the stenosis prevents adequate myocardial oxygen supply. Four main factors contribute to oxygen demand: heart rate, systolic blood pressure, myocardial wall tension, and myocardial contractility. In states of increased demand such as illness, stress, and exercise \u2013 we rely on the body\u2019s ability to up-regulate myocardial oxygen supply appropriately."}
+{"id": "article-100323_9", "title": "Stable Angina -- Pathophysiology", "content": "The\u00a04 main factors contributing to myocardial oxygen supply are coronary artery diameter and tone, collateral blood flow, perfusion pressure, and heart rate. While coronary artery stenosis is the most common, other conditions can lead to a decreased myocardial oxygen supply. These examples include but are not limited to, coronary artery vasospasm, embolism, dissection, and micro-vascular disease. [2] [5] [6]", "contents": "Stable Angina -- Pathophysiology. The\u00a04 main factors contributing to myocardial oxygen supply are coronary artery diameter and tone, collateral blood flow, perfusion pressure, and heart rate. While coronary artery stenosis is the most common, other conditions can lead to a decreased myocardial oxygen supply. These examples include but are not limited to, coronary artery vasospasm, embolism, dissection, and micro-vascular disease. [2] [5] [6]"}
+{"id": "article-100323_10", "title": "Stable Angina -- Pathophysiology", "content": "When the myocardial oxygen demand exceeds the myocardial oxygen supply, this often manifests with symptoms. Myocardial ischemia stimulates chemosensitive and mechanoreceptive receptors within the cardiac muscle fibers and surrounding the coronary vessels.\u00a0The activation of these receptors triggers impulses through the sympathetic afferent pathways from the heart to the cervical and thoracic spine. Each spinal level has a corresponding dermatome; the discomfort described by the patient often follows the specific dermatomal pattern. [7] [8] It is important to conduct a thorough workup and evaluation to determine the cause of angina in each individual; understanding the etiology allows for medical optimization and appropriate management of risk factors.", "contents": "Stable Angina -- Pathophysiology. When the myocardial oxygen demand exceeds the myocardial oxygen supply, this often manifests with symptoms. Myocardial ischemia stimulates chemosensitive and mechanoreceptive receptors within the cardiac muscle fibers and surrounding the coronary vessels.\u00a0The activation of these receptors triggers impulses through the sympathetic afferent pathways from the heart to the cervical and thoracic spine. Each spinal level has a corresponding dermatome; the discomfort described by the patient often follows the specific dermatomal pattern. [7] [8] It is important to conduct a thorough workup and evaluation to determine the cause of angina in each individual; understanding the etiology allows for medical optimization and appropriate management of risk factors."}
+{"id": "article-100323_11", "title": "Stable Angina -- History and Physical", "content": "Individuals with stable angina often have a subacute versus chronic presentation. It is important to use history and physical as a screening tool to identify high-risk individuals. Routine screening of blood pressure, weight, sleep habits, stress, exercise tolerance, tobacco, alcohol, and illicit drug use should be incorporated.", "contents": "Stable Angina -- History and Physical. Individuals with stable angina often have a subacute versus chronic presentation. It is important to use history and physical as a screening tool to identify high-risk individuals. Routine screening of blood pressure, weight, sleep habits, stress, exercise tolerance, tobacco, alcohol, and illicit drug use should be incorporated."}
+{"id": "article-100323_12", "title": "Stable Angina -- History and Physical", "content": "As previously mentioned, typical angina usually presents as chest discomfort or an anginal equivalent provoked by exertion and alleviated at rest or with nitroglycerin. Anginal equivalents vary, but they are commonly described as shortness of breath, nausea, or fatigue disproportionate to the activity level.", "contents": "Stable Angina -- History and Physical. As previously mentioned, typical angina usually presents as chest discomfort or an anginal equivalent provoked by exertion and alleviated at rest or with nitroglycerin. Anginal equivalents vary, but they are commonly described as shortness of breath, nausea, or fatigue disproportionate to the activity level."}
+{"id": "article-100323_13", "title": "Stable Angina -- History and Physical", "content": "It is important to distinguish between cardiac and non-cardiac chest discomfort. Discussing the details of the patient\u2019s symptoms further guide this differentiation. Relevant details include the pain's quality, location, influencing factors, timing, and duration. [9]", "contents": "Stable Angina -- History and Physical. It is important to distinguish between cardiac and non-cardiac chest discomfort. Discussing the details of the patient\u2019s symptoms further guide this differentiation. Relevant details include the pain's quality, location, influencing factors, timing, and duration. [9]"}
+{"id": "article-100323_14", "title": "Stable Angina -- History and Physical", "content": "Typical angina is often described as pressure-like, heaviness, tightness, or squeezing. It most commonly affects a broad area of the chest rather than a specific spot. There may be radiation of the pain, depending on which dermatomes are affected. [10] [11] Symptoms\u00a0are described as more severe with increased demand (ie, walking, lifting, emotional stress, etc). Symptoms generally last 2 to\u00a05 minutes, and relief is experienced when the provoking activity is stopped or the patient takes nitroglycerin. [9] The physical exam is most commonly unremarkable. In the setting of typical angina, you would not expect active ischemia,\u00a0leading to nonspecific physical exam findings.", "contents": "Stable Angina -- History and Physical. Typical angina is often described as pressure-like, heaviness, tightness, or squeezing. It most commonly affects a broad area of the chest rather than a specific spot. There may be radiation of the pain, depending on which dermatomes are affected. [10] [11] Symptoms\u00a0are described as more severe with increased demand (ie, walking, lifting, emotional stress, etc). Symptoms generally last 2 to\u00a05 minutes, and relief is experienced when the provoking activity is stopped or the patient takes nitroglycerin. [9] The physical exam is most commonly unremarkable. In the setting of typical angina, you would not expect active ischemia,\u00a0leading to nonspecific physical exam findings."}
+{"id": "article-100323_15", "title": "Stable Angina -- Evaluation", "content": "The evaluation of stable\u00a0angina includes: Obtain an electrocardiogram to evaluate for active ischemia or evidence of previous infarction. Obtain a chest x-ray to assist in ruling out noncardiac explanations for chest pain (ie, infection, trauma, pneumothorax, etc) Obtain\u00a0a complete blood count, comprehensive metabolic panel, lipid panel, and troponin. Lab work\u00a0is important in risk stratification and ruling out noncardiac explanations (ie, anemia, infection, renal disease, etc) Use previous work up to risk stratify, consider stress testing versus further coronary evaluation in moderate to high-risk individuals.", "contents": "Stable Angina -- Evaluation. The evaluation of stable\u00a0angina includes: Obtain an electrocardiogram to evaluate for active ischemia or evidence of previous infarction. Obtain a chest x-ray to assist in ruling out noncardiac explanations for chest pain (ie, infection, trauma, pneumothorax, etc) Obtain\u00a0a complete blood count, comprehensive metabolic panel, lipid panel, and troponin. Lab work\u00a0is important in risk stratification and ruling out noncardiac explanations (ie, anemia, infection, renal disease, etc) Use previous work up to risk stratify, consider stress testing versus further coronary evaluation in moderate to high-risk individuals."}
+{"id": "article-100323_16", "title": "Stable Angina -- Treatment / Management", "content": "Treatment for stable angina is geared toward reducing risk factors for presumed underlying coronary heart disease.\u00a0An interdisciplinary approach\u00a0would likely benefit\u00a0individuals\u00a0with multiple comorbidities: nutrition, diabetic educator, addiction counselor, and physical and occupational therapy.", "contents": "Stable Angina -- Treatment / Management. Treatment for stable angina is geared toward reducing risk factors for presumed underlying coronary heart disease.\u00a0An interdisciplinary approach\u00a0would likely benefit\u00a0individuals\u00a0with multiple comorbidities: nutrition, diabetic educator, addiction counselor, and physical and occupational therapy."}
+{"id": "article-100323_17", "title": "Stable Angina -- Treatment / Management -- First-line Treatment Includes Lifestyle Modifications", "content": "Tobacco cessation results in the biggest risk reduction. Cigarette smoking is the leading avoidable cause of premature death. The risk of cardiovascular mortality in current smokers is roughly\u00a02 times that of nonsmokers. Interestingly enough, the risk of cardiovascular mortality in former smokers is roughly equal to that\u00a0of\u00a0individuals who have never smoked. That said, it is imperative to continuously encourage smoking cessation regardless of age or duration of smoking history [12]", "contents": "Stable Angina -- Treatment / Management -- First-line Treatment Includes Lifestyle Modifications. Tobacco cessation results in the biggest risk reduction. Cigarette smoking is the leading avoidable cause of premature death. The risk of cardiovascular mortality in current smokers is roughly\u00a02 times that of nonsmokers. Interestingly enough, the risk of cardiovascular mortality in former smokers is roughly equal to that\u00a0of\u00a0individuals who have never smoked. That said, it is imperative to continuously encourage smoking cessation regardless of age or duration of smoking history [12]"}
+{"id": "article-100323_18", "title": "Stable Angina -- Treatment / Management -- First-line Treatment Includes Lifestyle Modifications", "content": "Cholesterol reduction Evidence has supported that adherence to the Mediterranean diet (high in vegetables and fruits) reduces the risk of cardiovascular disease. [13]", "contents": "Stable Angina -- Treatment / Management -- First-line Treatment Includes Lifestyle Modifications. Cholesterol reduction Evidence has supported that adherence to the Mediterranean diet (high in vegetables and fruits) reduces the risk of cardiovascular disease. [13]"}
+{"id": "article-100323_19", "title": "Stable Angina -- Treatment / Management -- First-line Treatment Includes Lifestyle Modifications", "content": "Blood pressure control The 2017 AHA/ACC guidelines define hypertension as systolic blood pressure\u00a0\u2265130 mmHg or diastolic pressure \u226580 mmHg. [14] Goal blood pressure\u00a0is unique to each patient; however, it is important to remember that for each 20/10 mmHg increase in systolic/diastolic blood pressure, evidence has supported a 2-fold increased risk of coronary heart and stroke-related mortality. [15]", "contents": "Stable Angina -- Treatment / Management -- First-line Treatment Includes Lifestyle Modifications. Blood pressure control The 2017 AHA/ACC guidelines define hypertension as systolic blood pressure\u00a0\u2265130 mmHg or diastolic pressure \u226580 mmHg. [14] Goal blood pressure\u00a0is unique to each patient; however, it is important to remember that for each 20/10 mmHg increase in systolic/diastolic blood pressure, evidence has supported a 2-fold increased risk of coronary heart and stroke-related mortality. [15]"}
+{"id": "article-100323_20", "title": "Stable Angina -- Treatment / Management -- First-line Treatment Includes Lifestyle Modifications", "content": "Diabetes mellitus management Weight reduction, increased physical activity, and adequate control of comorbidities are recommended. [16]", "contents": "Stable Angina -- Treatment / Management -- First-line Treatment Includes Lifestyle Modifications. Diabetes mellitus management Weight reduction, increased physical activity, and adequate control of comorbidities are recommended. [16]"}
+{"id": "article-100323_21", "title": "Stable Angina -- Treatment / Management -- First-line Treatment Includes Lifestyle Modifications", "content": "Weight loss Obesity is the second leading modifiable cause of premature death. [17] Weight-loss regimens should be catered to each patient, and the discussion should include lifestyle modifications and surgical options if appropriate.", "contents": "Stable Angina -- Treatment / Management -- First-line Treatment Includes Lifestyle Modifications. Weight loss Obesity is the second leading modifiable cause of premature death. [17] Weight-loss regimens should be catered to each patient, and the discussion should include lifestyle modifications and surgical options if appropriate."}
+{"id": "article-100323_22", "title": "Stable Angina -- Treatment / Management -- First-line Treatment Includes Lifestyle Modifications", "content": "Aerobic exercise An average of 150 minutes of moderate-intensity\u00a0exercise per week or 75 minutes of high-intensity exercise per week has been shown to decrease overall cardiac risk factors and, in turn, the risk of coronary heart disease. [18]", "contents": "Stable Angina -- Treatment / Management -- First-line Treatment Includes Lifestyle Modifications. Aerobic exercise An average of 150 minutes of moderate-intensity\u00a0exercise per week or 75 minutes of high-intensity exercise per week has been shown to decrease overall cardiac risk factors and, in turn, the risk of coronary heart disease. [18]"}
+{"id": "article-100323_23", "title": "Stable Angina -- Treatment / Management", "content": "Pharmacologic", "contents": "Stable Angina -- Treatment / Management. Pharmacologic"}
+{"id": "article-100323_24", "title": "Stable Angina -- Treatment / Management", "content": "Aspirin: Determine the risk of coronary heart disease in each patient. In low-risk individuals, the use of aspirin for primary prevention decreases the risk of nonfatal MI without benefit in all-cause mortality and nonfatal stroke. [19] Risk stratification is important as the use of aspirin comes with an increased risk of major bleeding. [20] Extracranial bleeding is the most common, however daily low-dose aspirin does increase the risk of intracranial hemorrhage as well. [21] As there is no evidence to support a mortality benefit for the use of aspirin in low-risk individuals, the risk of bleeding may outweigh the anticipated benefit. This should be decided on a case-by-case basis. High-risk individuals or individuals with known cardiovascular disease benefit from\u00a0low-dose daily aspirin. According to the meta-analysis performed by the Antithrombotic Trialists' Collaboration, daily aspirin significantly reduced the risk of nonfatal MI, nonfatal stroke, and vascular death by 22%. [22]", "contents": "Stable Angina -- Treatment / Management. Aspirin: Determine the risk of coronary heart disease in each patient. In low-risk individuals, the use of aspirin for primary prevention decreases the risk of nonfatal MI without benefit in all-cause mortality and nonfatal stroke. [19] Risk stratification is important as the use of aspirin comes with an increased risk of major bleeding. [20] Extracranial bleeding is the most common, however daily low-dose aspirin does increase the risk of intracranial hemorrhage as well. [21] As there is no evidence to support a mortality benefit for the use of aspirin in low-risk individuals, the risk of bleeding may outweigh the anticipated benefit. This should be decided on a case-by-case basis. High-risk individuals or individuals with known cardiovascular disease benefit from\u00a0low-dose daily aspirin. According to the meta-analysis performed by the Antithrombotic Trialists' Collaboration, daily aspirin significantly reduced the risk of nonfatal MI, nonfatal stroke, and vascular death by 22%. [22]"}
+{"id": "article-100323_25", "title": "Stable Angina -- Treatment / Management", "content": "HMG-CoA reductase inhibitor: Statin therapy in high, moderate, and low-risk primary prevention subjects without clinical evidence of coronary disease has demonstrated a reduction in myocardial infarction, stroke, cardiovascular death, and total mortality. [23]", "contents": "Stable Angina -- Treatment / Management. HMG-CoA reductase inhibitor: Statin therapy in high, moderate, and low-risk primary prevention subjects without clinical evidence of coronary disease has demonstrated a reduction in myocardial infarction, stroke, cardiovascular death, and total mortality. [23]"}
+{"id": "article-100323_26", "title": "Stable Angina -- Treatment / Management", "content": "ACE-inhibitor/angiotensin receptor blocker (ARB): It may be used in primary prevention to assist in blood pressure control and is recommended in the setting of high-risk individuals or known cardiovascular disease for cardioprotective efforts. The use of ACE inhibitors or ARBs in high-risk individuals has been shown to reduce the risk of cardiovascular and all-cause mortality. [24]", "contents": "Stable Angina -- Treatment / Management. ACE-inhibitor/angiotensin receptor blocker (ARB): It may be used in primary prevention to assist in blood pressure control and is recommended in the setting of high-risk individuals or known cardiovascular disease for cardioprotective efforts. The use of ACE inhibitors or ARBs in high-risk individuals has been shown to reduce the risk of cardiovascular and all-cause mortality. [24]"}
+{"id": "article-100323_27", "title": "Stable Angina -- Treatment / Management", "content": "Symptom Control Beta-blockers: Beta-blockers\u00a0have been shown to decrease heart rate, blood pressure, and contractility, leading to decreased myocardial oxygen demand and decreased anginal\u00a0symptoms. [25] Nitrates: Nitrates relax vascular smooth muscle, leading to dilation of veins primarily; this decreases cardiac preload and, in turn, decreases myocardial oxygen demand, relieving anginal symptoms. [26] Ranolazine: The mechanism of action of this medication is not entirely understood; however, it is FDA-approved for symptom control in stable angina. [27]", "contents": "Stable Angina -- Treatment / Management. Symptom Control Beta-blockers: Beta-blockers\u00a0have been shown to decrease heart rate, blood pressure, and contractility, leading to decreased myocardial oxygen demand and decreased anginal\u00a0symptoms. [25] Nitrates: Nitrates relax vascular smooth muscle, leading to dilation of veins primarily; this decreases cardiac preload and, in turn, decreases myocardial oxygen demand, relieving anginal symptoms. [26] Ranolazine: The mechanism of action of this medication is not entirely understood; however, it is FDA-approved for symptom control in stable angina. [27]"}
+{"id": "article-100323_28", "title": "Stable Angina -- Differential Diagnosis", "content": "Below are several important differential diagnoses to consider (see Image. Types of Angina in the Coronary Artery). Brief details are listed next to each diagnosis to help differentiate from stable angina. Please reference their designated topics for specific details and diagnostic criteria for each differential diagnosis.", "contents": "Stable Angina -- Differential Diagnosis. Below are several important differential diagnoses to consider (see Image. Types of Angina in the Coronary Artery). Brief details are listed next to each diagnosis to help differentiate from stable angina. Please reference their designated topics for specific details and diagnostic criteria for each differential diagnosis."}
+{"id": "article-100323_29", "title": "Stable Angina -- Differential Diagnosis -- Cardiovascular", "content": "Acute coronary syndrome Unstable angina: Detailed history is pertinent.\u00a0Chest pain is less likely to follow a predictable pattern, and the patient may even experience chest pain at rest. NSTEMI: Elevated cardiac enzymes with or without EKG changes. STEMI: Elevated cardiac enzymes with regional\u00a0ST elevations were noted on the EKG. Myocarditis:\u00a0Elevated cardiac enzymes with EKG changes. Pericarditis: Diffuse ST elevations noted on EKG with or without an elevation in cardiac enzymes. Chest pain is pleuritic and\u00a0is often relieved by leaning forward.", "contents": "Stable Angina -- Differential Diagnosis -- Cardiovascular. Acute coronary syndrome Unstable angina: Detailed history is pertinent.\u00a0Chest pain is less likely to follow a predictable pattern, and the patient may even experience chest pain at rest. NSTEMI: Elevated cardiac enzymes with or without EKG changes. STEMI: Elevated cardiac enzymes with regional\u00a0ST elevations were noted on the EKG. Myocarditis:\u00a0Elevated cardiac enzymes with EKG changes. Pericarditis: Diffuse ST elevations noted on EKG with or without an elevation in cardiac enzymes. Chest pain is pleuritic and\u00a0is often relieved by leaning forward."}
+{"id": "article-100323_30", "title": "Stable Angina -- Differential Diagnosis -- Gastrointestinal", "content": "Esophageal spasm:\u00a0Temporal relationship to meals with or without dysphagia Gastroesophageal reflux disease:\u00a0Temporal relationship to meals", "contents": "Stable Angina -- Differential Diagnosis -- Gastrointestinal. Esophageal spasm:\u00a0Temporal relationship to meals with or without dysphagia Gastroesophageal reflux disease:\u00a0Temporal relationship to meals"}
+{"id": "article-100323_31", "title": "Stable Angina -- Differential Diagnosis -- Pulmonary", "content": "Asthma: Abnormal lung sounds are expected on the exam. Anticipate improvement in symptoms with pulmonary hygiene and inhaled beta-agonists. Chronic obstructive pulmonary disease:\u00a0Abnormal lung sounds are expected on the exam. Anticipate improvement in symptoms with pulmonary hygiene and inhaled beta-agonists. Pulmonary embolus: Chest pain pleuritic in nature. Typically, the presentation includes tachycardia and hypoxemia.", "contents": "Stable Angina -- Differential Diagnosis -- Pulmonary. Asthma: Abnormal lung sounds are expected on the exam. Anticipate improvement in symptoms with pulmonary hygiene and inhaled beta-agonists. Chronic obstructive pulmonary disease:\u00a0Abnormal lung sounds are expected on the exam. Anticipate improvement in symptoms with pulmonary hygiene and inhaled beta-agonists. Pulmonary embolus: Chest pain pleuritic in nature. Typically, the presentation includes tachycardia and hypoxemia."}
+{"id": "article-100323_32", "title": "Stable Angina -- Differential Diagnosis -- Musculoskeletal", "content": "Costochondritis: Chest pain reproducible on the exam. History often reveals recent heavy lifting or exercise. Trauma: History reveals the mechanism of trauma. Imaging may reveal fractures.", "contents": "Stable Angina -- Differential Diagnosis -- Musculoskeletal. Costochondritis: Chest pain reproducible on the exam. History often reveals recent heavy lifting or exercise. Trauma: History reveals the mechanism of trauma. Imaging may reveal fractures."}
+{"id": "article-100323_33", "title": "Stable Angina -- Prognosis", "content": "The prognosis varies depending on the etiology of stable angina. Regardless of the etiology, aggressive risk factor modification is imperative. In\u00a0individuals with stable angina, screening for increased frequency of symptoms or transition to unstable angina should be routinely performed.", "contents": "Stable Angina -- Prognosis. The prognosis varies depending on the etiology of stable angina. Regardless of the etiology, aggressive risk factor modification is imperative. In\u00a0individuals with stable angina, screening for increased frequency of symptoms or transition to unstable angina should be routinely performed."}
+{"id": "article-100323_34", "title": "Stable Angina -- Complications", "content": "The most important complication of stable angina is\u00a0the possibility of\u00a0progression to acute coronary syndrome. Risk factor modification and medical optimization should be utilized to decrease risk. These individuals require routine monitoring and attentive primary care providers.", "contents": "Stable Angina -- Complications. The most important complication of stable angina is\u00a0the possibility of\u00a0progression to acute coronary syndrome. Risk factor modification and medical optimization should be utilized to decrease risk. These individuals require routine monitoring and attentive primary care providers."}
+{"id": "article-100323_35", "title": "Stable Angina -- Deterrence and Patient Education", "content": "Coronary heart disease is the leading cause of death in the United States, and efforts to educate the public regarding signs and symptoms of myocardial infarction, unstable angina, and stable angina should be continued. Efforts to educate the public regarding preventative measures such as risk factor modification and lifestyle modifications should also be a priority.", "contents": "Stable Angina -- Deterrence and Patient Education. Coronary heart disease is the leading cause of death in the United States, and efforts to educate the public regarding signs and symptoms of myocardial infarction, unstable angina, and stable angina should be continued. Efforts to educate the public regarding preventative measures such as risk factor modification and lifestyle modifications should also be a priority."}
+{"id": "article-100323_36", "title": "Stable Angina -- Enhancing Healthcare Team Outcomes", "content": "Typical angina affects over 10 million people in the United States. The presentation can vary from chest pressure to fatigue, shortness of breath, and nausea. If this ultimately leads to myocardial infarction or unstable angina, the cardiology team is imperative in treatment; however, there are often many providers that see this individual before that evolution. It is important to utilize an interprofessional team to suit each patient best. The primary care provider plays a large role in primary and secondary prevention, likely for many years before the development of symptoms. This provider may also recruit the help of a nutritionist, diabetic educator, addiction counselor, and physical and occupational therapist to help modify risk factors. The use of an interdisciplinary team is recommended to optimize patient outcomes.", "contents": "Stable Angina -- Enhancing Healthcare Team Outcomes. Typical angina affects over 10 million people in the United States. The presentation can vary from chest pressure to fatigue, shortness of breath, and nausea. If this ultimately leads to myocardial infarction or unstable angina, the cardiology team is imperative in treatment; however, there are often many providers that see this individual before that evolution. It is important to utilize an interprofessional team to suit each patient best. The primary care provider plays a large role in primary and secondary prevention, likely for many years before the development of symptoms. This provider may also recruit the help of a nutritionist, diabetic educator, addiction counselor, and physical and occupational therapist to help modify risk factors. The use of an interdisciplinary team is recommended to optimize patient outcomes."}
+{"id": "article-100323_37", "title": "Stable Angina -- Review Questions", "content": "Access free multiple choice questions on this topic. Click here for a simplified version. Comment on this article.", "contents": "Stable Angina -- Review Questions. Access free multiple choice questions on this topic. Click here for a simplified version. Comment on this article."}

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+{"id": "article-100456_0", "title": "Pattern Electroretinogram -- Continuing Education Activity", "content": "The pattern electroretinogram (PERG) is a specialized electrophysiologic test of central retinal function in response to a pattern reversing stimulus. There are standard protocols for eliciting the retinal electrical response. The PERG is a valuable diagnostic tool that can aid providers in determining a correct diagnosis in patients with retinal disease beyond standard clinical examination capabilities. This activity reviews the PERG procedure and technique and highlights the role of the interprofessional team in evaluating and improving care for patients using this procedure.", "contents": "Pattern Electroretinogram -- Continuing Education Activity. The pattern electroretinogram (PERG) is a specialized electrophysiologic test of central retinal function in response to a pattern reversing stimulus. There are standard protocols for eliciting the retinal electrical response. The PERG is a valuable diagnostic tool that can aid providers in determining a correct diagnosis in patients with retinal disease beyond standard clinical examination capabilities. This activity reviews the PERG procedure and technique and highlights the role of the interprofessional team in evaluating and improving care for patients using this procedure."}
+{"id": "article-100456_1", "title": "Pattern Electroretinogram -- Continuing Education Activity", "content": "Objectives: Identify the indications for pattern electroretinogram (PERG). Describe the typical pattern electroretinogram (PERG) findings associated with optic nerve dysfunction. Review the interfering factors for the pattern electroretinogram (PERG). Explain the importance of collaboration and communication among the interprofessional team to enhance the delivery of care for patients affected by retinal disease using pattern electroretinogram (PERG). Access free multiple choice questions on this topic.", "contents": "Pattern Electroretinogram -- Continuing Education Activity. Objectives: Identify the indications for pattern electroretinogram (PERG). Describe the typical pattern electroretinogram (PERG) findings associated with optic nerve dysfunction. Review the interfering factors for the pattern electroretinogram (PERG). Explain the importance of collaboration and communication among the interprofessional team to enhance the delivery of care for patients affected by retinal disease using pattern electroretinogram (PERG). Access free multiple choice questions on this topic."}
+{"id": "article-100456_2", "title": "Pattern Electroretinogram -- Introduction", "content": "The pattern electroretinogram (PERG) is an electrophysiologic ophthalmologic test that provides non-invasive objective, quantitative measurement of central retinal function. It objectively measures functional loss and recovery. [1] PERG is the retinal response to a pattern-reversing, black-and-white checkerboard or stripped stimulus. [2] The PERG assesses both macular and retinal ganglion cell electrical activity and can help differentiate between diseases of macular versus optic nerve dysfunction. [3] Analysis of the PERG waveform components can provide useful diagnostic information for distinguishing various anterior visual pathway diseases, especially when the etiology of vision dysfunction remains uncertain following standard clinical examination.", "contents": "Pattern Electroretinogram -- Introduction. The pattern electroretinogram (PERG) is an electrophysiologic ophthalmologic test that provides non-invasive objective, quantitative measurement of central retinal function. It objectively measures functional loss and recovery. [1] PERG is the retinal response to a pattern-reversing, black-and-white checkerboard or stripped stimulus. [2] The PERG assesses both macular and retinal ganglion cell electrical activity and can help differentiate between diseases of macular versus optic nerve dysfunction. [3] Analysis of the PERG waveform components can provide useful diagnostic information for distinguishing various anterior visual pathway diseases, especially when the etiology of vision dysfunction remains uncertain following standard clinical examination."}
+{"id": "article-100456_3", "title": "Pattern Electroretinogram -- Anatomy and Physiology", "content": "The structural architecture of the retina constitutes ten layers comprising various cell-types and synaptic connections involved in visual processing. The inner retina includes nerve fiber layer axons, ganglion cells as well as their dendritic synaptic connections, and amacrine cells. The outer retina consists of the rod and cone photoreceptors, which transmit visual information to second-order neurons known as bipolar cells in the central retina.\u00a0Following the transduction of visual information (phototransduction) from the outer retina, the inner retinal ganglion cells then transmit this electrical information to the brain via the optic nerve for visual information processing. [4]", "contents": "Pattern Electroretinogram -- Anatomy and Physiology. The structural architecture of the retina constitutes ten layers comprising various cell-types and synaptic connections involved in visual processing. The inner retina includes nerve fiber layer axons, ganglion cells as well as their dendritic synaptic connections, and amacrine cells. The outer retina consists of the rod and cone photoreceptors, which transmit visual information to second-order neurons known as bipolar cells in the central retina.\u00a0Following the transduction of visual information (phototransduction) from the outer retina, the inner retinal ganglion cells then transmit this electrical information to the brain via the optic nerve for visual information processing. [4]"}
+{"id": "article-100456_4", "title": "Pattern Electroretinogram -- Indications", "content": "The pattern electroretinogram (PERG) is a specialized test beyond standard ophthalmologic examination. Electrophysiologic testing may be indicated in the following scenarios: Diagnosis and management of optic nerve and macular dysfunction Monitor retinal disease associated with toxic drug exposure Assess inflammatory, compressive, and traumatic lesions [5]", "contents": "Pattern Electroretinogram -- Indications. The pattern electroretinogram (PERG) is a specialized test beyond standard ophthalmologic examination. Electrophysiologic testing may be indicated in the following scenarios: Diagnosis and management of optic nerve and macular dysfunction Monitor retinal disease associated with toxic drug exposure Assess inflammatory, compressive, and traumatic lesions [5]"}
+{"id": "article-100456_5", "title": "Pattern Electroretinogram -- Contraindications", "content": "There are no specific contraindications for the PERG. Patients with seizure disorders\u00a0can safely undergo\u00a0the PERG as the stimulus frequency is outside of the range, responsible for inducing most epileptic seizures. Patients who report photosensitive seizures should be evaluated with caution if the frequency which induces their seizures is around 30 Hz or is unknown.", "contents": "Pattern Electroretinogram -- Contraindications. There are no specific contraindications for the PERG. Patients with seizure disorders\u00a0can safely undergo\u00a0the PERG as the stimulus frequency is outside of the range, responsible for inducing most epileptic seizures. Patients who report photosensitive seizures should be evaluated with caution if the frequency which induces their seizures is around 30 Hz or is unknown."}
+{"id": "article-100456_6", "title": "Pattern Electroretinogram -- Equipment", "content": "The instruments required to perform\u00a0pattern electroretinogram (PERG) are the following: Electrodes Amplification system Data recording system", "contents": "Pattern Electroretinogram -- Equipment. The instruments required to perform\u00a0pattern electroretinogram (PERG) are the following: Electrodes Amplification system Data recording system"}
+{"id": "article-100456_7", "title": "Pattern Electroretinogram -- Personnel", "content": "Appropriately trained technicians perform pattern electroretinogram (PERG) in large referral centers equipped with an electrophysiology laboratory. Retina specialists and neuro-ophthalmologists are typically responsible for the interpretation of the electrophysiological results.", "contents": "Pattern Electroretinogram -- Personnel. Appropriately trained technicians perform pattern electroretinogram (PERG) in large referral centers equipped with an electrophysiology laboratory. Retina specialists and neuro-ophthalmologists are typically responsible for the interpretation of the electrophysiological results."}
+{"id": "article-100456_8", "title": "Pattern Electroretinogram -- Preparation -- Electrode Placement", "content": "Recording Electrodes Depending on the type of electrode, the recording electrode is placed on the corneal surface, on the bulbar conjunctiva adjacent to the inferior limbus of the cornea. The International Society for Clinical Electrophysiology of Vision (ISCEV) recommends that skin (surface) recording electrodes should not regularly be used for recording the standard pattern electroretinogram (PERG). [2] Skin electrodes placed on the lower eyelid will record a lower PERG amplitude than those in contact with the eye. Skin recording\u00a0electrodes may, however, be useful under specific circumstances when a corneal electrode is contraindicated or in pediatric practice.\u00a0 Skin electrode have also successfully been used in studies looking at patients with glaucoma, but as the use of a skin electrode deviates from the PERG standard, ISCEV recommends that it should be noted in the report. [2] Topical anesthesia is applied to minimize ocular surface discomfort with corneal contact electrodes. [2]", "contents": "Pattern Electroretinogram -- Preparation -- Electrode Placement. Recording Electrodes Depending on the type of electrode, the recording electrode is placed on the corneal surface, on the bulbar conjunctiva adjacent to the inferior limbus of the cornea. The International Society for Clinical Electrophysiology of Vision (ISCEV) recommends that skin (surface) recording electrodes should not regularly be used for recording the standard pattern electroretinogram (PERG). [2] Skin electrodes placed on the lower eyelid will record a lower PERG amplitude than those in contact with the eye. Skin recording\u00a0electrodes may, however, be useful under specific circumstances when a corneal electrode is contraindicated or in pediatric practice.\u00a0 Skin electrode have also successfully been used in studies looking at patients with glaucoma, but as the use of a skin electrode deviates from the PERG standard, ISCEV recommends that it should be noted in the report. [2] Topical anesthesia is applied to minimize ocular surface discomfort with corneal contact electrodes. [2]"}
+{"id": "article-100456_9", "title": "Pattern Electroretinogram -- Preparation -- Electrode Placement", "content": "Reference Electrodes Place separate surface electrodes on the skin close to the outer canthus of each ipsilateral eye. For monocular PERG recordings, the contralateral occluded eye may be used for placement of the reference electrode. Forehead, earlobe, or mastoid are not recommended for placement as this may contaminate the PERG with potentials generated by the fellow eye. Ground Electrodes Typically placed on the forehead and connected to the \"ground input\" of the recording system. [2]", "contents": "Pattern Electroretinogram -- Preparation -- Electrode Placement. Reference Electrodes Place separate surface electrodes on the skin close to the outer canthus of each ipsilateral eye. For monocular PERG recordings, the contralateral occluded eye may be used for placement of the reference electrode. Forehead, earlobe, or mastoid are not recommended for placement as this may contaminate the PERG with potentials generated by the fellow eye. Ground Electrodes Typically placed on the forehead and connected to the \"ground input\" of the recording system. [2]"}
+{"id": "article-100456_10", "title": "Pattern Electroretinogram -- Preparation -- Patient Preparation", "content": "Per the International Society for Clinical Electrophysiology of Vision (ISCEV) guidelines: Electrically isolated recording environment Record without pupil dilation to maximize image quality Minimum 30-minutes of recovery time in normal room lighting is required for patients exposed to strong light stimuli from alternative imaging techniques (i.e., fundus photography or fluorescein angiography) Instruct patients to fixate on a target within the stimulator while minimizing eye movement. Patients who are unable to see the fixation point may be advised to look straight ahead while maintaining a steady gaze. The binocular recording is recommended as this improves fixation stability and reduced examination time. A monocular recording is recommended in individuals with ocular misalignment. [2]", "contents": "Pattern Electroretinogram -- Preparation -- Patient Preparation. Per the International Society for Clinical Electrophysiology of Vision (ISCEV) guidelines: Electrically isolated recording environment Record without pupil dilation to maximize image quality Minimum 30-minutes of recovery time in normal room lighting is required for patients exposed to strong light stimuli from alternative imaging techniques (i.e., fundus photography or fluorescein angiography) Instruct patients to fixate on a target within the stimulator while minimizing eye movement. Patients who are unable to see the fixation point may be advised to look straight ahead while maintaining a steady gaze. The binocular recording is recommended as this improves fixation stability and reduced examination time. A monocular recording is recommended in individuals with ocular misalignment. [2]"}
+{"id": "article-100456_11", "title": "Pattern Electroretinogram -- Technique or Treatment", "content": "The pattern electroretinogram (PERG) response can be either transient or steady-state, depending on the stimulus. The standard, transient PERG, is recorded in response to low contrast-reversal frequency stimuli (1-2 Hz), whereas the steady-state PERG is seen with a higher reversal frequency (8 Hz). Since the steady-state PERG does not allow for direct measurements of individual waveform components,\u00a0it can be harder to interpret and requires appropriate knowledge and software to evaluate the recordings.\u00a0 High frequency steady-state recordings negate some of the effects of poor fixation on the recording, increasing intertest reproducibility and steady-state PERG has been optimized for the early detection of glaucoma. [6]", "contents": "Pattern Electroretinogram -- Technique or Treatment. The pattern electroretinogram (PERG) response can be either transient or steady-state, depending on the stimulus. The standard, transient PERG, is recorded in response to low contrast-reversal frequency stimuli (1-2 Hz), whereas the steady-state PERG is seen with a higher reversal frequency (8 Hz). Since the steady-state PERG does not allow for direct measurements of individual waveform components,\u00a0it can be harder to interpret and requires appropriate knowledge and software to evaluate the recordings.\u00a0 High frequency steady-state recordings negate some of the effects of poor fixation on the recording, increasing intertest reproducibility and steady-state PERG has been optimized for the early detection of glaucoma. [6]"}
+{"id": "article-100456_12", "title": "Pattern Electroretinogram -- Technique or Treatment", "content": "The standard, transient response separates the PERG into wave components, including a negative wave at about 35 msec (N35) followed by a positive wave at approximately 50 msec (P50) and a large, negative wave at around 95 msec (N95). [2]", "contents": "Pattern Electroretinogram -- Technique or Treatment. The standard, transient response separates the PERG into wave components, including a negative wave at about 35 msec (N35) followed by a positive wave at approximately 50 msec (P50) and a large, negative wave at around 95 msec (N95). [2]"}
+{"id": "article-100456_13", "title": "Pattern Electroretinogram -- Technique or Treatment -- Waveform Components", "content": "P50", "contents": "Pattern Electroretinogram -- Technique or Treatment -- Waveform Components. P50"}
+{"id": "article-100456_14", "title": "Pattern Electroretinogram -- Technique or Treatment -- Waveform Components", "content": "The P50-wave is the initial positive deflection originating from RGCs as well as from outer retinal photoreceptor cells, namely the macular cones. This wave-component is largely a measure of outer retinal function. N95 The N95-wave is the negative deflection following the P50-wave that originates from the inner retina. This wave-component reflects the RGC function.", "contents": "Pattern Electroretinogram -- Technique or Treatment -- Waveform Components. The P50-wave is the initial positive deflection originating from RGCs as well as from outer retinal photoreceptor cells, namely the macular cones. This wave-component is largely a measure of outer retinal function. N95 The N95-wave is the negative deflection following the P50-wave that originates from the inner retina. This wave-component reflects the RGC function."}
+{"id": "article-100456_15", "title": "Pattern Electroretinogram -- Technique or Treatment -- Waveform Analysis (Figure 1)", "content": "Amplitude", "contents": "Pattern Electroretinogram -- Technique or Treatment -- Waveform Analysis (Figure 1). Amplitude"}
+{"id": "article-100456_16", "title": "Pattern Electroretinogram -- Technique or Treatment -- Waveform Analysis (Figure 1)", "content": "The amplitude is the maximal light-induced electrical response (voltage) generated by the various retinal cells. PERGs can be analyzed according to the amplitudes and implicit times of the wave components. The P50 amplitude is calculated from the trough of N35 to the peak of P50. The N95 amplitude is calculated from the peak of P50 to the trough of N95. In turn, N95 amplitude includes the P50 amplitude, and P50 includes that of N35. If the N35 is poorly defined, the P50 amplitude is calculated from the average baseline, which is between time zero and the onset of P50 to its peak. Implicit Time", "contents": "Pattern Electroretinogram -- Technique or Treatment -- Waveform Analysis (Figure 1). The amplitude is the maximal light-induced electrical response (voltage) generated by the various retinal cells. PERGs can be analyzed according to the amplitudes and implicit times of the wave components. The P50 amplitude is calculated from the trough of N35 to the peak of P50. The N95 amplitude is calculated from the peak of P50 to the trough of N95. In turn, N95 amplitude includes the P50 amplitude, and P50 includes that of N35. If the N35 is poorly defined, the P50 amplitude is calculated from the average baseline, which is between time zero and the onset of P50 to its peak. Implicit Time"}
+{"id": "article-100456_17", "title": "Pattern Electroretinogram -- Technique or Treatment -- Waveform Analysis (Figure 1)", "content": "Implicit time (time-to-peak) refers to the time needed for the electrical response to reach maximum amplitude. Implicit time is calculated from stimulus onset to the peak of the corresponding wave-component and reflects the rate of signal conduction. Latency Latency is the period from stimulus onset to response onset, as opposed to the peak of the response (i.e., implicit time). The N95 to P50-Wave Ratio The ratio of the N95- to P50-wave amplitudes provides an index of inner to outer retinal function. [2]", "contents": "Pattern Electroretinogram -- Technique or Treatment -- Waveform Analysis (Figure 1). Implicit time (time-to-peak) refers to the time needed for the electrical response to reach maximum amplitude. Implicit time is calculated from stimulus onset to the peak of the corresponding wave-component and reflects the rate of signal conduction. Latency Latency is the period from stimulus onset to response onset, as opposed to the peak of the response (i.e., implicit time). The N95 to P50-Wave Ratio The ratio of the N95- to P50-wave amplitudes provides an index of inner to outer retinal function. [2]"}
+{"id": "article-100456_18", "title": "Pattern Electroretinogram -- Technique or Treatment -- Protocols", "content": "The PERG response has a small amplitude and differs depending on the technique used. The ISCEV standards for generating the PERG response and for minimizing variability between procedures, thus enabling data to be compared among laboratories. ISCEV defines the following clinical protocols for PERG stimulus parameters and recording:", "contents": "Pattern Electroretinogram -- Technique or Treatment -- Protocols. The PERG response has a small amplitude and differs depending on the technique used. The ISCEV standards for generating the PERG response and for minimizing variability between procedures, thus enabling data to be compared among laboratories. ISCEV defines the following clinical protocols for PERG stimulus parameters and recording:"}
+{"id": "article-100456_19", "title": "Pattern Electroretinogram -- Technique or Treatment -- Field and Check Size", "content": "The standard PERG stimulus is a black and white reversing checkerboard. The check size for the standard PERG is a width of 0.8 degrees (\u00b1 0.2) for each individual square check (\u00b1 5% error). While a square stimulus field is not required, the aspect ratio between the width and the height of the stimulus field should be from 4:3 to 1:1. The mean width and height of the stimulus field should be 15 degrees (\u00b1 3).", "contents": "Pattern Electroretinogram -- Technique or Treatment -- Field and Check Size. The standard PERG stimulus is a black and white reversing checkerboard. The check size for the standard PERG is a width of 0.8 degrees (\u00b1 0.2) for each individual square check (\u00b1 5% error). While a square stimulus field is not required, the aspect ratio between the width and the height of the stimulus field should be from 4:3 to 1:1. The mean width and height of the stimulus field should be 15 degrees (\u00b1 3)."}
+{"id": "article-100456_20", "title": "Pattern Electroretinogram -- Technique or Treatment -- Luminance", "content": "The PERG response is complicated to elicit given a low stimulus luminance. A photopic luminance higher than 80 cd/m is required for the white areas of the stimulus. Mean stimulus luminance must be constant with no transient changes in luminance during checkerboard reversals.", "contents": "Pattern Electroretinogram -- Technique or Treatment -- Luminance. The PERG response is complicated to elicit given a low stimulus luminance. A photopic luminance higher than 80 cd/m is required for the white areas of the stimulus. Mean stimulus luminance must be constant with no transient changes in luminance during checkerboard reversals."}
+{"id": "article-100456_21", "title": "Pattern Electroretinogram -- Technique or Treatment -- Contrast", "content": "The contrast between black and white square checks should be close to 100% and no less than 80%.", "contents": "Pattern Electroretinogram -- Technique or Treatment -- Contrast. The contrast between black and white square checks should be close to 100% and no less than 80%."}
+{"id": "article-100456_22", "title": "Pattern Electroretinogram -- Technique or Treatment -- Background Illumination", "content": "Background illumination beyond the checkerboard stimulus and typically involves using dim or ordinary room lighting. For all recordings, ambient lighting should be the same bright lights should be kept out of a subject\u2019s direct view.", "contents": "Pattern Electroretinogram -- Technique or Treatment -- Background Illumination. Background illumination beyond the checkerboard stimulus and typically involves using dim or ordinary room lighting. For all recordings, ambient lighting should be the same bright lights should be kept out of a subject\u2019s direct view."}
+{"id": "article-100456_23", "title": "Pattern Electroretinogram -- Technique or Treatment -- Data Display System", "content": "Traditionally the stimulus for PERG has been displayed on a cathode-ray tube (CRT) monitor. Liquid crystal display (LCD) and light-emitting diode (LED) displays can have a flash artifact when the pattern reverses, which complicates the recorded response and no longer generates a PERG but rather a hybrid flash electroretinogram coupled with a PERG. This is hard to interpret as the waveform components no longer correspond to the anatomical areas listed above and thus should be avoided. It should be ensured that if LCD or LED displays are used, it is devoid of a flash artifact.", "contents": "Pattern Electroretinogram -- Technique or Treatment -- Data Display System. Traditionally the stimulus for PERG has been displayed on a cathode-ray tube (CRT) monitor. Liquid crystal display (LCD) and light-emitting diode (LED) displays can have a flash artifact when the pattern reverses, which complicates the recorded response and no longer generates a PERG but rather a hybrid flash electroretinogram coupled with a PERG. This is hard to interpret as the waveform components no longer correspond to the anatomical areas listed above and thus should be avoided. It should be ensured that if LCD or LED displays are used, it is devoid of a flash artifact."}
+{"id": "article-100456_24", "title": "Pattern Electroretinogram -- Technique or Treatment -- Reversal Rate", "content": "The reversal rate of 4.0 \u00b1 0.8 reversals per second (rps) should be used when recording the standard PERG response.", "contents": "Pattern Electroretinogram -- Technique or Treatment -- Reversal Rate. The reversal rate of 4.0 \u00b1 0.8 reversals per second (rps) should be used when recording the standard PERG response."}
+{"id": "article-100456_25", "title": "Pattern Electroretinogram -- Technique or Treatment -- Recording", "content": "At least 100 artifact-free sweeps should be acquired and averaged. However, more sweeps will be needed under circumstances when the PERG response is small, undetectable, or collected with significant background noise. Two trials for each stimulus condition must be acquired to confirm standard PERG reproducibility. Superimposing PERG responses can help to evaluate the quality and reproducibility of recordings.", "contents": "Pattern Electroretinogram -- Technique or Treatment -- Recording. At least 100 artifact-free sweeps should be acquired and averaged. However, more sweeps will be needed under circumstances when the PERG response is small, undetectable, or collected with significant background noise. Two trials for each stimulus condition must be acquired to confirm standard PERG reproducibility. Superimposing PERG responses can help to evaluate the quality and reproducibility of recordings."}
+{"id": "article-100456_26", "title": "Pattern Electroretinogram -- Technique or Treatment -- Averaging and Signal Analysis", "content": "Given the small amplitude of the PERG response, signal averaging is required. The analysis period or sweep time should be at least 150 ms with a stimulation rate of 4 rps and 250 ms intervals between reversals.", "contents": "Pattern Electroretinogram -- Technique or Treatment -- Averaging and Signal Analysis. Given the small amplitude of the PERG response, signal averaging is required. The analysis period or sweep time should be at least 150 ms with a stimulation rate of 4 rps and 250 ms intervals between reversals."}
+{"id": "article-100456_27", "title": "Pattern Electroretinogram -- Technique or Treatment -- Artifact Rejection", "content": "The limit for computerized rejection should be no higher than \u00b1 100 microvolts.", "contents": "Pattern Electroretinogram -- Technique or Treatment -- Artifact Rejection. The limit for computerized rejection should be no higher than \u00b1 100 microvolts."}
+{"id": "article-100456_28", "title": "Pattern Electroretinogram -- Technique or Treatment -- Sampling Rate", "content": "A sampling rate minimum of 1,000 Hz (i.e., 1 ms per point) is recommended.", "contents": "Pattern Electroretinogram -- Technique or Treatment -- Sampling Rate. A sampling rate minimum of 1,000 Hz (i.e., 1 ms per point) is recommended."}
+{"id": "article-100456_29", "title": "Pattern Electroretinogram -- Complications", "content": "The pattern electroretinogram (PERG) is a non-invasive test with minimal risks. Patients may experience mild ocular discomfort during the procedure or, in very rare cases, develop a corneal abrasion depending on the type of electrode used. Other interfering factors are described below.", "contents": "Pattern Electroretinogram -- Complications. The pattern electroretinogram (PERG) is a non-invasive test with minimal risks. Patients may experience mild ocular discomfort during the procedure or, in very rare cases, develop a corneal abrasion depending on the type of electrode used. Other interfering factors are described below."}
+{"id": "article-100456_30", "title": "Pattern Electroretinogram -- Complications -- Interfering Factors", "content": "Deviating from standardized testing conditions (i.e., lighting, flash intensity, recording environment, duration of light or dark adaptation, and pupil size) Electrode-based artifacts including poor contact with skin or cornea, incorrect placement, unstable position, and high electrical impedance Eye blinking or movement Defocus or uncorrected refractive error Reduced electrical response with aging Ocular media opacification Diurnal fluctuation Depressed response with anesthesia Variability in recordings between different device types. [2]", "contents": "Pattern Electroretinogram -- Complications -- Interfering Factors. Deviating from standardized testing conditions (i.e., lighting, flash intensity, recording environment, duration of light or dark adaptation, and pupil size) Electrode-based artifacts including poor contact with skin or cornea, incorrect placement, unstable position, and high electrical impedance Eye blinking or movement Defocus or uncorrected refractive error Reduced electrical response with aging Ocular media opacification Diurnal fluctuation Depressed response with anesthesia Variability in recordings between different device types. [2]"}
+{"id": "article-100456_31", "title": "Pattern Electroretinogram -- Clinical Significance", "content": "Electrophysiological abnormalities frequently occur early and often precede structural findings on retinal imaging. The PERG has critical clinical applications in unexplained vision loss, especially when the fundus appears normal or when there is disc pallor in the absence of visible vessel irregularities accompanied by significant macular abnormalities. [7]", "contents": "Pattern Electroretinogram -- Clinical Significance. Electrophysiological abnormalities frequently occur early and often precede structural findings on retinal imaging. The PERG has critical clinical applications in unexplained vision loss, especially when the fundus appears normal or when there is disc pallor in the absence of visible vessel irregularities accompanied by significant macular abnormalities. [7]"}
+{"id": "article-100456_32", "title": "Pattern Electroretinogram -- Clinical Significance -- Optic Nerve Versus Macular Dysfunction", "content": "The PERG response may be normal or decreased in optic nerve dysfunction. In particular, a decreased N95 amplitude is almost invariably observed in optic nerve disease with primary RGC dysfunction. P50 is typically spared in optic nerve disease. Notably, however, P50 amplitude and implicit time may be reduced in severe disease.", "contents": "Pattern Electroretinogram -- Clinical Significance -- Optic Nerve Versus Macular Dysfunction. The PERG response may be normal or decreased in optic nerve dysfunction. In particular, a decreased N95 amplitude is almost invariably observed in optic nerve disease with primary RGC dysfunction. P50 is typically spared in optic nerve disease. Notably, however, P50 amplitude and implicit time may be reduced in severe disease."}
+{"id": "article-100456_33", "title": "Pattern Electroretinogram -- Clinical Significance -- Optic Nerve Versus Macular Dysfunction", "content": "In contrast, an undetectable PERG or significant P50 amplitude reduction in the absence of decreased implicit time is indicative of macular dysfunction. Besides, P50 amplitude reduction in macular dysfunction may be likely be accompanied by concomitant 95, such whereby the N95: P50 ratio is unchanged, although the N95 is occasionally better preserved. [8]", "contents": "Pattern Electroretinogram -- Clinical Significance -- Optic Nerve Versus Macular Dysfunction. In contrast, an undetectable PERG or significant P50 amplitude reduction in the absence of decreased implicit time is indicative of macular dysfunction. Besides, P50 amplitude reduction in macular dysfunction may be likely be accompanied by concomitant 95, such whereby the N95: P50 ratio is unchanged, although the N95 is occasionally better preserved. [8]"}
+{"id": "article-100456_34", "title": "Pattern Electroretinogram -- Clinical Significance -- Hereditary Optic Neuropathy", "content": "Leber\u2019s Hereditary Optic Neuropathy (LHON) : A rare, maternally inherited mitochondrial disease of the RGCs characterized by bilateral loss of vision typically manifesting in the second to third decades of life. LHON exhibits significant N95 reduction with P50 preservation of the PERG response. [7] [9]", "contents": "Pattern Electroretinogram -- Clinical Significance -- Hereditary Optic Neuropathy. Leber\u2019s Hereditary Optic Neuropathy (LHON) : A rare, maternally inherited mitochondrial disease of the RGCs characterized by bilateral loss of vision typically manifesting in the second to third decades of life. LHON exhibits significant N95 reduction with P50 preservation of the PERG response. [7] [9]"}
+{"id": "article-100456_35", "title": "Pattern Electroretinogram -- Clinical Significance -- Hereditary Optic Neuropathy", "content": "Dominant Optic Atrophy (DOA) : An autosomal dominant optic neuropathy affecting the RGCs most commonly associated with an OPA1 nuclear gene mutation. In contrast to LHON, DOA is classically diagnosed during the first decade of life with a slowly progressive and symmetric loss of vision. DOA shows a preferential decrease in N95 amplitude in the early stages of disease followed by reduced P50 amplitude and implicit time in advanced stages. [7] [10]", "contents": "Pattern Electroretinogram -- Clinical Significance -- Hereditary Optic Neuropathy. Dominant Optic Atrophy (DOA) : An autosomal dominant optic neuropathy affecting the RGCs most commonly associated with an OPA1 nuclear gene mutation. In contrast to LHON, DOA is classically diagnosed during the first decade of life with a slowly progressive and symmetric loss of vision. DOA shows a preferential decrease in N95 amplitude in the early stages of disease followed by reduced P50 amplitude and implicit time in advanced stages. [7] [10]"}
+{"id": "article-100456_36", "title": "Pattern Electroretinogram -- Clinical Significance -- Multiple Sclerosis", "content": "Multiple sclerosis (MS) is an inflammatory demyelinating disease of the central nervous system, including the anterior visual pathways, namely the optic nerve. Optic neuritis, inflammation of the optic nerve, characteristically presents as unilateral vision loss with pain on eye movement. Patients are typically females between 30 to 50 years of age. Demyelination of the retinal ganglion cell axons leads to optic nerve atrophy. PERG studies in MS have shown preferential N95 amplitude reduction with P50 sparing. Notably, reports have shown reductions in both N95 and P50 in acute optic neuritis, with the recovery of P50 to normal after remission. [11] [12]", "contents": "Pattern Electroretinogram -- Clinical Significance -- Multiple Sclerosis. Multiple sclerosis (MS) is an inflammatory demyelinating disease of the central nervous system, including the anterior visual pathways, namely the optic nerve. Optic neuritis, inflammation of the optic nerve, characteristically presents as unilateral vision loss with pain on eye movement. Patients are typically females between 30 to 50 years of age. Demyelination of the retinal ganglion cell axons leads to optic nerve atrophy. PERG studies in MS have shown preferential N95 amplitude reduction with P50 sparing. Notably, reports have shown reductions in both N95 and P50 in acute optic neuritis, with the recovery of P50 to normal after remission. [11] [12]"}
+{"id": "article-100456_37", "title": "Pattern Electroretinogram -- Clinical Significance -- Non-Arteritic Ischemic Optic Neuropathy", "content": "Nonarteritic anterior ischemic optic neuropathy (NAION) is acute onset, ischemic damage of the optic nerve most commonly affecting elderly patients greater than 50 years of age, presenting with altitudinal visual field defects. Risk factors include age, hypertension, diabetes mellitus, smoking, and crowding of the optic nerve. NAION patients typically exhibit N95 amplitude reduction with the preservation of P50 in the PERG response. [13] [14] Notably, reports have also suggested P50 amplitude reduction with increased implicit time secondary to compromised blood flow to the retinal layers. [15]", "contents": "Pattern Electroretinogram -- Clinical Significance -- Non-Arteritic Ischemic Optic Neuropathy. Nonarteritic anterior ischemic optic neuropathy (NAION) is acute onset, ischemic damage of the optic nerve most commonly affecting elderly patients greater than 50 years of age, presenting with altitudinal visual field defects. Risk factors include age, hypertension, diabetes mellitus, smoking, and crowding of the optic nerve. NAION patients typically exhibit N95 amplitude reduction with the preservation of P50 in the PERG response. [13] [14] Notably, reports have also suggested P50 amplitude reduction with increased implicit time secondary to compromised blood flow to the retinal layers. [15]"}
+{"id": "article-100456_38", "title": "Pattern Electroretinogram -- Clinical Significance -- Glaucoma", "content": "Glaucoma, a leading cause of irreversible blindness worldwide, is a progressive optic neuropathy characterized by retinal ganglion cell degeneration and peripheral visual field loss. PERG has been recognized as an important test in diagnosing and managing glaucoma and diabetic edema. [16] [17] Glaucoma has shown diminished N95 amplitude and prolonged implicit time in the PERG response. Notably, glaucoma suspects have similarly shown prolonged N95 implicit time, although no significant attenuation in amplitude. P50 is preserved in both glaucoma and glaucoma suspects. [18]", "contents": "Pattern Electroretinogram -- Clinical Significance -- Glaucoma. Glaucoma, a leading cause of irreversible blindness worldwide, is a progressive optic neuropathy characterized by retinal ganglion cell degeneration and peripheral visual field loss. PERG has been recognized as an important test in diagnosing and managing glaucoma and diabetic edema. [16] [17] Glaucoma has shown diminished N95 amplitude and prolonged implicit time in the PERG response. Notably, glaucoma suspects have similarly shown prolonged N95 implicit time, although no significant attenuation in amplitude. P50 is preserved in both glaucoma and glaucoma suspects. [18]"}
+{"id": "article-100456_39", "title": "Pattern Electroretinogram -- Clinical Significance -- Neurodegenerative Diseases", "content": "Alzheimer Disease (AD) : The most common form of dementia pathologically hallmarked by fibrillar beta-amyloid and hyper-phosphorylated tau accumulations in the central nervous system. [19] Several PERG studies have provided evidence of retinal electrophysiologic dysfunction in AD. In particular, PERG responses in AD have shown significant amplitude reduction and prolonged implicit time in both N95 and P50, suggesting that retinal dysfunction in AD may involve the outer retina in addition to the inner retina. [20] Studies have also provided evidence of retinal dysfunction in early AD. PERG responses have shown decreased N95 and P50 amplitudes along with P50 implicit time prolongation. [21]", "contents": "Pattern Electroretinogram -- Clinical Significance -- Neurodegenerative Diseases. Alzheimer Disease (AD) : The most common form of dementia pathologically hallmarked by fibrillar beta-amyloid and hyper-phosphorylated tau accumulations in the central nervous system. [19] Several PERG studies have provided evidence of retinal electrophysiologic dysfunction in AD. In particular, PERG responses in AD have shown significant amplitude reduction and prolonged implicit time in both N95 and P50, suggesting that retinal dysfunction in AD may involve the outer retina in addition to the inner retina. [20] Studies have also provided evidence of retinal dysfunction in early AD. PERG responses have shown decreased N95 and P50 amplitudes along with P50 implicit time prolongation. [21]"}
+{"id": "article-100456_40", "title": "Pattern Electroretinogram -- Clinical Significance -- Neurodegenerative Diseases", "content": "Parkinson Disease (PD) : A neurodegenerative disorder involving abnormal \u03b1-synuclein (\u03b1-syn) protein deposition leading dopaminergic neuronal atrophy. [22] PERG studies have shown significant N95 amplitude reduction in addition to P50 amplitude reduction with prolonged implicit time. [23] [24] [25]", "contents": "Pattern Electroretinogram -- Clinical Significance -- Neurodegenerative Diseases. Parkinson Disease (PD) : A neurodegenerative disorder involving abnormal \u03b1-synuclein (\u03b1-syn) protein deposition leading dopaminergic neuronal atrophy. [22] PERG studies have shown significant N95 amplitude reduction in addition to P50 amplitude reduction with prolonged implicit time. [23] [24] [25]"}
+{"id": "article-100456_41", "title": "Pattern Electroretinogram -- Enhancing Healthcare Team Outcomes", "content": "The neurosensory retina is a complex structure, and patients with ophthalmologic disease often present with unexplained vision loss. Identifying the etiology of disease within the retinal infrastructure is a diagnostic challenge. Therefore, an interprofessional team approach is crucial for providing adequate patient care. Patients with acute onset vision loss frequently present in the emergency department. Nurses triage the patient as the first point of contact based on symptom severity and onset.", "contents": "Pattern Electroretinogram -- Enhancing Healthcare Team Outcomes. The neurosensory retina is a complex structure, and patients with ophthalmologic disease often present with unexplained vision loss. Identifying the etiology of disease within the retinal infrastructure is a diagnostic challenge. Therefore, an interprofessional team approach is crucial for providing adequate patient care. Patients with acute onset vision loss frequently present in the emergency department. Nurses triage the patient as the first point of contact based on symptom severity and onset."}
+{"id": "article-100456_42", "title": "Pattern Electroretinogram -- Enhancing Healthcare Team Outcomes", "content": "Given the concern for emergent conditions and an indeterminate clinical diagnosis and, providers and nursing staff routinely order a costly workup involving a battery of tests, and the majority of which return negative. In turn, patients are instructed to follow up with an outpatient ophthalmologist. Typically, this will involve a standard eye examination by a comprehensive ophthalmologist. However, these preliminary diagnostic tests mostly detect structural abnormalities, which are not always consistent with clinical presentation. In turn, patient diagnoses may be mistaken for a benign condition and, in some cases, presumed to be malingering. Neuro-ophthalmology is the field that is commonly acknowledged when the etiology of vision impairment remains unknown, despite extensive medical workup. [9] [Level 4]", "contents": "Pattern Electroretinogram -- Enhancing Healthcare Team Outcomes. Given the concern for emergent conditions and an indeterminate clinical diagnosis and, providers and nursing staff routinely order a costly workup involving a battery of tests, and the majority of which return negative. In turn, patients are instructed to follow up with an outpatient ophthalmologist. Typically, this will involve a standard eye examination by a comprehensive ophthalmologist. However, these preliminary diagnostic tests mostly detect structural abnormalities, which are not always consistent with clinical presentation. In turn, patient diagnoses may be mistaken for a benign condition and, in some cases, presumed to be malingering. Neuro-ophthalmology is the field that is commonly acknowledged when the etiology of vision impairment remains unknown, despite extensive medical workup. [9] [Level 4]"}
+{"id": "article-100456_43", "title": "Pattern Electroretinogram -- Enhancing Healthcare Team Outcomes", "content": "Considering a broad differential is essential to distinguish retinal dysfunction from alternative, similar appearing causes since the option of therapy depends on the underlying etiology of the disease process. Electroretinography, in conjunction with clinical findings, provides invaluable data for patient management while avoiding unnecessary testing. Transparent communication and care coordination between nurses, providers, ophthalmologists, including subspecialists, are essential for deriving a correct diagnosis and therapeutic decision-making. [Level 5]", "contents": "Pattern Electroretinogram -- Enhancing Healthcare Team Outcomes. Considering a broad differential is essential to distinguish retinal dysfunction from alternative, similar appearing causes since the option of therapy depends on the underlying etiology of the disease process. Electroretinography, in conjunction with clinical findings, provides invaluable data for patient management while avoiding unnecessary testing. Transparent communication and care coordination between nurses, providers, ophthalmologists, including subspecialists, are essential for deriving a correct diagnosis and therapeutic decision-making. [Level 5]"}
+{"id": "article-100456_44", "title": "Pattern Electroretinogram -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Pattern Electroretinogram -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

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+{"id": "article-100468_0", "title": "Trisomy 13 -- Continuing Education Activity", "content": "Trisomy 13 is a chromosomal aneuploidy characterized by meiotic nondisjunction. The phenotypic holoprosencephaly and midline fusion aberrancies are related to a defective fusion of the prechordal mesoderm. Patau syndrome has a mortality of over 95%. This activity addresses this condition and provides clinicians with the information to evaluate and manage this condition when it presents.", "contents": "Trisomy 13 -- Continuing Education Activity. Trisomy 13 is a chromosomal aneuploidy characterized by meiotic nondisjunction. The phenotypic holoprosencephaly and midline fusion aberrancies are related to a defective fusion of the prechordal mesoderm. Patau syndrome has a mortality of over 95%. This activity addresses this condition and provides clinicians with the information to evaluate and manage this condition when it presents."}
+{"id": "article-100468_1", "title": "Trisomy 13 -- Continuing Education Activity", "content": "Objectives: Identify the etiology and epidemiology of trisomy 13. Review the factors relating to the prenatal diagnosis of trisomy 13. Summarize the management options available for trisomy 13. Describe some interprofessional team strategies for improving care coordination and communication in the diagnosis of trisomy 13. Access free multiple choice questions on this topic.", "contents": "Trisomy 13 -- Continuing Education Activity. Objectives: Identify the etiology and epidemiology of trisomy 13. Review the factors relating to the prenatal diagnosis of trisomy 13. Summarize the management options available for trisomy 13. Describe some interprofessional team strategies for improving care coordination and communication in the diagnosis of trisomy 13. Access free multiple choice questions on this topic."}
+{"id": "article-100468_2", "title": "Trisomy 13 -- Introduction", "content": "Trisomy 13 is a chromosomal aneuploidy  originally described by Patau et al. in 1960. [1] The occurrence of trisomy 13 is 1 in 10,000\u00a0to 20,000 live births with antenatal mortality of over 95% of gestations. [2] [3] It can occur as complete, partial, or mosaic expression. [1] The complete trisomy is the most common presentation representing about 80% of all patients. This expression characteristically demonstrates the presence of three chromosomes 13 copies. [1] The partial expression is characterized by a Robertsonian translocation t(13;14),\u00a0while only 5% of all cases present with mosaicism. [4] Mosaicism is characterized by a percentage of cells remaining trisomic while others maintain euploidy. [1]", "contents": "Trisomy 13 -- Introduction. Trisomy 13 is a chromosomal aneuploidy  originally described by Patau et al. in 1960. [1] The occurrence of trisomy 13 is 1 in 10,000\u00a0to 20,000 live births with antenatal mortality of over 95% of gestations. [2] [3] It can occur as complete, partial, or mosaic expression. [1] The complete trisomy is the most common presentation representing about 80% of all patients. This expression characteristically demonstrates the presence of three chromosomes 13 copies. [1] The partial expression is characterized by a Robertsonian translocation t(13;14),\u00a0while only 5% of all cases present with mosaicism. [4] Mosaicism is characterized by a percentage of cells remaining trisomic while others maintain euploidy. [1]"}
+{"id": "article-100468_3", "title": "Trisomy 13 -- Introduction", "content": "Trisomy 13 arises from the nondisjunction of germ cells during meiosis I or II of either parental cells. [5] Nonetheless, maternal germ cell nondisjunction correlated to the increased age of conception contributes to 91% of cases. [3] The mode of inheritance for the complete trisomy 13 is caused by spontaneous interference in meiosis, while vertical inheritance is hereditary in balanced translocations. [5]", "contents": "Trisomy 13 -- Introduction. Trisomy 13 arises from the nondisjunction of germ cells during meiosis I or II of either parental cells. [5] Nonetheless, maternal germ cell nondisjunction correlated to the increased age of conception contributes to 91% of cases. [3] The mode of inheritance for the complete trisomy 13 is caused by spontaneous interference in meiosis, while vertical inheritance is hereditary in balanced translocations. [5]"}
+{"id": "article-100468_4", "title": "Trisomy 13 -- Introduction", "content": "Phenotypic findings in trisomy 13 are associated with patterns of congenital anomalies and mental disabilities incompatible with life. [5] The embryological defects in trisomy 13 develop in the absence of fusion of prechordal mesoderm, which phenotypically presents as midline defects. These midline defects are associated with aberrant SHH genes. [6] Despite the accelerated mortality of trisomy 13, it remains clinically significant due to its variable expressivity in patients with compatible mosaicisms. [1]", "contents": "Trisomy 13 -- Introduction. Phenotypic findings in trisomy 13 are associated with patterns of congenital anomalies and mental disabilities incompatible with life. [5] The embryological defects in trisomy 13 develop in the absence of fusion of prechordal mesoderm, which phenotypically presents as midline defects. These midline defects are associated with aberrant SHH genes. [6] Despite the accelerated mortality of trisomy 13, it remains clinically significant due to its variable expressivity in patients with compatible mosaicisms. [1]"}
+{"id": "article-100468_5", "title": "Trisomy 13 -- Etiology", "content": "Trisomy 13 results from the nondisjunction of homologous chromosomes during gametogenesis, characterized by three copies of chromosome 13 in somatic and germ cell lines. [5] Maternal nondisjunction represents 91% of cases typically due to errors in meiosis I. Meiotic errors originate from the aberrant recombination of chromosomes, which has a greater incidence among conceptions in women older than 35 years of age. [3]", "contents": "Trisomy 13 -- Etiology. Trisomy 13 results from the nondisjunction of homologous chromosomes during gametogenesis, characterized by three copies of chromosome 13 in somatic and germ cell lines. [5] Maternal nondisjunction represents 91% of cases typically due to errors in meiosis I. Meiotic errors originate from the aberrant recombination of chromosomes, which has a greater incidence among conceptions in women older than 35 years of age. [3]"}
+{"id": "article-100468_6", "title": "Trisomy 13 -- Etiology", "content": "A less phenotypically challenging trisomy can occur in a translocation. These translocations originate from two acrocentric breaks in the juxtacentromeric regions (usually chromosomes 13 and 14). The phenotypic expression will depend on the balance of the translocation. Balanced Robertsonian translocations will be less severe than those with an altered genetic quantity, as seen in unbalanced translocations. [7] The mosaic form of trisomy 13 occurs when some cell lines have the extra chromosomal material. [5] Mosaicism phenotype presents with varied expressivity with an increased intellectual sparing. [1]", "contents": "Trisomy 13 -- Etiology. A less phenotypically challenging trisomy can occur in a translocation. These translocations originate from two acrocentric breaks in the juxtacentromeric regions (usually chromosomes 13 and 14). The phenotypic expression will depend on the balance of the translocation. Balanced Robertsonian translocations will be less severe than those with an altered genetic quantity, as seen in unbalanced translocations. [7] The mosaic form of trisomy 13 occurs when some cell lines have the extra chromosomal material. [5] Mosaicism phenotype presents with varied expressivity with an increased intellectual sparing. [1]"}
+{"id": "article-100468_7", "title": "Trisomy 13 -- Epidemiology", "content": "Trisomy 13 is the third most common trisomy, occurring in 1 in 10,000\u00a0to 20,000 live births.\u00a0The antenatal mortality represents the majority of deaths, with a postnatal survival rate of 6\u00a0to 12% beyond the first year of life. [2] About 90% of trisomy 13 diagnoses made in developed countries are antenatal. [8] Cardiac and nervous system anomalies are amongst the most common malformations in trisomy 13. [9]", "contents": "Trisomy 13 -- Epidemiology. Trisomy 13 is the third most common trisomy, occurring in 1 in 10,000\u00a0to 20,000 live births.\u00a0The antenatal mortality represents the majority of deaths, with a postnatal survival rate of 6\u00a0to 12% beyond the first year of life. [2] About 90% of trisomy 13 diagnoses made in developed countries are antenatal. [8] Cardiac and nervous system anomalies are amongst the most common malformations in trisomy 13. [9]"}
+{"id": "article-100468_8", "title": "Trisomy 13 -- Pathophysiology", "content": "The meiotic nondisjunction in trisomy 13 causes a series of genetic aberrancies related to defects in prechordal mesoderm fusion. [6] The faulty fusion causes midline defects, which develop into phenotypic malformations incompatible with life. Some specific genetic mapping has identified a vast array of tumors in trisomy 13 carriers. [2]", "contents": "Trisomy 13 -- Pathophysiology. The meiotic nondisjunction in trisomy 13 causes a series of genetic aberrancies related to defects in prechordal mesoderm fusion. [6] The faulty fusion causes midline defects, which develop into phenotypic malformations incompatible with life. Some specific genetic mapping has identified a vast array of tumors in trisomy 13 carriers. [2]"}
+{"id": "article-100468_9", "title": "Trisomy 13 -- Histopathology", "content": "The anatomic-histological classification of trisomy 13 was described in 1966 by Snodgrass et al. as two categories based on the presence or absence of holoprosencephaly. [10] Further evaluation of the external phenotype is commonly presented with postaxial hexadactyly. Midline malformations of internal organs are frequent, which include septal cardiac defects and M\u00fcllerian defects such as uterus didelphys. [10] The microscopic examination of aborted fetuses with trisomy 13 presents abnormal metanephric differentiation with the persistence of embryologic structures. Most of the embryologic malformations are traceable to mesoderm migration via the presence of olfactory aplasia since normal morphogenic development of craniofacial and forebrain structures occurs in the third week of embryogenesis. [10]", "contents": "Trisomy 13 -- Histopathology. The anatomic-histological classification of trisomy 13 was described in 1966 by Snodgrass et al. as two categories based on the presence or absence of holoprosencephaly. [10] Further evaluation of the external phenotype is commonly presented with postaxial hexadactyly. Midline malformations of internal organs are frequent, which include septal cardiac defects and M\u00fcllerian defects such as uterus didelphys. [10] The microscopic examination of aborted fetuses with trisomy 13 presents abnormal metanephric differentiation with the persistence of embryologic structures. Most of the embryologic malformations are traceable to mesoderm migration via the presence of olfactory aplasia since normal morphogenic development of craniofacial and forebrain structures occurs in the third week of embryogenesis. [10]"}
+{"id": "article-100468_10", "title": "Trisomy 13 -- History and Physical", "content": "The typical findings in trisomy 13 include holoprosencephaly, Dandy-Walker malformation, aplasia cutis, cleft lip-palate, postaxial polydactyly, congenital heart disease, polycystic kidney disease, urogenital anomalies, and gynecological dysgenesis. [1] [10] Internal systems can also be compromised with hyperinsulinism portrayed by persistent hypoglycemia. While in utero, the most common findings are related to growth delay. [5]", "contents": "Trisomy 13 -- History and Physical. The typical findings in trisomy 13 include holoprosencephaly, Dandy-Walker malformation, aplasia cutis, cleft lip-palate, postaxial polydactyly, congenital heart disease, polycystic kidney disease, urogenital anomalies, and gynecological dysgenesis. [1] [10] Internal systems can also be compromised with hyperinsulinism portrayed by persistent hypoglycemia. While in utero, the most common findings are related to growth delay. [5]"}
+{"id": "article-100468_11", "title": "Trisomy 13 -- Evaluation", "content": "The initial evaluation of trisomy 13 starts with fetal nuchal translucency (FNT) which, is done in weeks 11\u00a0to 14 of gestation. As with other trisomies, the measurement typically appears greater or equal to 3.5mm. [11] Part of the first-trimester screening also includes the measurement of free beta subunit or total human chorionic gonadotropin (B-hCG) and pregnancy-associated plasma protein-A (PAPP-A). During the first trimester, both biomarkers appear decreased, making it undifferentiated from trisomy 18 screening. [11]", "contents": "Trisomy 13 -- Evaluation. The initial evaluation of trisomy 13 starts with fetal nuchal translucency (FNT) which, is done in weeks 11\u00a0to 14 of gestation. As with other trisomies, the measurement typically appears greater or equal to 3.5mm. [11] Part of the first-trimester screening also includes the measurement of free beta subunit or total human chorionic gonadotropin (B-hCG) and pregnancy-associated plasma protein-A (PAPP-A). During the first trimester, both biomarkers appear decreased, making it undifferentiated from trisomy 18 screening. [11]"}
+{"id": "article-100468_12", "title": "Trisomy 13 -- Evaluation", "content": "Non-invasive prenatal testing (NIPT ) is possible using cell-free DNA in maternal plasma to differentiate trisomy 18 and 21 from 13; nonetheless, cost per value continues to support the use of invasive techniques. [12] Chorionic villus sampling (CVS) can be performed in an early window between gestational weeks 11 and 13, while amniocentesis is generally performed in weeks 15\u00a0to 18. [5] Recent studies suggest that the high mortality associated with trisomies 13 and 18 relate to the termination of pregnancies in up to 55% of gestations with a confirmed diagnosis. [13] Nonetheless, a definite diagnosis is only achievable from a postnatal karyotype and fluorescence in situ hybridization (FISH) techniques. [5]", "contents": "Trisomy 13 -- Evaluation. Non-invasive prenatal testing (NIPT ) is possible using cell-free DNA in maternal plasma to differentiate trisomy 18 and 21 from 13; nonetheless, cost per value continues to support the use of invasive techniques. [12] Chorionic villus sampling (CVS) can be performed in an early window between gestational weeks 11 and 13, while amniocentesis is generally performed in weeks 15\u00a0to 18. [5] Recent studies suggest that the high mortality associated with trisomies 13 and 18 relate to the termination of pregnancies in up to 55% of gestations with a confirmed diagnosis. [13] Nonetheless, a definite diagnosis is only achievable from a postnatal karyotype and fluorescence in situ hybridization (FISH) techniques. [5]"}
+{"id": "article-100468_13", "title": "Trisomy 13 -- Treatment / Management", "content": "Historical evidence suggested that the syndromic presence of multiple organ dysfunctions in trisomy 13 and 18 were incompatible with life. Nonetheless, the growing communication in society has portrayed anecdotal evidence of survivors from these conditions leading guidelines and decision making into a moral gray zone. [14]", "contents": "Trisomy 13 -- Treatment / Management. Historical evidence suggested that the syndromic presence of multiple organ dysfunctions in trisomy 13 and 18 were incompatible with life. Nonetheless, the growing communication in society has portrayed anecdotal evidence of survivors from these conditions leading guidelines and decision making into a moral gray zone. [14]"}
+{"id": "article-100468_14", "title": "Trisomy 13 -- Treatment / Management", "content": "The current approach focuses on creating a communicative relationship between the parents and physicians informing them about the quality of life and the treatment options specific to their child's abnormalities. [15] Although surgical techniques exist for the majority of lethal malformations associated with trisomy 13, the ten-year survival post-intervention remains low at 12.9%. [16]", "contents": "Trisomy 13 -- Treatment / Management. The current approach focuses on creating a communicative relationship between the parents and physicians informing them about the quality of life and the treatment options specific to their child's abnormalities. [15] Although surgical techniques exist for the majority of lethal malformations associated with trisomy 13, the ten-year survival post-intervention remains low at 12.9%. [16]"}
+{"id": "article-100468_15", "title": "Trisomy 13 -- Differential Diagnosis", "content": "The differential diagnosis of trisomy 13 should include Edwards syndrome due to its similarities during the initial gestational screening. [11] Other diagnoses should include partial duplication of 13q and pseudotrisomy 13. [17] The use of modern non-invasive techniques facilitates the differential diagnosis of pathologies usually prenatally associated with the same characteristics of trisomy 13. [12]", "contents": "Trisomy 13 -- Differential Diagnosis. The differential diagnosis of trisomy 13 should include Edwards syndrome due to its similarities during the initial gestational screening. [11] Other diagnoses should include partial duplication of 13q and pseudotrisomy 13. [17] The use of modern non-invasive techniques facilitates the differential diagnosis of pathologies usually prenatally associated with the same characteristics of trisomy 13. [12]"}
+{"id": "article-100468_16", "title": "Trisomy 13 -- Prognosis", "content": "Evidence suggests that postnatal mortality is approximately 50% during the first month and up to 90% during the first year. [1] Recent information provided by organizations such as the support organization for Trisomy 13, 18, and related disorders (SOFT) has allowed the direct intervention of patients rather than palliative care. [5] These measures have impacted the survival rate of patients; nonetheless, there is a lack of study data to support the benefit of aggressive intervention and global survival rate.", "contents": "Trisomy 13 -- Prognosis. Evidence suggests that postnatal mortality is approximately 50% during the first month and up to 90% during the first year. [1] Recent information provided by organizations such as the support organization for Trisomy 13, 18, and related disorders (SOFT) has allowed the direct intervention of patients rather than palliative care. [5] These measures have impacted the survival rate of patients; nonetheless, there is a lack of study data to support the benefit of aggressive intervention and global survival rate."}
+{"id": "article-100468_17", "title": "Trisomy 13 -- Complications", "content": "Maternal complications are associated with trisomy 13, concurring in an increase in mortality for both the mother and the fetus. Data suggest that a trisomy 13 gestation is related to an increased prevalence of preeclampsia and early delivery. [18] Nevertheless, neonatal mortality is associated with central apnea, structural cardiac incompatibilities, pulmonary hypertension, aspiration, and upper respiratory tract obstructions. [5]", "contents": "Trisomy 13 -- Complications. Maternal complications are associated with trisomy 13, concurring in an increase in mortality for both the mother and the fetus. Data suggest that a trisomy 13 gestation is related to an increased prevalence of preeclampsia and early delivery. [18] Nevertheless, neonatal mortality is associated with central apnea, structural cardiac incompatibilities, pulmonary hypertension, aspiration, and upper respiratory tract obstructions. [5]"}
+{"id": "article-100468_18", "title": "Trisomy 13 -- Deterrence and Patient Education", "content": "Antenatal integration of a multidisciplinary team should merit consideration to improve outcomes on both integral maternal health and the viability of the gestation. The evaluation team should include an obstetrician, fetal concerns center nurse, genetic counselor, neonatologist, and social worker. [13] Educating the patient should include the mode of inheritance of the disease, the complications of choosing to continue to pregnancy, and the value associated interventions of postnatal care.", "contents": "Trisomy 13 -- Deterrence and Patient Education. Antenatal integration of a multidisciplinary team should merit consideration to improve outcomes on both integral maternal health and the viability of the gestation. The evaluation team should include an obstetrician, fetal concerns center nurse, genetic counselor, neonatologist, and social worker. [13] Educating the patient should include the mode of inheritance of the disease, the complications of choosing to continue to pregnancy, and the value associated interventions of postnatal care."}
+{"id": "article-100468_19", "title": "Trisomy 13 -- Pearls and Other Issues", "content": "Trisomy 13 is the third most common nondisjunction meiotic triploidy followed by Edwards and Down syndrome. [1] The three genetic presentations are complete nondisjunction trisomy 13, a Robertsonian translocation, and mosaicism. The most common cause of holoprosencephaly is related to trisomy 13. [1] During the first-trimester screening of trisomy 13, FNT will appear equal or greater than 3.5mm, with a decreased B-hCG, and PAPP-A. [11] Most gestations with trisomy 13 are terminated, the continuation of pregnancy increases the risk of preeclampsia. [18]", "contents": "Trisomy 13 -- Pearls and Other Issues. Trisomy 13 is the third most common nondisjunction meiotic triploidy followed by Edwards and Down syndrome. [1] The three genetic presentations are complete nondisjunction trisomy 13, a Robertsonian translocation, and mosaicism. The most common cause of holoprosencephaly is related to trisomy 13. [1] During the first-trimester screening of trisomy 13, FNT will appear equal or greater than 3.5mm, with a decreased B-hCG, and PAPP-A. [11] Most gestations with trisomy 13 are terminated, the continuation of pregnancy increases the risk of preeclampsia. [18]"}
+{"id": "article-100468_20", "title": "Trisomy 13 -- Enhancing Healthcare Team Outcomes", "content": "Nondisjunction defects during miosis are related to increased maternal age, especially those above 35 years. Evidence suggests that maternal history of a previous trisomy increases the risk of a subsequent one. [19] Prenatal counseling is associated with a decrease in the intensive treatment approach, increasing palliative care options for the neonate. [13]", "contents": "Trisomy 13 -- Enhancing Healthcare Team Outcomes. Nondisjunction defects during miosis are related to increased maternal age, especially those above 35 years. Evidence suggests that maternal history of a previous trisomy increases the risk of a subsequent one. [19] Prenatal counseling is associated with a decrease in the intensive treatment approach, increasing palliative care options for the neonate. [13]"}
+{"id": "article-100468_21", "title": "Trisomy 13 -- Review Questions", "content": "Access free multiple choice questions on this topic. Click here for a simplified version. Comment on this article.", "contents": "Trisomy 13 -- Review Questions. Access free multiple choice questions on this topic. Click here for a simplified version. Comment on this article."}

statpearls/chunk/article-100616.jsonl

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+{"id": "article-100616_0", "title": "Cefotaxime -- Continuing Education Activity", "content": "Cefotaxime is a medication used to manage and treat cervicitis/urethritis and pneumonia. Cefotaxime is a beta-lactam antibiotic classified as a third-generation cephalosporin. Its broad-spectrum antibacterial activity is useful in treating the susceptible strains of bacteria affecting the lower respiratory tract, genito-urinary tract, central nervous system, intra-abdominal infections, bone and joint infections, skin infections, gynecologic infections, and septicemia. This activity outlines the indications, mechanism of action, and contraindications for cefotaxime is a valuable agent in treating and managing bacterial infections. This activity will highlight the mechanism of action, adverse event profile, resistance, and other key factors pertinent to healthcare team members in the care of patients with pneumonia and urethritis/cervicitis and related conditions.", "contents": "Cefotaxime -- Continuing Education Activity. Cefotaxime is a medication used to manage and treat cervicitis/urethritis and pneumonia. Cefotaxime is a beta-lactam antibiotic classified as a third-generation cephalosporin. Its broad-spectrum antibacterial activity is useful in treating the susceptible strains of bacteria affecting the lower respiratory tract, genito-urinary tract, central nervous system, intra-abdominal infections, bone and joint infections, skin infections, gynecologic infections, and septicemia. This activity outlines the indications, mechanism of action, and contraindications for cefotaxime is a valuable agent in treating and managing bacterial infections. This activity will highlight the mechanism of action, adverse event profile, resistance, and other key factors pertinent to healthcare team members in the care of patients with pneumonia and urethritis/cervicitis and related conditions."}
+{"id": "article-100616_1", "title": "Cefotaxime -- Continuing Education Activity", "content": "Objectives: Describe the pathophysiology of cefotaxime resistance. Identify the most common adverse events associated with cefotaxime therapy. Outline the mechanism of action of cefotaxime. Review some interprofessional team strategies for improving care coordination and communication to advance cefotaxime and improve outcomes. Access free multiple choice questions on this topic.", "contents": "Cefotaxime -- Continuing Education Activity. Objectives: Describe the pathophysiology of cefotaxime resistance. Identify the most common adverse events associated with cefotaxime therapy. Outline the mechanism of action of cefotaxime. Review some interprofessional team strategies for improving care coordination and communication to advance cefotaxime and improve outcomes. Access free multiple choice questions on this topic."}
+{"id": "article-100616_2", "title": "Cefotaxime -- Indications", "content": "Cefotaxime is a\u00a0beta-lactam antibiotic\u00a0classified as a third-generation cephalosporin, which was first synthesized in 1976 and is FDA approved to treat gram-positive, gram-negative, and anaerobic bacteria. [1] Its broad-spectrum antibacterial activity is useful in treating the susceptible strains of bacteria affecting the lower respiratory tract, genito-urinary\u00a0tract, central nervous system, intra-abdominal infections, bone and joint infections,\u00a0skin infections, gynecologic infections, and septicemia. [2] Cefotaxime may also be used prophylactically prior to surgery to prevent surgical infections.", "contents": "Cefotaxime -- Indications. Cefotaxime is a\u00a0beta-lactam antibiotic\u00a0classified as a third-generation cephalosporin, which was first synthesized in 1976 and is FDA approved to treat gram-positive, gram-negative, and anaerobic bacteria. [1] Its broad-spectrum antibacterial activity is useful in treating the susceptible strains of bacteria affecting the lower respiratory tract, genito-urinary\u00a0tract, central nervous system, intra-abdominal infections, bone and joint infections,\u00a0skin infections, gynecologic infections, and septicemia. [2] Cefotaxime may also be used prophylactically prior to surgery to prevent surgical infections."}
+{"id": "article-100616_3", "title": "Cefotaxime -- Indications", "content": "Among the susceptible strains, Enterobacteriaceae is particularly sensitive to cefotaxime and may treat multi-drug resistant strains of Enterobacteriaceae . [3] Although it has a broad spectrum of bactericidal activity, it is not as effective against pseudomonas aeruginosa infections compared to other third-generation antibiotics and is not recommended as monotherapy. [3] Intramuscular treatment with cefotaxime for sexually transmitted infections with Neisseria gonorrhoeae has shown a positive outcome in both men and women.\u00a0Cefotaxime has beneficial therapeutic activity treating pneumonia affecting the lower respiratory tract primarily caused by Gram-negative bacilli, and the bactericidal agent has shown significant efficacy in treating complicated infections affecting the urinary tract. [4]", "contents": "Cefotaxime -- Indications. Among the susceptible strains, Enterobacteriaceae is particularly sensitive to cefotaxime and may treat multi-drug resistant strains of Enterobacteriaceae . [3] Although it has a broad spectrum of bactericidal activity, it is not as effective against pseudomonas aeruginosa infections compared to other third-generation antibiotics and is not recommended as monotherapy. [3] Intramuscular treatment with cefotaxime for sexually transmitted infections with Neisseria gonorrhoeae has shown a positive outcome in both men and women.\u00a0Cefotaxime has beneficial therapeutic activity treating pneumonia affecting the lower respiratory tract primarily caused by Gram-negative bacilli, and the bactericidal agent has shown significant efficacy in treating complicated infections affecting the urinary tract. [4]"}
+{"id": "article-100616_4", "title": "Cefotaxime -- Indications", "content": "Compared with the other cephalosporins, a favorable characteristic of cefotaxime is that it does not cause a notable occurrence of coagulopathies and pseudocholelithiasis. [4] Trials comparing cefotaxime with the third-generation cephalosporin ceftriaxone have exhibited similar clinical efficiency. [4] Clinical trials have also shown 75% to 100% resolution in hospitalized patients with moderate to severe infections. [5] [4] Cefotaxime may also be interchangeable with ceftriaxone as off-label use for the treatment of endocarditis by Haemophilus parainfluenzae , H. aphrophilus , Actinobacillus actinomycetemcomitans , Cardiobacterium hominis , Eikenella corrodens , and Kingella kingae (HACEK) organisms. [6] Cefotaxime can readily cross the blood-brain barrier when administered intravenously and may treat gram-negative infections resistant to previous generations of cephalosporins. [7]", "contents": "Cefotaxime -- Indications. Compared with the other cephalosporins, a favorable characteristic of cefotaxime is that it does not cause a notable occurrence of coagulopathies and pseudocholelithiasis. [4] Trials comparing cefotaxime with the third-generation cephalosporin ceftriaxone have exhibited similar clinical efficiency. [4] Clinical trials have also shown 75% to 100% resolution in hospitalized patients with moderate to severe infections. [5] [4] Cefotaxime may also be interchangeable with ceftriaxone as off-label use for the treatment of endocarditis by Haemophilus parainfluenzae , H. aphrophilus , Actinobacillus actinomycetemcomitans , Cardiobacterium hominis , Eikenella corrodens , and Kingella kingae (HACEK) organisms. [6] Cefotaxime can readily cross the blood-brain barrier when administered intravenously and may treat gram-negative infections resistant to previous generations of cephalosporins. [7]"}
+{"id": "article-100616_5", "title": "Cefotaxime -- Indications -- Susceptible Organisms", "content": "Gram-positive bacteria Enterococcus spp Staphylococcus aureus Staphylococcus epidermidis Streptococcus pneumoniae Streptococcus pyogenes Streptococcus viridans spp Anaerobic bacteria Bacteroides spp. Clostridium spp Fusobacterium spp Peptococcus spp Peptostreptococcus spp Gram-negative bacteria Acinetobacter spp. Citrobacter spp Enterobacter spp Escherichia coli Haemophilus influenzae Haemophilus parainfluenzae Klebsiella spp. Morganella morganii Neisseria gonorrhoeae Neisseria meningitidis Proteus mirabilis Proteus vulgaris Providencia rettgeri Providencia stuartii Serratia marcescens", "contents": "Cefotaxime -- Indications -- Susceptible Organisms. Gram-positive bacteria Enterococcus spp Staphylococcus aureus Staphylococcus epidermidis Streptococcus pneumoniae Streptococcus pyogenes Streptococcus viridans spp Anaerobic bacteria Bacteroides spp. Clostridium spp Fusobacterium spp Peptococcus spp Peptostreptococcus spp Gram-negative bacteria Acinetobacter spp. Citrobacter spp Enterobacter spp Escherichia coli Haemophilus influenzae Haemophilus parainfluenzae Klebsiella spp. Morganella morganii Neisseria gonorrhoeae Neisseria meningitidis Proteus mirabilis Proteus vulgaris Providencia rettgeri Providencia stuartii Serratia marcescens"}
+{"id": "article-100616_6", "title": "Cefotaxime -- Mechanism of Action", "content": "Cefotaxime is a bactericidal agent that exerts its mechanism of action by binding penicillin-binding proteins (PBPs) via beta-lactam rings and inhibiting the definitive activity of transpeptidation in peptidoglycan cell wall synthesis of susceptible bacterial organisms. [8] [9] Its action demonstrates a great affinity for PBP Ib and PBP III cell wall proteins.", "contents": "Cefotaxime -- Mechanism of Action. Cefotaxime is a bactericidal agent that exerts its mechanism of action by binding penicillin-binding proteins (PBPs) via beta-lactam rings and inhibiting the definitive activity of transpeptidation in peptidoglycan cell wall synthesis of susceptible bacterial organisms. [8] [9] Its action demonstrates a great affinity for PBP Ib and PBP III cell wall proteins."}
+{"id": "article-100616_7", "title": "Cefotaxime -- Mechanism of Action", "content": "The inability to form a bacterial cell wall further causes the autolysis of the bacteria. [7] Similarly to other third-generation cephalosporins, its broad spectrum action makes it efficacious against gram-positive and gram-negative bacteria.", "contents": "Cefotaxime -- Mechanism of Action. The inability to form a bacterial cell wall further causes the autolysis of the bacteria. [7] Similarly to other third-generation cephalosporins, its broad spectrum action makes it efficacious against gram-positive and gram-negative bacteria."}
+{"id": "article-100616_8", "title": "Cefotaxime -- Mechanism of Action -- Resistance", "content": "Beta-lactamases can cause hydrolysis to cefotaxime, further hindering its bactericidal effects. Although susceptive, cefotaxime is quite durable against the activity of most \u03b2-lactamases.", "contents": "Cefotaxime -- Mechanism of Action -- Resistance. Beta-lactamases can cause hydrolysis to cefotaxime, further hindering its bactericidal effects. Although susceptive, cefotaxime is quite durable against the activity of most \u03b2-lactamases."}
+{"id": "article-100616_9", "title": "Cefotaxime -- Mechanism of Action -- Metabolism", "content": "Once administered, cefotaxime undergoes metabolism\u00a0within\u00a0the liver, and the majority of it is excreted renally. In the liver, cefotaxime\u00a0converts to desacetylcefotaxime, which is further converted to desacetylcefotaxime lactone and then to M metabolites. [10] More than 80% is recovered in the urine, with one-third being in the form of desacetylcefotaxime (des-CTX).\u00a0Although desacetylcefotaxime (des-CTX) is the major metabolite of cefotaxime, its activity is eight-fold weaker than cefotaxime. [11]", "contents": "Cefotaxime -- Mechanism of Action -- Metabolism. Once administered, cefotaxime undergoes metabolism\u00a0within\u00a0the liver, and the majority of it is excreted renally. In the liver, cefotaxime\u00a0converts to desacetylcefotaxime, which is further converted to desacetylcefotaxime lactone and then to M metabolites. [10] More than 80% is recovered in the urine, with one-third being in the form of desacetylcefotaxime (des-CTX).\u00a0Although desacetylcefotaxime (des-CTX) is the major metabolite of cefotaxime, its activity is eight-fold weaker than cefotaxime. [11]"}
+{"id": "article-100616_10", "title": "Cefotaxime -- Administration", "content": "Cefotaxime is available and distributed in powder form and as a premixed solution for intramuscular and intervenous administration. The powder form is available in 500 mg, 1 g, 2 g, and 10 g vials. The premixed solution is available as 1g and 2g\u00a0for\u00a0injection.", "contents": "Cefotaxime -- Administration. Cefotaxime is available and distributed in powder form and as a premixed solution for intramuscular and intervenous administration. The powder form is available in 500 mg, 1 g, 2 g, and 10 g vials. The premixed solution is available as 1g and 2g\u00a0for\u00a0injection."}
+{"id": "article-100616_11", "title": "Cefotaxime -- Administration -- Gonococcal Infections", "content": "Urethritis (Males): 0.5 g intramuscular injection (can be administered as a single dose) Cervicitis (Females): 0.5 g\u00a0intramuscular injection\u00a0(can be administered as a single dose) Rectal infection (Males): 1 g\u00a0intramuscular injection\u00a0(can be administered as a single dose) Rectal infection( Females): 0.5 g\u00a0intramuscular injection\u00a0(can be administered as a single dose) Cefotaxime has no coverage for Chlamydia trachomatis, and treatment should be added if this organism is suspected.", "contents": "Cefotaxime -- Administration -- Gonococcal Infections. Urethritis (Males): 0.5 g intramuscular injection (can be administered as a single dose) Cervicitis (Females): 0.5 g\u00a0intramuscular injection\u00a0(can be administered as a single dose) Rectal infection (Males): 1 g\u00a0intramuscular injection\u00a0(can be administered as a single dose) Rectal infection( Females): 0.5 g\u00a0intramuscular injection\u00a0(can be administered as a single dose) Cefotaxime has no coverage for Chlamydia trachomatis, and treatment should be added if this organism is suspected."}
+{"id": "article-100616_12", "title": "Cefotaxime -- Administration -- Septicemia", "content": "2 g I.V. every 6\u00a0to 8 hours. (Daily dose of 6\u00a0to 8 grams)", "contents": "Cefotaxime -- Administration -- Septicemia. 2 g I.V. every 6\u00a0to 8 hours. (Daily dose of 6\u00a0to 8 grams)"}
+{"id": "article-100616_13", "title": "Cefotaxime -- Administration -- Spontaneous Bacterial Peritonitis (SBP)", "content": "Cefotaxime is the drug of choice in patients with SBP due to\u00a0its ability to achieve excellent levels in the\u00a0blood and ascitic fluid. The typical dose in SBP would be 2 g intravenous every 8 hours.", "contents": "Cefotaxime -- Administration -- Spontaneous Bacterial Peritonitis (SBP). Cefotaxime is the drug of choice in patients with SBP due to\u00a0its ability to achieve excellent levels in the\u00a0blood and ascitic fluid. The typical dose in SBP would be 2 g intravenous every 8 hours."}
+{"id": "article-100616_14", "title": "Cefotaxime -- Administration -- Uncomplicated Infections", "content": "1 g intramuscular or IV every 12 hours. (Daily dose of 2 grams)", "contents": "Cefotaxime -- Administration -- Uncomplicated Infections. 1 g intramuscular or IV every 12 hours. (Daily dose of 2 grams)"}
+{"id": "article-100616_15", "title": "Cefotaxime -- Administration -- Moderate to Severe Infections", "content": "1\u00a0to 2 g intramuscular or IV every 8 hours. (Daily dose of 3\u00a0to 6 grams)", "contents": "Cefotaxime -- Administration -- Moderate to Severe Infections. 1\u00a0to 2 g intramuscular or IV every 8 hours. (Daily dose of 3\u00a0to 6 grams)"}
+{"id": "article-100616_16", "title": "Cefotaxime -- Administration -- Life-threatening Infections", "content": "2 g intramuscular or IV every 4 hours. (Daily dose of\u00a012 grams)", "contents": "Cefotaxime -- Administration -- Life-threatening Infections. 2 g intramuscular or IV every 4 hours. (Daily dose of\u00a012 grams)"}
+{"id": "article-100616_17", "title": "Cefotaxime -- Administration -- Cesarean Section", "content": "First dose: 1 g IV (Umbilical cord should be clamped) Second dose:\u00a01 g intramuscular or IV (six hours\u00a0after the first dose) Third dose:\u00a01 g intramuscular or IV\u00a0(twelve hours\u00a0after the first dose)", "contents": "Cefotaxime -- Administration -- Cesarean Section. First dose: 1 g IV (Umbilical cord should be clamped) Second dose:\u00a01 g intramuscular or IV (six hours\u00a0after the first dose) Third dose:\u00a01 g intramuscular or IV\u00a0(twelve hours\u00a0after the first dose)"}
+{"id": "article-100616_18", "title": "Cefotaxime -- Administration -- Surgery Prophylaxis", "content": "1 g intramuscular or IV 30 minutes before surgery.", "contents": "Cefotaxime -- Administration -- Surgery Prophylaxis. 1 g intramuscular or IV 30 minutes before surgery."}
+{"id": "article-100616_19", "title": "Cefotaxime -- Administration -- Neonates (age 0\u00a0to 4 weeks)", "content": "(Age 0\u00a0to 1 week) 50 mg/kg per dose\u00a0IV every 12 hours (Age 1\u00a0to 4 weeks) 50 mg/kg per dose\u00a0IV every 8 hours", "contents": "Cefotaxime -- Administration -- Neonates (age 0\u00a0to 4 weeks). (Age 0\u00a0to 1 week) 50 mg/kg per dose\u00a0IV every 12 hours (Age 1\u00a0to 4 weeks) 50 mg/kg per dose\u00a0IV every 8 hours"}
+{"id": "article-100616_20", "title": "Cefotaxime -- Administration -- Infants and Children (age 1 month to 12 years old)", "content": "50 to 180 mg/kg intramuscular or IV every 6 to 8 hours (for individuals with body weight <50kg) 1\u00a0to 2 grams intramuscular or IV every 8 hours.\u00a0(for individuals with body weight >50kg) Individuals with a body weight>50 kg should follow adult dosing. The daily dosage should not exceed 12 grams for infants and children.", "contents": "Cefotaxime -- Administration -- Infants and Children (age 1 month to 12 years old). 50 to 180 mg/kg intramuscular or IV every 6 to 8 hours (for individuals with body weight <50kg) 1\u00a0to 2 grams intramuscular or IV every 8 hours.\u00a0(for individuals with body weight >50kg) Individuals with a body weight>50 kg should follow adult dosing. The daily dosage should not exceed 12 grams for infants and children."}
+{"id": "article-100616_21", "title": "Cefotaxime -- Adverse Effects", "content": "Local reaction: pain, swelling Hypersensitivity: rash, pruritis, anaphylaxis Gastrointestinal effects: nausea, vomiting, diarrhea Pseudomembranous Colitis Headache Elevation in liver enzymes Elevation in BUN and creatinine Hematologic: Neutropenia, leukopenia, agranulocytosis", "contents": "Cefotaxime -- Adverse Effects. Local reaction: pain, swelling Hypersensitivity: rash, pruritis, anaphylaxis Gastrointestinal effects: nausea, vomiting, diarrhea Pseudomembranous Colitis Headache Elevation in liver enzymes Elevation in BUN and creatinine Hematologic: Neutropenia, leukopenia, agranulocytosis"}
+{"id": "article-100616_22", "title": "Cefotaxime -- Adverse Effects", "content": "Local reactions such as pain, swelling, and rash are the most common adverse effects\u00a0following cefotaxime administration. Like other cephalosporins, cefotaxime\u00a0does not cause disulfiram-like reactions. Cefotaxime used concurrently with nephrotoxic agents may\u00a0promote\u00a0nephrotoxic effects on the kidney, and such use requires caution. Patients with hypersensitivity to the cephalosporin or penicillin group may result in an anaphylactic reaction and are manageable with epinephrine, antihistamines, vasopressors, or corticosteroids.", "contents": "Cefotaxime -- Adverse Effects. Local reactions such as pain, swelling, and rash are the most common adverse effects\u00a0following cefotaxime administration. Like other cephalosporins, cefotaxime\u00a0does not cause disulfiram-like reactions. Cefotaxime used concurrently with nephrotoxic agents may\u00a0promote\u00a0nephrotoxic effects on the kidney, and such use requires caution. Patients with hypersensitivity to the cephalosporin or penicillin group may result in an anaphylactic reaction and are manageable with epinephrine, antihistamines, vasopressors, or corticosteroids."}
+{"id": "article-100616_23", "title": "Cefotaxime -- Contraindications", "content": "Hypersensitivity to cefotaxime is an absolute contraindication to its use. Patients with known allergies to penicillin or other cephalosporins should also avoid cefotaxime.", "contents": "Cefotaxime -- Contraindications. Hypersensitivity to cefotaxime is an absolute contraindication to its use. Patients with known allergies to penicillin or other cephalosporins should also avoid cefotaxime."}
+{"id": "article-100616_24", "title": "Cefotaxime -- Monitoring", "content": "Cefotaxime\u00a0administration and dosing require adjusting in\u00a0geriatric populations, patients with decreased renal function, and hepatic dysfunction.\u00a0Renal function\u00a0and liver enzymes\u00a0require routine monitoring.\u00a0The half-life of cefotaxime is generally one hour, and severe kidney dysfunction may prolong the half-life of cefotaxime and its metabolite desacetylcefotaxime. [9] CBC should also be monitored with cefotaxime use as there are reports of hematologic changes such as neutropenia, leukopenia, and agranulocytosis. Cefotaxime, like other cephalosporins, may also cause a false positive direct coombs test.", "contents": "Cefotaxime -- Monitoring. Cefotaxime\u00a0administration and dosing require adjusting in\u00a0geriatric populations, patients with decreased renal function, and hepatic dysfunction.\u00a0Renal function\u00a0and liver enzymes\u00a0require routine monitoring.\u00a0The half-life of cefotaxime is generally one hour, and severe kidney dysfunction may prolong the half-life of cefotaxime and its metabolite desacetylcefotaxime. [9] CBC should also be monitored with cefotaxime use as there are reports of hematologic changes such as neutropenia, leukopenia, and agranulocytosis. Cefotaxime, like other cephalosporins, may also cause a false positive direct coombs test."}
+{"id": "article-100616_25", "title": "Cefotaxime -- Monitoring", "content": "Cefotaxime is an FDA Pregnancy Category B drug. Cefotaxime use in pregnancy has not been studied clearly and should be used cautiously. Cefotaxime is reported to cross the placenta during pregnancy. It is also present in low\u00a0concentrations in breast milk during lactation.", "contents": "Cefotaxime -- Monitoring. Cefotaxime is an FDA Pregnancy Category B drug. Cefotaxime use in pregnancy has not been studied clearly and should be used cautiously. Cefotaxime is reported to cross the placenta during pregnancy. It is also present in low\u00a0concentrations in breast milk during lactation."}
+{"id": "article-100616_26", "title": "Cefotaxime -- Toxicity", "content": "Cefotaxime is metabolized\u00a0by\u00a0the liver and excreted through the kidneys, and dysfunctions may result in decreased drug clearance\u00a0leading to\u00a0increased plasma concentrations.\u00a0About 50\u00a0to 60% of the agent is excreted unchanged, and 15 to 20%\u00a0is\u00a0excreted as a desacetyl metabolite desacetylcefotaxime. [9] Toxicity may result in convulsions, dyspnea, hypothermia, cyanosis, reversible encephalopathy, and death. Mortality has occurred with dosages of 6000 mg/kg/day. Treatment for cefotaxime toxicity requires supportive management.", "contents": "Cefotaxime -- Toxicity. Cefotaxime is metabolized\u00a0by\u00a0the liver and excreted through the kidneys, and dysfunctions may result in decreased drug clearance\u00a0leading to\u00a0increased plasma concentrations.\u00a0About 50\u00a0to 60% of the agent is excreted unchanged, and 15 to 20%\u00a0is\u00a0excreted as a desacetyl metabolite desacetylcefotaxime. [9] Toxicity may result in convulsions, dyspnea, hypothermia, cyanosis, reversible encephalopathy, and death. Mortality has occurred with dosages of 6000 mg/kg/day. Treatment for cefotaxime toxicity requires supportive management."}
+{"id": "article-100616_27", "title": "Cefotaxime -- Enhancing Healthcare Team Outcomes", "content": "Cefotaxime is a broad-spectrum antibiotic that is FDA-approved and indicated to treat gram-positive, gram-negative, and anaerobic organisms of susceptible strains causing pneumonia, urinary tract infections, cervicitis, endometritis, urethritis, and sepsis.\u00a0The care for patients suffering from infectious diseases prompts critical care from an interprofessional team of healthcare professionals, as preventable contagious disorders can lead to medication resistance, complications, and mortality. These healthcare professionals include a primary care physician, an internist, an infectious disease specialist, critical care, a gynecologist, a nurse, and a pharmacist.", "contents": "Cefotaxime -- Enhancing Healthcare Team Outcomes. Cefotaxime is a broad-spectrum antibiotic that is FDA-approved and indicated to treat gram-positive, gram-negative, and anaerobic organisms of susceptible strains causing pneumonia, urinary tract infections, cervicitis, endometritis, urethritis, and sepsis.\u00a0The care for patients suffering from infectious diseases prompts critical care from an interprofessional team of healthcare professionals, as preventable contagious disorders can lead to medication resistance, complications, and mortality. These healthcare professionals include a primary care physician, an internist, an infectious disease specialist, critical care, a gynecologist, a nurse, and a pharmacist."}
+{"id": "article-100616_28", "title": "Cefotaxime -- Enhancing Healthcare Team Outcomes", "content": "Primary care clinicians, internists, and specialists should educate the patients about the consequences of non-compliance with therapy for the full duration and how resistance to treatment can further cause complications and result in mortality. The primary care physician should routinely monitor renal function, liver enzymes, and CBC as cefotaxime is metabolized and cleared in the liver and kidneys, respectively, and has also been shown to cause hematologic adverse effects. Cefotaxime should be renally dosed in patients with compromised renal function, such as CKD or ESRD, and patients receiving hemodialysis.", "contents": "Cefotaxime -- Enhancing Healthcare Team Outcomes. Primary care clinicians, internists, and specialists should educate the patients about the consequences of non-compliance with therapy for the full duration and how resistance to treatment can further cause complications and result in mortality. The primary care physician should routinely monitor renal function, liver enzymes, and CBC as cefotaxime is metabolized and cleared in the liver and kidneys, respectively, and has also been shown to cause hematologic adverse effects. Cefotaxime should be renally dosed in patients with compromised renal function, such as CKD or ESRD, and patients receiving hemodialysis."}
+{"id": "article-100616_29", "title": "Cefotaxime -- Enhancing Healthcare Team Outcomes", "content": "Patients developing diarrhea while receiving treatment with antibiotics should be assessed for Clostridium difficile infection. Colonic flora is changed when receiving treatment with antibiotics, making it susceptible to Clostridium difficile infection resulting in mild to severe forms of diarrhea. Diagnostics and treatment focused on Clostridium difficile , electrolyte, and volume depletion should be initiated, and discontinuing management with cefotaxime should be considered.", "contents": "Cefotaxime -- Enhancing Healthcare Team Outcomes. Patients developing diarrhea while receiving treatment with antibiotics should be assessed for Clostridium difficile infection. Colonic flora is changed when receiving treatment with antibiotics, making it susceptible to Clostridium difficile infection resulting in mild to severe forms of diarrhea. Diagnostics and treatment focused on Clostridium difficile , electrolyte, and volume depletion should be initiated, and discontinuing management with cefotaxime should be considered."}
+{"id": "article-100616_30", "title": "Cefotaxime -- Enhancing Healthcare Team Outcomes", "content": "Counseling and\u00a0careful monitoring\u00a0are necessary during pregnancy, as clinical studies during its use in pregnancy are limited, and cefotaxime FDA pregnancy category B. Cefotaxime is reported to also be present in breastmilk in low amounts, and infants should be monitored accordingly. [12] Physicians should be up to date with the newly FDA-approved cefotaxime indications dosing, and their effects in the event drug resistance does develop.", "contents": "Cefotaxime -- Enhancing Healthcare Team Outcomes. Counseling and\u00a0careful monitoring\u00a0are necessary during pregnancy, as clinical studies during its use in pregnancy are limited, and cefotaxime FDA pregnancy category B. Cefotaxime is reported to also be present in breastmilk in low amounts, and infants should be monitored accordingly. [12] Physicians should be up to date with the newly FDA-approved cefotaxime indications dosing, and their effects in the event drug resistance does develop."}
+{"id": "article-100616_31", "title": "Cefotaxime -- Enhancing Healthcare Team Outcomes", "content": "During the treatment of gonorrhea causing urethritis or cervicitis, treatment for chlamydia should be added as cefotaxime does not have coverage for this organism. An interprofessional healthcare team approach to antimicrobial care with cefotaxime involving collaborative interventions and communication is key to building patient rapport and developing a therapeutic alliance so the patients comply with therapy adequately\u00a0to eradicate the bacteria\u00a0and prevent\u00a0further spread.\u00a0Continued communication and teamwork between healthcare professionals will improve antimicrobial stewardship, improve patient outcomes, limit microbial resistance, and lower the incidence of multidrug-resistant organisms.", "contents": "Cefotaxime -- Enhancing Healthcare Team Outcomes. During the treatment of gonorrhea causing urethritis or cervicitis, treatment for chlamydia should be added as cefotaxime does not have coverage for this organism. An interprofessional healthcare team approach to antimicrobial care with cefotaxime involving collaborative interventions and communication is key to building patient rapport and developing a therapeutic alliance so the patients comply with therapy adequately\u00a0to eradicate the bacteria\u00a0and prevent\u00a0further spread.\u00a0Continued communication and teamwork between healthcare professionals will improve antimicrobial stewardship, improve patient outcomes, limit microbial resistance, and lower the incidence of multidrug-resistant organisms."}
+{"id": "article-100616_32", "title": "Cefotaxime -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Cefotaxime -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

statpearls/chunk/article-100629.jsonl

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+{"id": "article-100629_0", "title": "Endovascular Papillary Angioendothelioma -- Continuing Education Activity", "content": "Endovascular papillary angioendothelioma (EPA), also known as Dabska tumor (DT) and papillary intralymphatic angioendothelioma (PILA), represents a borderline entity between hemangioma and angiosarcoma. DT has an overall favorable prognosis; however, there is potential for local recurrence and low-grade metastasis. This activity reviews the evaluation, treatment, and prognosis of endovascular papillary angioendothelioma and highlights the role of the interprofessional team in the care of patients with this condition.", "contents": "Endovascular Papillary Angioendothelioma -- Continuing Education Activity. Endovascular papillary angioendothelioma (EPA), also known as Dabska tumor (DT) and papillary intralymphatic angioendothelioma (PILA), represents a borderline entity between hemangioma and angiosarcoma. DT has an overall favorable prognosis; however, there is potential for local recurrence and low-grade metastasis. This activity reviews the evaluation, treatment, and prognosis of endovascular papillary angioendothelioma and highlights the role of the interprofessional team in the care of patients with this condition."}
+{"id": "article-100629_1", "title": "Endovascular Papillary Angioendothelioma -- Continuing Education Activity", "content": "Objectives: Describe the pathophysiology of endovascular papillary angioendothelioma. Review the appropriate evaluation of endovascular papillary angioendothelioma. Outline the management options for patients with endovascular papillary angioendothelioma. Summarize the importance of collaboration and communication amongst the interprofessional team to enhance care coordination for patients with endovascular papillary angioendothelioma. Access free multiple choice questions on this topic.", "contents": "Endovascular Papillary Angioendothelioma -- Continuing Education Activity. Objectives: Describe the pathophysiology of endovascular papillary angioendothelioma. Review the appropriate evaluation of endovascular papillary angioendothelioma. Outline the management options for patients with endovascular papillary angioendothelioma. Summarize the importance of collaboration and communication amongst the interprofessional team to enhance care coordination for patients with endovascular papillary angioendothelioma. Access free multiple choice questions on this topic."}
+{"id": "article-100629_2", "title": "Endovascular Papillary Angioendothelioma -- Introduction", "content": "Endovascular papillary angioendothelioma (EPA), also known as Dabska tumor (DT) and papillary intralymphatic angioendothelioma (PILA), represents a borderline entity between hemangioma and angiosarcoma. EPA has\u00a0an overall favorable prognosis. However,\u00a0it does have the potential for local recurrence and low-grade metastasis. It most frequently presents in children in various skin locations, subcutaneous tissue, and in deeper areas of the body. However, there have been reports of\u00a0EPA in adults and internal organs. [1]", "contents": "Endovascular Papillary Angioendothelioma -- Introduction. Endovascular papillary angioendothelioma (EPA), also known as Dabska tumor (DT) and papillary intralymphatic angioendothelioma (PILA), represents a borderline entity between hemangioma and angiosarcoma. EPA has\u00a0an overall favorable prognosis. However,\u00a0it does have the potential for local recurrence and low-grade metastasis. It most frequently presents in children in various skin locations, subcutaneous tissue, and in deeper areas of the body. However, there have been reports of\u00a0EPA in adults and internal organs. [1]"}
+{"id": "article-100629_3", "title": "Endovascular Papillary Angioendothelioma -- Introduction", "content": "Lesions are typically\u00a0two to three\u00a0centimeters in size at the time of presentation. A biopsy is diagnostic, and treatment is wide surgical excision. [2] Because of the rarity of these tumors, most of the information is available from case reports and case series.", "contents": "Endovascular Papillary Angioendothelioma -- Introduction. Lesions are typically\u00a0two to three\u00a0centimeters in size at the time of presentation. A biopsy is diagnostic, and treatment is wide surgical excision. [2] Because of the rarity of these tumors, most of the information is available from case reports and case series."}
+{"id": "article-100629_4", "title": "Endovascular Papillary Angioendothelioma -- Etiology", "content": "Endovascular papillary angioendothelioma may appear de novo or arise within an area of chronic lymphedema or a preexisting vascular malformation such as a hemangioma or a lymphangioma circumscriptum, etc. [3] [4] [5] The common differentials include retiform hemangioendothelioma, angiosarcoma, reactive angioendotheliomatosis, and benign intravascular endothelial hyperplasia. [6]", "contents": "Endovascular Papillary Angioendothelioma -- Etiology. Endovascular papillary angioendothelioma may appear de novo or arise within an area of chronic lymphedema or a preexisting vascular malformation such as a hemangioma or a lymphangioma circumscriptum, etc. [3] [4] [5] The common differentials include retiform hemangioendothelioma, angiosarcoma, reactive angioendotheliomatosis, and benign intravascular endothelial hyperplasia. [6]"}
+{"id": "article-100629_5", "title": "Endovascular Papillary Angioendothelioma -- Etiology", "content": "A lymphatic origin for this entity has been proposed due to common morphologic and immunophenotypic findings between adjacent lymphatics and lymphangioma in EPA, as well as the expression of vascular endothelial growth factor and lymphatic immunohistochemical marker, D2-40. [7]", "contents": "Endovascular Papillary Angioendothelioma -- Etiology. A lymphatic origin for this entity has been proposed due to common morphologic and immunophenotypic findings between adjacent lymphatics and lymphangioma in EPA, as well as the expression of vascular endothelial growth factor and lymphatic immunohistochemical marker, D2-40. [7]"}
+{"id": "article-100629_6", "title": "Endovascular Papillary Angioendothelioma -- Epidemiology", "content": "The Dabska tumor was originally described by Dabska et al. in 1969 in a case series with\u00a0six patients, all children. [2] Since then, less than 40 cases have been described in the literature. These reported cases show no clear gender predilection, and approximately 75% of patients are children; however, it has also been reported in the elderly. [8] A case series of 12 patients showed an age range of 8-59 with a mean of 30 years, suggesting a wider range. [9] Although it usually presents as an intradermal lesion, there have been reports of involvement of the spleen, testicle, tongue, and bone. [10] [11] [12] [13]", "contents": "Endovascular Papillary Angioendothelioma -- Epidemiology. The Dabska tumor was originally described by Dabska et al. in 1969 in a case series with\u00a0six patients, all children. [2] Since then, less than 40 cases have been described in the literature. These reported cases show no clear gender predilection, and approximately 75% of patients are children; however, it has also been reported in the elderly. [8] A case series of 12 patients showed an age range of 8-59 with a mean of 30 years, suggesting a wider range. [9] Although it usually presents as an intradermal lesion, there have been reports of involvement of the spleen, testicle, tongue, and bone. [10] [11] [12] [13]"}
+{"id": "article-100629_7", "title": "Endovascular Papillary Angioendothelioma -- Pathophysiology", "content": "Endovascular papillary angioendothelioma is within a borderline area between benign lesions such as hemangioma and malignant ones like angiosarcoma. There have been cases of these tumors arising within preexisting vascular lesions such as cavernous hemangiomas. Morphologic similarity has also been observed with retiform hemangioendothelioma and may represent the spectrum of the same lesion. Based on the literature review, currently, the diagnosis of EPA is limited to low-grade sarcoma, demonstrating characteristic histopathological and immunohistochemistry features. [6]", "contents": "Endovascular Papillary Angioendothelioma -- Pathophysiology. Endovascular papillary angioendothelioma is within a borderline area between benign lesions such as hemangioma and malignant ones like angiosarcoma. There have been cases of these tumors arising within preexisting vascular lesions such as cavernous hemangiomas. Morphologic similarity has also been observed with retiform hemangioendothelioma and may represent the spectrum of the same lesion. Based on the literature review, currently, the diagnosis of EPA is limited to low-grade sarcoma, demonstrating characteristic histopathological and immunohistochemistry features. [6]"}
+{"id": "article-100629_8", "title": "Endovascular Papillary Angioendothelioma -- Histopathology", "content": "Histopathological evaluation remains a gold standard for the diagnosis of these rare tumors. They are characterized by numerous interconnecting vascular channels with papillary projections or tuft like structures as observed in renal glomeruli. Endothelial cells lining the vascular channels have a classic hobnail or matchstick appearance due to\u00a0an apically placed nucleus that produces a surface bulge. [11] [14] Also, these cells demonstrate a high nuclear to cytoplasmic ratio with mitotic activity to a moderate degree. [14] Intravascular and perivascular lymphocytic infiltrates have also been observed. [6] Among all these features, the demonstration of papillary projections seems to be the most important for the diagnosis of endovascular papillary angioendothelioma.", "contents": "Endovascular Papillary Angioendothelioma -- Histopathology. Histopathological evaluation remains a gold standard for the diagnosis of these rare tumors. They are characterized by numerous interconnecting vascular channels with papillary projections or tuft like structures as observed in renal glomeruli. Endothelial cells lining the vascular channels have a classic hobnail or matchstick appearance due to\u00a0an apically placed nucleus that produces a surface bulge. [11] [14] Also, these cells demonstrate a high nuclear to cytoplasmic ratio with mitotic activity to a moderate degree. [14] Intravascular and perivascular lymphocytic infiltrates have also been observed. [6] Among all these features, the demonstration of papillary projections seems to be the most important for the diagnosis of endovascular papillary angioendothelioma."}
+{"id": "article-100629_9", "title": "Endovascular Papillary Angioendothelioma -- Histopathology", "content": "Immunohistochemistry further aids in diagnosis by identifying the tissue origin. EPA tumor cells react positively to vascular and lymphatic markers. They are classically positive for CD34, VEGFR - 3, CD31, D2-40, and factor VIII related antigen. [6] D2-40 is a lymphatic endothelial marker; its positivity differentiates it from other tumors exhibiting similar characteristics on histology. [6]", "contents": "Endovascular Papillary Angioendothelioma -- Histopathology. Immunohistochemistry further aids in diagnosis by identifying the tissue origin. EPA tumor cells react positively to vascular and lymphatic markers. They are classically positive for CD34, VEGFR - 3, CD31, D2-40, and factor VIII related antigen. [6] D2-40 is a lymphatic endothelial marker; its positivity differentiates it from other tumors exhibiting similar characteristics on histology. [6]"}
+{"id": "article-100629_10", "title": "Endovascular Papillary Angioendothelioma -- Histopathology", "content": "Small storage granules consisting of von Willebrand factor and P-selectin, called Weibel Palade bodies,\u00a0might be demonstrated upon examination under the electron microscope of the tumor cells. Also seen are irregular nuclei, abundant perinuclear cytoplasmic filaments, and pinocytotic vesicles. [11]", "contents": "Endovascular Papillary Angioendothelioma -- Histopathology. Small storage granules consisting of von Willebrand factor and P-selectin, called Weibel Palade bodies,\u00a0might be demonstrated upon examination under the electron microscope of the tumor cells. Also seen are irregular nuclei, abundant perinuclear cytoplasmic filaments, and pinocytotic vesicles. [11]"}
+{"id": "article-100629_11", "title": "Endovascular Papillary Angioendothelioma -- History and Physical", "content": "Generally, endovascular papillary angioendothelioma presents as a slow-growing, painless nodule\u00a0that is typically localized to the subcutaneous tissue of the extremities, dermis,\u00a0and less commonly on the trunk, head, and neck. [11] Some cases have been reported in deeper locations such as the bone, brain, spleen, tongue, and testis. [8] Notably, no other primary sources were discovered in these instances, nor was lymph node involvement identified. [6]", "contents": "Endovascular Papillary Angioendothelioma -- History and Physical. Generally, endovascular papillary angioendothelioma presents as a slow-growing, painless nodule\u00a0that is typically localized to the subcutaneous tissue of the extremities, dermis,\u00a0and less commonly on the trunk, head, and neck. [11] Some cases have been reported in deeper locations such as the bone, brain, spleen, tongue, and testis. [8] Notably, no other primary sources were discovered in these instances, nor was lymph node involvement identified. [6]"}
+{"id": "article-100629_12", "title": "Endovascular Papillary Angioendothelioma -- History and Physical", "content": "Most cutaneous tumors come to medical attention when they are\u00a0two to three\u00a0centimeters in size. [15] However, much larger lesions have been reported, and have been seen up to 40 centimeters in diameter. The tumors may vary in appearance. Some are described as an ill-defined mass, a plaque, or a nodule with projections into the surrounding tissue. The overlying skin may be pink, blue, or violaceous in color with an atrophic dermis.", "contents": "Endovascular Papillary Angioendothelioma -- History and Physical. Most cutaneous tumors come to medical attention when they are\u00a0two to three\u00a0centimeters in size. [15] However, much larger lesions have been reported, and have been seen up to 40 centimeters in diameter. The tumors may vary in appearance. Some are described as an ill-defined mass, a plaque, or a nodule with projections into the surrounding tissue. The overlying skin may be pink, blue, or violaceous in color with an atrophic dermis."}
+{"id": "article-100629_13", "title": "Endovascular Papillary Angioendothelioma -- History and Physical", "content": "Symptomatology is also variable. Patients may complain of pain, ulceration, or bleeding from the affected site. [6] Though these lesions tend to be low grade, cases of regional nodal involvement and pulmonary metastasis have been reported in the literature. [16] Hence, it is essential for complete physical evaluation, including a metastatic workup.", "contents": "Endovascular Papillary Angioendothelioma -- History and Physical. Symptomatology is also variable. Patients may complain of pain, ulceration, or bleeding from the affected site. [6] Though these lesions tend to be low grade, cases of regional nodal involvement and pulmonary metastasis have been reported in the literature. [16] Hence, it is essential for complete physical evaluation, including a metastatic workup."}
+{"id": "article-100629_14", "title": "Endovascular Papillary Angioendothelioma -- Evaluation", "content": "The definitive diagnosis of\u00a0EPA\u00a0is made with a biopsy. As this is such a rare entity, protocols for disease involvement, surveillance, and follow-up have yet to be established. It is reasonable to consider obtaining a chest radiograph for any patient with pulmonary symptoms due to a reported case of a patient dying of pulmonary metastases. Lymph node examination may be performed if there is suspicion for involvement. [15]", "contents": "Endovascular Papillary Angioendothelioma -- Evaluation. The definitive diagnosis of\u00a0EPA\u00a0is made with a biopsy. As this is such a rare entity, protocols for disease involvement, surveillance, and follow-up have yet to be established. It is reasonable to consider obtaining a chest radiograph for any patient with pulmonary symptoms due to a reported case of a patient dying of pulmonary metastases. Lymph node examination may be performed if there is suspicion for involvement. [15]"}
+{"id": "article-100629_15", "title": "Endovascular Papillary Angioendothelioma -- Treatment / Management", "content": "Surgical excision is recommended. In general, the prognosis is favorable for Dabska tumors even with invasion into deeper structures. However, the malignant potential of this tumor should not be ignored, and close follow-up should be maintained. [6] Regional lymphadenectomy should be performed when those structures appear involved. [15]", "contents": "Endovascular Papillary Angioendothelioma -- Treatment / Management. Surgical excision is recommended. In general, the prognosis is favorable for Dabska tumors even with invasion into deeper structures. However, the malignant potential of this tumor should not be ignored, and close follow-up should be maintained. [6] Regional lymphadenectomy should be performed when those structures appear involved. [15]"}
+{"id": "article-100629_16", "title": "Endovascular Papillary Angioendothelioma -- Treatment / Management", "content": "In one case report, the authors chose to follow National Comprehensive Cancer Network (NCCN) practice guidelines in oncology for soft tissue sarcoma of extremity/trunk stage IIA (T1bN0M0G2), which recommends chest imaging (plain radiograph or chest computed tomography) every 3 to 6 months for 2 to 3 years, then every six months for two years, and then annually for ongoing monitoring. [6]", "contents": "Endovascular Papillary Angioendothelioma -- Treatment / Management. In one case report, the authors chose to follow National Comprehensive Cancer Network (NCCN) practice guidelines in oncology for soft tissue sarcoma of extremity/trunk stage IIA (T1bN0M0G2), which recommends chest imaging (plain radiograph or chest computed tomography) every 3 to 6 months for 2 to 3 years, then every six months for two years, and then annually for ongoing monitoring. [6]"}
+{"id": "article-100629_17", "title": "Endovascular Papillary Angioendothelioma -- Differential Diagnosis", "content": "The differential diagnosis of this tumor is histologic, as many neoplasms display intravascular proliferation. The differential should include intravascular papillary endothelial hyperplasia (Masson tumor), epithelioid hemangioendothelioma, angiosarcoma, lymphangioma-like Kaposi sarcoma, and retiform hemangioendothelioma. [7]", "contents": "Endovascular Papillary Angioendothelioma -- Differential Diagnosis. The differential diagnosis of this tumor is histologic, as many neoplasms display intravascular proliferation. The differential should include intravascular papillary endothelial hyperplasia (Masson tumor), epithelioid hemangioendothelioma, angiosarcoma, lymphangioma-like Kaposi sarcoma, and retiform hemangioendothelioma. [7]"}
+{"id": "article-100629_18", "title": "Endovascular Papillary Angioendothelioma -- Differential Diagnosis", "content": "The unique feature of\u00a0EPA is the papillary structure lined by atypical columnar endothelial cells. A similar formation has been described extravascularly in the patch stage Kaposi sarcoma. Ordinary angiosarcomas may also show focal morphologic patterns of EPA, and in a study of 80 cases of angiosarcoma of soft tissue, 14% showed evidence papillary fronds. [16] Angiosarcoma, however, shows more significant endothelial atypia and diffuse growth outside of blood vessels. [7]", "contents": "Endovascular Papillary Angioendothelioma -- Differential Diagnosis. The unique feature of\u00a0EPA is the papillary structure lined by atypical columnar endothelial cells. A similar formation has been described extravascularly in the patch stage Kaposi sarcoma. Ordinary angiosarcomas may also show focal morphologic patterns of EPA, and in a study of 80 cases of angiosarcoma of soft tissue, 14% showed evidence papillary fronds. [16] Angiosarcoma, however, shows more significant endothelial atypia and diffuse growth outside of blood vessels. [7]"}
+{"id": "article-100629_19", "title": "Endovascular Papillary Angioendothelioma -- Differential Diagnosis", "content": "Organized thrombi cause the Masson phenomenon, showing papillary processes of the fibrous cores covered with a layer of endothelial cells. Unlike EPA, the Masson phenomenon is contained within blood vessels, and there are often visible intravascular thrombi. It lacks the presence of columnar endothelial cells and has a single endothelial cell layer surrounding hyalinized stromal cores. [7]", "contents": "Endovascular Papillary Angioendothelioma -- Differential Diagnosis. Organized thrombi cause the Masson phenomenon, showing papillary processes of the fibrous cores covered with a layer of endothelial cells. Unlike EPA, the Masson phenomenon is contained within blood vessels, and there are often visible intravascular thrombi. It lacks the presence of columnar endothelial cells and has a single endothelial cell layer surrounding hyalinized stromal cores. [7]"}
+{"id": "article-100629_20", "title": "Endovascular Papillary Angioendothelioma -- Differential Diagnosis", "content": "Epithelioid hemangioendothelioma display endothelial cells with eosinophilic vacuolated cytoplasm. The tumor cells arrange as cords, trabeculae, or sheets with myxoid or hyalinized stroma, and often spread outside of the blood vessel. [7]", "contents": "Endovascular Papillary Angioendothelioma -- Differential Diagnosis. Epithelioid hemangioendothelioma display endothelial cells with eosinophilic vacuolated cytoplasm. The tumor cells arrange as cords, trabeculae, or sheets with myxoid or hyalinized stroma, and often spread outside of the blood vessel. [7]"}
+{"id": "article-100629_21", "title": "Endovascular Papillary Angioendothelioma -- Differential Diagnosis", "content": "Of note, there have been reports in the literature of benign acquired vascular proliferations displaying areas with Dabska features simulating malignancy. Therefore, the presence of\u00a0atypical architectural features in an otherwise benign-looking acquired vascular proliferation should not lead to unnecessarily aggressive treatment. [17]", "contents": "Endovascular Papillary Angioendothelioma -- Differential Diagnosis. Of note, there have been reports in the literature of benign acquired vascular proliferations displaying areas with Dabska features simulating malignancy. Therefore, the presence of\u00a0atypical architectural features in an otherwise benign-looking acquired vascular proliferation should not lead to unnecessarily aggressive treatment. [17]"}
+{"id": "article-100629_22", "title": "Endovascular Papillary Angioendothelioma -- Surgical Oncology", "content": "Currently, wide local excision remains the treatment of choice for these tumors. [16] In most of the patients, this treatment is sufficient without any recurrence. However, a few cases of lymph nodal involvement and pulmonary metastasis have been reported, thus advocating the need for close follow up and long term evaluation. [16]", "contents": "Endovascular Papillary Angioendothelioma -- Surgical Oncology. Currently, wide local excision remains the treatment of choice for these tumors. [16] In most of the patients, this treatment is sufficient without any recurrence. However, a few cases of lymph nodal involvement and pulmonary metastasis have been reported, thus advocating the need for close follow up and long term evaluation. [16]"}
+{"id": "article-100629_23", "title": "Endovascular Papillary Angioendothelioma -- Radiation Oncology", "content": "Evidence for radiation therapy in these tumors is limited. Of the six patients reported by the Dabska et al. group, three received radiation therapy; of these, two received preoperative radiation while one received it after surgery. [14] Those who received preoperative radiation did not report any response; however, this could be due to the suboptimal dose delivered to these patients. The recommended radiation dose in the preoperative setting for sarcomas is around 50Gy,\u00a0and the dose they received was around 30Gy. Currently, there are no recommendations for radiation therapy; however, due to deep invasion features observed, it may play a role in the recurrent setting.", "contents": "Endovascular Papillary Angioendothelioma -- Radiation Oncology. Evidence for radiation therapy in these tumors is limited. Of the six patients reported by the Dabska et al. group, three received radiation therapy; of these, two received preoperative radiation while one received it after surgery. [14] Those who received preoperative radiation did not report any response; however, this could be due to the suboptimal dose delivered to these patients. The recommended radiation dose in the preoperative setting for sarcomas is around 50Gy,\u00a0and the dose they received was around 30Gy. Currently, there are no recommendations for radiation therapy; however, due to deep invasion features observed, it may play a role in the recurrent setting."}
+{"id": "article-100629_24", "title": "Endovascular Papillary Angioendothelioma -- Radiation Oncology", "content": "Due to the rarity of these tumors, the benefit of radiation therapy in a randomized trial would be difficult to obtain. Hence it would be prudent to consider radiation in tumors showing features of a high risk of recurrences such as size > 5 cm, deep invasion, and positive margins based upon their behavior pattern similar to low-grade sarcomas.", "contents": "Endovascular Papillary Angioendothelioma -- Radiation Oncology. Due to the rarity of these tumors, the benefit of radiation therapy in a randomized trial would be difficult to obtain. Hence it would be prudent to consider radiation in tumors showing features of a high risk of recurrences such as size > 5 cm, deep invasion, and positive margins based upon their behavior pattern similar to low-grade sarcomas."}
+{"id": "article-100629_25", "title": "Endovascular Papillary Angioendothelioma -- Pertinent Studies and Ongoing Trials", "content": "Due to the rarity of these tumors, it is challenging to obtain level I evidence for treatment recommendations. Currently, the practice guidelines are obtained from published case series and reports.", "contents": "Endovascular Papillary Angioendothelioma -- Pertinent Studies and Ongoing Trials. Due to the rarity of these tumors, it is challenging to obtain level I evidence for treatment recommendations. Currently, the practice guidelines are obtained from published case series and reports."}
+{"id": "article-100629_26", "title": "Endovascular Papillary Angioendothelioma -- Treatment Planning", "content": "Patterns of failure are yet to be determined for this rare tumor; meanwhile, it would be prudent to consider radiation in a post-operative setting for tumors exhibiting high-risk features for recurrence. Dose, technique, and volume delineation should be based on the principles of radiation therapy in sarcoma.", "contents": "Endovascular Papillary Angioendothelioma -- Treatment Planning. Patterns of failure are yet to be determined for this rare tumor; meanwhile, it would be prudent to consider radiation in a post-operative setting for tumors exhibiting high-risk features for recurrence. Dose, technique, and volume delineation should be based on the principles of radiation therapy in sarcoma."}
+{"id": "article-100629_27", "title": "Endovascular Papillary Angioendothelioma -- Medical Oncology", "content": "Based on the literature review, the role of systemic therapy remains yet to be established. Chemotherapy has shown response in angiosarcomas; there may be a role for chemotherapy in the metastatic setting. [18] It is highly recommended for institutions to report their experience with radiation therapy and systemic therapy, which will further add to the literature and guide others in treating these rare tumors with the best possible approach.", "contents": "Endovascular Papillary Angioendothelioma -- Medical Oncology. Based on the literature review, the role of systemic therapy remains yet to be established. Chemotherapy has shown response in angiosarcomas; there may be a role for chemotherapy in the metastatic setting. [18] It is highly recommended for institutions to report their experience with radiation therapy and systemic therapy, which will further add to the literature and guide others in treating these rare tumors with the best possible approach."}
+{"id": "article-100629_28", "title": "Endovascular Papillary Angioendothelioma -- Prognosis", "content": "In general, endovascular papillary angioendothelioma are low-grade tumors with favorable outcomes managed with surgery alone. Long term review of originally described patients with Dabska tumors has reported excellent outcomes. [14] However, lymph node metastasis and pulmonary metastasis have been documented, so close follow up and evaluation is warranted. [16]", "contents": "Endovascular Papillary Angioendothelioma -- Prognosis. In general, endovascular papillary angioendothelioma are low-grade tumors with favorable outcomes managed with surgery alone. Long term review of originally described patients with Dabska tumors has reported excellent outcomes. [14] However, lymph node metastasis and pulmonary metastasis have been documented, so close follow up and evaluation is warranted. [16]"}
+{"id": "article-100629_29", "title": "Endovascular Papillary Angioendothelioma -- Complications", "content": "Endovascular papillary angioendothelioma are slow-growing tumors with favorable prognosis. However, there have been reports of pulmonary metastasis; hence these tumors are not to be underestimated and should be evaluated and treated in time.", "contents": "Endovascular Papillary Angioendothelioma -- Complications. Endovascular papillary angioendothelioma are slow-growing tumors with favorable prognosis. However, there have been reports of pulmonary metastasis; hence these tumors are not to be underestimated and should be evaluated and treated in time."}
+{"id": "article-100629_30", "title": "Endovascular Papillary Angioendothelioma -- Deterrence and Patient Education", "content": "Endovascular papillary angioendothelioma must be kept in the differential, especially for children presenting with slow-growing intradermal nodules and evaluated accordingly. Awareness among dermatologists is crucial, as most likely, they will be the primary providers to whom the children will present.", "contents": "Endovascular Papillary Angioendothelioma -- Deterrence and Patient Education. Endovascular papillary angioendothelioma must be kept in the differential, especially for children presenting with slow-growing intradermal nodules and evaluated accordingly. Awareness among dermatologists is crucial, as most likely, they will be the primary providers to whom the children will present."}
+{"id": "article-100629_31", "title": "Endovascular Papillary Angioendothelioma -- Enhancing Healthcare Team Outcomes", "content": "Endovascular papillary\u00a0angioendothelioma, also known as Dabska tumor and papillary intralymphatic\u00a0angioendothelioma, is a rare tumor of deeper skin. The diagnosis is made with a biopsy. Because of the vast differential for a painless skin lesion, the management should be by an interprofessional team that consists of a dermatologist, plastic surgeon, oncologist, and general surgeon.", "contents": "Endovascular Papillary Angioendothelioma -- Enhancing Healthcare Team Outcomes. Endovascular papillary\u00a0angioendothelioma, also known as Dabska tumor and papillary intralymphatic\u00a0angioendothelioma, is a rare tumor of deeper skin. The diagnosis is made with a biopsy. Because of the vast differential for a painless skin lesion, the management should be by an interprofessional team that consists of a dermatologist, plastic surgeon, oncologist, and general surgeon."}
+{"id": "article-100629_32", "title": "Endovascular Papillary Angioendothelioma -- Enhancing Healthcare Team Outcomes", "content": "Primary clinicians who are not familiar with the management of such lesions should refer the patient to an oncologist. EPA has\u00a0an overall favorable prognosis, but it does have the potential for local recurrence and low-grade metastasis. Thus, long term follows up is required.", "contents": "Endovascular Papillary Angioendothelioma -- Enhancing Healthcare Team Outcomes. Primary clinicians who are not familiar with the management of such lesions should refer the patient to an oncologist. EPA has\u00a0an overall favorable prognosis, but it does have the potential for local recurrence and low-grade metastasis. Thus, long term follows up is required."}
+{"id": "article-100629_33", "title": "Endovascular Papillary Angioendothelioma -- Review Questions", "content": "Access free multiple choice questions on this topic. Click here for a simplified version. Comment on this article.", "contents": "Endovascular Papillary Angioendothelioma -- Review Questions. Access free multiple choice questions on this topic. Click here for a simplified version. Comment on this article."}

statpearls/chunk/article-100713.jsonl

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+{"id": "article-100713_0", "title": "Disability Evaluation -- Continuing Education Activity", "content": "Impairment and disability are a concern for people around the globe. Injury, illness, or disease that inhibits an individual from participating in their home environment, social environment, or work environment can have widespread effects on their lives and livelihood. This article succinctly presents relevant terminology and definitions, important concepts such as disability claims and return to work, and introduces the impairment rating system.", "contents": "Disability Evaluation -- Continuing Education Activity. Impairment and disability are a concern for people around the globe. Injury, illness, or disease that inhibits an individual from participating in their home environment, social environment, or work environment can have widespread effects on their lives and livelihood. This article succinctly presents relevant terminology and definitions, important concepts such as disability claims and return to work, and introduces the impairment rating system."}
+{"id": "article-100713_1", "title": "Disability Evaluation -- Continuing Education Activity", "content": "Objectives: Summarize the differences between impairment, disability, and handicap. Outline the diagnosis-based impairment method and how to determine an impairment score. Describe and review the Americans with Disabilities Act. Discuss the interprofessional approach to safely and quickly returning a patient to work when recovering from a disability. Access free multiple choice questions on this topic.", "contents": "Disability Evaluation -- Continuing Education Activity. Objectives: Summarize the differences between impairment, disability, and handicap. Outline the diagnosis-based impairment method and how to determine an impairment score. Describe and review the Americans with Disabilities Act. Discuss the interprofessional approach to safely and quickly returning a patient to work when recovering from a disability. Access free multiple choice questions on this topic."}
+{"id": "article-100713_2", "title": "Disability Evaluation -- Introduction", "content": "According to the CDC, 1 in 4 Americans lives with a disability. This equates to approximately 61 million Americans. Disability, by nature, is a dynamic concept because it involves the relationship between the patient and their injury, physical environment, social atmosphere, economic factors, and religious beliefs. Patients can be affected in functions related to cognition through functions involved with living independently. Although 2 in 5 patients above the age of 65 have a disability, anyone can become disabled at any time in their life. The number of disabled persons is forecasted to be a rapidly growing statistic for several reasons. One reason is the incidence and prevalence of obesity, heart disease, and diabetes. The aforementioned chronic conditions are all risk factors for disability, and as a result of their increase, the incidence of disability will too increase.\u00a0 Another reason is the increase in life expectancy due to advances in medicine and surgery. More people are surviving what would previously be considered a life-ending ailment. However, a common complication of surviving one of these previously life-ending ailments is residual limb deformity, chronic pain, and impaired mobility, to list a few. These complications can affect the way a person interacts with their environment, therefore, leading to disability. Disability has a continuously evolving definition and legal interpretation, as can be expected by the continuous change in socioeconomics and prevalence of chronic disease.", "contents": "Disability Evaluation -- Introduction. According to the CDC, 1 in 4 Americans lives with a disability. This equates to approximately 61 million Americans. Disability, by nature, is a dynamic concept because it involves the relationship between the patient and their injury, physical environment, social atmosphere, economic factors, and religious beliefs. Patients can be affected in functions related to cognition through functions involved with living independently. Although 2 in 5 patients above the age of 65 have a disability, anyone can become disabled at any time in their life. The number of disabled persons is forecasted to be a rapidly growing statistic for several reasons. One reason is the incidence and prevalence of obesity, heart disease, and diabetes. The aforementioned chronic conditions are all risk factors for disability, and as a result of their increase, the incidence of disability will too increase.\u00a0 Another reason is the increase in life expectancy due to advances in medicine and surgery. More people are surviving what would previously be considered a life-ending ailment. However, a common complication of surviving one of these previously life-ending ailments is residual limb deformity, chronic pain, and impaired mobility, to list a few. These complications can affect the way a person interacts with their environment, therefore, leading to disability. Disability has a continuously evolving definition and legal interpretation, as can be expected by the continuous change in socioeconomics and prevalence of chronic disease."}
+{"id": "article-100713_3", "title": "Disability Evaluation -- Introduction", "content": "When discussing disability, it is important to understand the terminology. Simply put, three main words: impairment, disability, and handicap. Impairment is essentially a dysfunction of a body system, such as an organ system or the musculoskeletal system. This can affect how a patient interacts with their home, social, or work environments and can often present as a lack of ability to do something. This is known as a disability. It is important to highlight that not all impairments lead to a disability. Disability can be further categorized into temporary or permanent and partial or total disability. Lastly, the term handicap relates the consequences of a disability for a patient to the community or social environment.\u00a0 For example, a person with an above-the-knee amputation has difficulty walking long distances and therefore needs to park their vehicle close to the entrance.", "contents": "Disability Evaluation -- Introduction. When discussing disability, it is important to understand the terminology. Simply put, three main words: impairment, disability, and handicap. Impairment is essentially a dysfunction of a body system, such as an organ system or the musculoskeletal system. This can affect how a patient interacts with their home, social, or work environments and can often present as a lack of ability to do something. This is known as a disability. It is important to highlight that not all impairments lead to a disability. Disability can be further categorized into temporary or permanent and partial or total disability. Lastly, the term handicap relates the consequences of a disability for a patient to the community or social environment.\u00a0 For example, a person with an above-the-knee amputation has difficulty walking long distances and therefore needs to park their vehicle close to the entrance."}
+{"id": "article-100713_4", "title": "Disability Evaluation -- Introduction", "content": "As a result of the continuous evolution of disablement, its conceptualization has evolved as well. There are three main paradigms through which disablement can be viewed and interpreted.\u00a0 The medical paradigm is the original model for disability guidelines. The medical model focuses on the pathology causing the impairment. It seeks to relate organ dysfunction at the simplest level to physical dysfunction. The main problem with this interpretation is that not all organ or system dysfunction has a specific treatment, therapeutic endpoint, or clear-cut disability.\u00a0 The social paradigm interprets the social and functional barriers associated with certain impairments. What special accommodations are required as a result?", "contents": "Disability Evaluation -- Introduction. As a result of the continuous evolution of disablement, its conceptualization has evolved as well. There are three main paradigms through which disablement can be viewed and interpreted.\u00a0 The medical paradigm is the original model for disability guidelines. The medical model focuses on the pathology causing the impairment. It seeks to relate organ dysfunction at the simplest level to physical dysfunction. The main problem with this interpretation is that not all organ or system dysfunction has a specific treatment, therapeutic endpoint, or clear-cut disability.\u00a0 The social paradigm interprets the social and functional barriers associated with certain impairments. What special accommodations are required as a result?"}
+{"id": "article-100713_5", "title": "Disability Evaluation -- Introduction", "content": "The benefit of this paradigm is that it allows people with a disabling impairment to become empowered and participate in society. The biopsychosocial paradigm is the preferred interpretation for disablement because it is multifaceted. The biological facet incorporates any mental or physical impairment. The psychological facet attempts to interpret the emotional state of the individual and take into account various personal and religious beliefs. The social facet addresses the environmental and infrastructural changes that are required to make the physical environment adaptable for patients with disabilities. The International Classification of Functioning, Disability, and Health (ICF) currently adopts the biopsychosocial paradigm. The ICF is the current scheme for disability created by the World Health Organization, created in 2001. The ICF is a comprehensive outline that incorporates the confounding factors between disease state and impairment or, more simply put, between health and function. [1] [2]", "contents": "Disability Evaluation -- Introduction. The benefit of this paradigm is that it allows people with a disabling impairment to become empowered and participate in society. The biopsychosocial paradigm is the preferred interpretation for disablement because it is multifaceted. The biological facet incorporates any mental or physical impairment. The psychological facet attempts to interpret the emotional state of the individual and take into account various personal and religious beliefs. The social facet addresses the environmental and infrastructural changes that are required to make the physical environment adaptable for patients with disabilities. The International Classification of Functioning, Disability, and Health (ICF) currently adopts the biopsychosocial paradigm. The ICF is the current scheme for disability created by the World Health Organization, created in 2001. The ICF is a comprehensive outline that incorporates the confounding factors between disease state and impairment or, more simply put, between health and function. [1] [2]"}
+{"id": "article-100713_6", "title": "Disability Evaluation -- Introduction", "content": "As eluded to earlier, there is a large legal component to disablement. The nature of the concept of disability is typically viewed in terms of ability to work and medical care costs. If someone is unable to work or participate in their environment because of a disability, they will need support from government services and legislation. In the United States, the Americans with Disabilities Act (ADA) was passed in 1990. Simply put, this piece of legislation would guarantee Americans with disabilities the equal right to employment opportunities, transportation, and public access. The ADA defines disability as \u201ca physical or mental impairment that substantially limits one or more of the major life activities, a person who has a history or record of such impairment, or a person who is perceived by others as having such an impairment.\u201d\u00a0 The ADA is a massive piece of legislation, and so this article will only highlight the stipulations relating to employment. For further information on the ADA, please visit ada.gov. [3]", "contents": "Disability Evaluation -- Introduction. As eluded to earlier, there is a large legal component to disablement. The nature of the concept of disability is typically viewed in terms of ability to work and medical care costs. If someone is unable to work or participate in their environment because of a disability, they will need support from government services and legislation. In the United States, the Americans with Disabilities Act (ADA) was passed in 1990. Simply put, this piece of legislation would guarantee Americans with disabilities the equal right to employment opportunities, transportation, and public access. The ADA defines disability as \u201ca physical or mental impairment that substantially limits one or more of the major life activities, a person who has a history or record of such impairment, or a person who is perceived by others as having such an impairment.\u201d\u00a0 The ADA is a massive piece of legislation, and so this article will only highlight the stipulations relating to employment. For further information on the ADA, please visit ada.gov. [3]"}
+{"id": "article-100713_7", "title": "Disability Evaluation -- Introduction", "content": "Employment is a major life activity, which in some instances can be life-sustaining. The ADA asks for reasonable accommodation of the employer unless it poses an undue hardship on the employer regarding cost or feasibility. If accommodation is provided, then there is no technical disability associated with a specific impairment in that specific environment. As mentioned before, not every impairment is a disability. For example, a soccer player with a transmetatarsal amputation may have to end his career and thus is disabled. Meanwhile, a computer technician with the same impairment may still be able to work and is therefore not disabled.\u00a0 Determining the feasibility of reasonable accommodation is up to the employer.", "contents": "Disability Evaluation -- Introduction. Employment is a major life activity, which in some instances can be life-sustaining. The ADA asks for reasonable accommodation of the employer unless it poses an undue hardship on the employer regarding cost or feasibility. If accommodation is provided, then there is no technical disability associated with a specific impairment in that specific environment. As mentioned before, not every impairment is a disability. For example, a soccer player with a transmetatarsal amputation may have to end his career and thus is disabled. Meanwhile, a computer technician with the same impairment may still be able to work and is therefore not disabled.\u00a0 Determining the feasibility of reasonable accommodation is up to the employer."}
+{"id": "article-100713_8", "title": "Disability Evaluation -- Introduction", "content": "Understanding how impairment will affect a particular individual is important because it will dictate if and how compensation is received. There are several rating systems for both impairment and disability to standardize assessment. However, one common flaw to the system is that the impairment system is often used in lieu of the disability rating system due to the complexity of the process. Multiple compensation systems have their own criteria and definitions. This article will touch on some of the common disability systems before going into the rating schema.", "contents": "Disability Evaluation -- Introduction. Understanding how impairment will affect a particular individual is important because it will dictate if and how compensation is received. There are several rating systems for both impairment and disability to standardize assessment. However, one common flaw to the system is that the impairment system is often used in lieu of the disability rating system due to the complexity of the process. Multiple compensation systems have their own criteria and definitions. This article will touch on some of the common disability systems before going into the rating schema."}
+{"id": "article-100713_9", "title": "Disability Evaluation -- Introduction", "content": "The Social Security Disability Insurance and Supplemental Social Security Income (SSDI and SSI) are two parallel disability insurance systems dictated by federal government legislation.\u00a0 SSDI is a system that provides benefits to persons who worked in a qualifying job for at least 5-10 years before the onset of the disability and became disabled before the age of 65. SSI, in contrast, provides income to individuals over the age of 65 or those who are blind or disabled. SSI does not require a work history.\u00a0 The process to apply for SSI starts with the Disability Determination Service. Application for SSI can either be accepted or rejected. If the latter, then it can be resubmitted for reconsideration, and in some instances, there can be a court hearing. [4] [5] [6]", "contents": "Disability Evaluation -- Introduction. The Social Security Disability Insurance and Supplemental Social Security Income (SSDI and SSI) are two parallel disability insurance systems dictated by federal government legislation.\u00a0 SSDI is a system that provides benefits to persons who worked in a qualifying job for at least 5-10 years before the onset of the disability and became disabled before the age of 65. SSI, in contrast, provides income to individuals over the age of 65 or those who are blind or disabled. SSI does not require a work history.\u00a0 The process to apply for SSI starts with the Disability Determination Service. Application for SSI can either be accepted or rejected. If the latter, then it can be resubmitted for reconsideration, and in some instances, there can be a court hearing. [4] [5] [6]"}
+{"id": "article-100713_10", "title": "Disability Evaluation -- Introduction", "content": "The industrial revolution inspired the Federal Workers\u2019 Compensation Systems at the turn of the 20th century. As more people were employed by factories and worked in dangerous working conditions, the rate of disability or death\u00a0resulting from work activities increased. As a result, a monetary compensation system was developed for individuals injured while at work or as a consequence of their employment. Some examples of the Federal Worker\u2019s Compensation programs include Federal Employees\u2019 Act, the Longshore and Harbor Workers\u2019 Compensation Act, Energy Employees Occupational Illness Compensation Act, and The Federal Black Lung Program. Many state programs exist as well, and they all have similar fundamental features, which include: compulsory insurance required for all employers, a no-fault system for injuries or illness acquired at work or through the course of work, wage loss benefits, survivor benefits, compensation for permanent partial or permanent total disability, and many more with various stipulations associated.", "contents": "Disability Evaluation -- Introduction. The industrial revolution inspired the Federal Workers\u2019 Compensation Systems at the turn of the 20th century. As more people were employed by factories and worked in dangerous working conditions, the rate of disability or death\u00a0resulting from work activities increased. As a result, a monetary compensation system was developed for individuals injured while at work or as a consequence of their employment. Some examples of the Federal Worker\u2019s Compensation programs include Federal Employees\u2019 Act, the Longshore and Harbor Workers\u2019 Compensation Act, Energy Employees Occupational Illness Compensation Act, and The Federal Black Lung Program. Many state programs exist as well, and they all have similar fundamental features, which include: compulsory insurance required for all employers, a no-fault system for injuries or illness acquired at work or through the course of work, wage loss benefits, survivor benefits, compensation for permanent partial or permanent total disability, and many more with various stipulations associated."}
+{"id": "article-100713_11", "title": "Disability Evaluation -- Introduction", "content": "The Veterans Benefits Admiration offers disability for individuals and service members\u00a0previously in full-time active military service and were discharged generally or honorably. There are three broad categories: (1) A service-connected disability, which is a disability that resulted from direct injury or disease while on active duty; (2) Nonservice-connected disability, which is due to an injury not incurred while on active duty; (3) Presumptive service connection which is a category that covers various chronic conditions that manifest within 1 year from discharge from active duty. The amount of compensation is related to the severity of impairment and disability endured and is not subject to state or federal income tax.", "contents": "Disability Evaluation -- Introduction. The Veterans Benefits Admiration offers disability for individuals and service members\u00a0previously in full-time active military service and were discharged generally or honorably. There are three broad categories: (1) A service-connected disability, which is a disability that resulted from direct injury or disease while on active duty; (2) Nonservice-connected disability, which is due to an injury not incurred while on active duty; (3) Presumptive service connection which is a category that covers various chronic conditions that manifest within 1 year from discharge from active duty. The amount of compensation is related to the severity of impairment and disability endured and is not subject to state or federal income tax."}
+{"id": "article-100713_12", "title": "Disability Evaluation -- Introduction", "content": "Personal injury claims are insurance provided to individuals who have injury arising out of negligence or intentional act. Personal injury claims typically arise from motor vehicle accidents, slip and fall claims, physical assault claims, and nursing home negligence. [7] [8]", "contents": "Disability Evaluation -- Introduction. Personal injury claims are insurance provided to individuals who have injury arising out of negligence or intentional act. Personal injury claims typically arise from motor vehicle accidents, slip and fall claims, physical assault claims, and nursing home negligence. [7] [8]"}
+{"id": "article-100713_13", "title": "Disability Evaluation -- Function", "content": "When an individual is applying for disability or filing a personal injury claim, the insurance company or court will ask for a second opinion, also known as an independent medical examination (IME). An IME is a one-time evaluation by a physician not directly involved in the patient's primary treatment. The IME is to answer questions related to the claim and to make diagnoses relevant to the claim. The information obtained in an IME can be used in litigation.\u00a0 Considering the nature of disability claims, the legal system is often involved. In these instances, the purpose of litigation is to establish causality and relate the current injury to any pre-existing and underlying conditions.\u00a0 Two main types of causation include medical causation, which is a cause and effect relationship between the disability claim and injury, and legal causation, which is to establish whether or not an injury would have occurred regardless of the alleged act.\u00a0 Further, when relating an injury to a pre-existing condition, there are two main categories, aggravation, and exacerbation.", "contents": "Disability Evaluation -- Function. When an individual is applying for disability or filing a personal injury claim, the insurance company or court will ask for a second opinion, also known as an independent medical examination (IME). An IME is a one-time evaluation by a physician not directly involved in the patient's primary treatment. The IME is to answer questions related to the claim and to make diagnoses relevant to the claim. The information obtained in an IME can be used in litigation.\u00a0 Considering the nature of disability claims, the legal system is often involved. In these instances, the purpose of litigation is to establish causality and relate the current injury to any pre-existing and underlying conditions.\u00a0 Two main types of causation include medical causation, which is a cause and effect relationship between the disability claim and injury, and legal causation, which is to establish whether or not an injury would have occurred regardless of the alleged act.\u00a0 Further, when relating an injury to a pre-existing condition, there are two main categories, aggravation, and exacerbation."}
+{"id": "article-100713_14", "title": "Disability Evaluation -- Function", "content": "Aggravation is defined as a permanent worsening of an existing condition that never returns to baseline. Exacerbation, on the other hand, is only a temporary worsening of the pre-existing condition as it eventually returns to the baseline level of injury or pain. An important concept when discussing disability is Maximum Medical Improvement (MMI). MMI\u00a0 is the point at which the individual is not expected to make any further functional improvement after sufficient time was given for physiologic healing and all appropriate modalities were exhausted. Pre-existing conditions need to be taken into account when determining MMI. [9] [10]", "contents": "Disability Evaluation -- Function. Aggravation is defined as a permanent worsening of an existing condition that never returns to baseline. Exacerbation, on the other hand, is only a temporary worsening of the pre-existing condition as it eventually returns to the baseline level of injury or pain. An important concept when discussing disability is Maximum Medical Improvement (MMI). MMI\u00a0 is the point at which the individual is not expected to make any further functional improvement after sufficient time was given for physiologic healing and all appropriate modalities were exhausted. Pre-existing conditions need to be taken into account when determining MMI. [9] [10]"}
+{"id": "article-100713_15", "title": "Disability Evaluation -- Function", "content": "It is important for primary care physicians and all physicians alike to understand that certain workgroups have pre-established rights. For example, prolonged high-stress environments have been shown to be a risk factor for cardiovascular disease. As such, employees of law enforcement or fire departments have a presumed risk for cardiovascular disease, and therefore cardiovascular disease in these populations can be considered work-related. This concept applies to many occupations.", "contents": "Disability Evaluation -- Function. It is important for primary care physicians and all physicians alike to understand that certain workgroups have pre-established rights. For example, prolonged high-stress environments have been shown to be a risk factor for cardiovascular disease. As such, employees of law enforcement or fire departments have a presumed risk for cardiovascular disease, and therefore cardiovascular disease in these populations can be considered work-related. This concept applies to many occupations."}
+{"id": "article-100713_16", "title": "Disability Evaluation -- Function", "content": "The impairment rating system is complex and can be challenging to understand. However, the system is designed to be easily interpreted by physicians who\u00a0care for patients with disabilities. The American Medical Association (AMA) produced a document called \u201cAMA Guides to the Evaluation of Permanent Impairment.\u201d This guide was intended to break down the disability rating system further and is frequently updated to reflect current guidelines and medical standards. An impairment rating is defined as \u201ca consensus-derived percentage estimate of a loss of activity reflecting the severity of a given health condition and the degree of associated limitations in terms of activities of daily living.\u201d\u00a0 Impairment ratings are further broken down to include: qualitative measurements, which are anatomically based and would include impairments such as amputation, joint ankyloses, neuropathies, and various other deformities; quantitative impairments, which are also anatomically based and are measured on a continuous scale that corresponds to the degree of impairment; and diagnosis based impairment (DBI) which is an ordinal ranking system that categorizes impairment by severity (such as a ligament sprain as least severe to a ligament rupture as most severe). The diagnosis-based impairment method can be seemingly complex and difficult to interpret.", "contents": "Disability Evaluation -- Function. The impairment rating system is complex and can be challenging to understand. However, the system is designed to be easily interpreted by physicians who\u00a0care for patients with disabilities. The American Medical Association (AMA) produced a document called \u201cAMA Guides to the Evaluation of Permanent Impairment.\u201d This guide was intended to break down the disability rating system further and is frequently updated to reflect current guidelines and medical standards. An impairment rating is defined as \u201ca consensus-derived percentage estimate of a loss of activity reflecting the severity of a given health condition and the degree of associated limitations in terms of activities of daily living.\u201d\u00a0 Impairment ratings are further broken down to include: qualitative measurements, which are anatomically based and would include impairments such as amputation, joint ankyloses, neuropathies, and various other deformities; quantitative impairments, which are also anatomically based and are measured on a continuous scale that corresponds to the degree of impairment; and diagnosis based impairment (DBI) which is an ordinal ranking system that categorizes impairment by severity (such as a ligament sprain as least severe to a ligament rupture as most severe). The diagnosis-based impairment method can be seemingly complex and difficult to interpret."}
+{"id": "article-100713_17", "title": "Disability Evaluation -- Function", "content": "After a diagnosis is made, the diagnosis must be matched with a class on the provided DBI grid (Image 1). The regional body parts are then further subdivided. Once the appropriate grid location is identified, then the grade modifiers are determined to adjust for the level of severity. The grade modifiers include a physical exam (GMPE), functional history (GMFH), and clinical studies (GMCS). The final impairment score is a summation of the grade modifiers. [11] [12] [13]", "contents": "Disability Evaluation -- Function. After a diagnosis is made, the diagnosis must be matched with a class on the provided DBI grid (Image 1). The regional body parts are then further subdivided. Once the appropriate grid location is identified, then the grade modifiers are determined to adjust for the level of severity. The grade modifiers include a physical exam (GMPE), functional history (GMFH), and clinical studies (GMCS). The final impairment score is a summation of the grade modifiers. [11] [12] [13]"}
+{"id": "article-100713_18", "title": "Disability Evaluation -- Function", "content": "Accurate diagnosis is important because each body region is subdivided, as previously mentioned. The spine has four anatomic regions: cervical, thoracic, lumbar, and pelvis. Each region has its own qualitative rating. The upper extremities are broken down into the digits and hand, wrist, elbow, and shoulder. Each region has a separate grid with adjustments that can be made for peripheral nerve injuries, CRPS, or amputation injuries, to list a few. The lower extremity is divided into three anatomic regions: ankle and foot, knee, and hip. Similar to the upper extremity, the lower extremity regions can have adjustments made for various pathologies.\u00a0 If there are multiple impairments, the impairments must be combined as described in the AMA guide and not simply summated. [14]", "contents": "Disability Evaluation -- Function. Accurate diagnosis is important because each body region is subdivided, as previously mentioned. The spine has four anatomic regions: cervical, thoracic, lumbar, and pelvis. Each region has its own qualitative rating. The upper extremities are broken down into the digits and hand, wrist, elbow, and shoulder. Each region has a separate grid with adjustments that can be made for peripheral nerve injuries, CRPS, or amputation injuries, to list a few. The lower extremity is divided into three anatomic regions: ankle and foot, knee, and hip. Similar to the upper extremity, the lower extremity regions can have adjustments made for various pathologies.\u00a0 If there are multiple impairments, the impairments must be combined as described in the AMA guide and not simply summated. [14]"}
+{"id": "article-100713_19", "title": "Disability Evaluation -- Issues of Concern", "content": "Disability and return to work. The main goal of disability management is to assist the patient in maintaining functional status or return to functional work status as soon as possible.\u00a0 Long periods of being out of work can, and have been shown to, contribute to poor physical and mental health. Common medical problems can be easily accommodated at the place of employment.", "contents": "Disability Evaluation -- Issues of Concern. Disability and return to work. The main goal of disability management is to assist the patient in maintaining functional status or return to functional work status as soon as possible.\u00a0 Long periods of being out of work can, and have been shown to, contribute to poor physical and mental health. Common medical problems can be easily accommodated at the place of employment."}
+{"id": "article-100713_20", "title": "Disability Evaluation -- Issues of Concern", "content": "The American College of Occupational and Environmental Medicine (ACOEM) provides good resources for managing disability patients preparing to return to work. An abbreviated list would include socioeconomic and psychological factors, attitudes and beliefs, health behaviors, clinical measures taken, perception of injury and pain, previous health interventions and diagnostic workups, employer/employee relationship, legal factors, and social environment.\u00a0 These aforementioned factors are often modifiable and identified early on. For example, there are screening tools that can be used to identify the patients perceived level of injury or pain: The Orebro musculoskeletal pain questionnaire is a self-survey that indicates perceived pain; The Back Disability Risk Questionnaire is a self-reported survey administered during the first two weeks of injury to identify the patients perceived level of injury; The Center of Epidemiologic Studies for Depression scale is a short self-reported questionnaire that identifies depression symptoms and has a good predictive ability for chronic pain patients. Additionally, the employer/employee relationship can be easily improved from the time of employment through the time of injury.", "contents": "Disability Evaluation -- Issues of Concern. The American College of Occupational and Environmental Medicine (ACOEM) provides good resources for managing disability patients preparing to return to work. An abbreviated list would include socioeconomic and psychological factors, attitudes and beliefs, health behaviors, clinical measures taken, perception of injury and pain, previous health interventions and diagnostic workups, employer/employee relationship, legal factors, and social environment.\u00a0 These aforementioned factors are often modifiable and identified early on. For example, there are screening tools that can be used to identify the patients perceived level of injury or pain: The Orebro musculoskeletal pain questionnaire is a self-survey that indicates perceived pain; The Back Disability Risk Questionnaire is a self-reported survey administered during the first two weeks of injury to identify the patients perceived level of injury; The Center of Epidemiologic Studies for Depression scale is a short self-reported questionnaire that identifies depression symptoms and has a good predictive ability for chronic pain patients. Additionally, the employer/employee relationship can be easily improved from the time of employment through the time of injury."}
+{"id": "article-100713_21", "title": "Disability Evaluation -- Issues of Concern", "content": "The ACOEM promotes the adoption of an injury-prevention cooperate infrastructure as a majority of work-related injuries are preventable. This infrastructure would include incentivizing healthy lifestyles and return to work programs. Promoting a safer environment and maintaining an interest in the employees\u2019 health and safety enhances the inherent relationship. If an employee is to be injured at work, the ACOEM has shown that early positive contact by the employer has shown to be a strong predictor of earlier return to work.\u00a0 The Canadian Institute for Work and Health has identified seven principles associated with return to work as seen in. [15] [16] [17]", "contents": "Disability Evaluation -- Issues of Concern. The ACOEM promotes the adoption of an injury-prevention cooperate infrastructure as a majority of work-related injuries are preventable. This infrastructure would include incentivizing healthy lifestyles and return to work programs. Promoting a safer environment and maintaining an interest in the employees\u2019 health and safety enhances the inherent relationship. If an employee is to be injured at work, the ACOEM has shown that early positive contact by the employer has shown to be a strong predictor of earlier return to work.\u00a0 The Canadian Institute for Work and Health has identified seven principles associated with return to work as seen in. [15] [16] [17]"}
+{"id": "article-100713_22", "title": "Disability Evaluation -- Issues of Concern", "content": "If the patient has the opportunity to return to work with modified duties, the patient should do so under the advisement and recommendation of the treating physician. Doing so can be productive and therapeutic. Modified work programs include either decreased or flexible work hours, decreased required shift tasks, and/or workplace modifications to accommodate needs. If the patient has no opportunity to have a temporary or modified job, then the patient may require a temporary total disability claim until MMI is achieved.\u00a0 The Functional Capacity Evaluation (FCE) is a standardized assessment of an injured individual\u2019s ability to return to a transitional, modified work environment. The FCE may require performance-based tests using job-specific equipment in a simulated or real environment. An additional Job Site Evaluation (JSE) can be obtained by using a specially trained therapist to assess the functions of the job and the physical demands required. [18]", "contents": "Disability Evaluation -- Issues of Concern. If the patient has the opportunity to return to work with modified duties, the patient should do so under the advisement and recommendation of the treating physician. Doing so can be productive and therapeutic. Modified work programs include either decreased or flexible work hours, decreased required shift tasks, and/or workplace modifications to accommodate needs. If the patient has no opportunity to have a temporary or modified job, then the patient may require a temporary total disability claim until MMI is achieved.\u00a0 The Functional Capacity Evaluation (FCE) is a standardized assessment of an injured individual\u2019s ability to return to a transitional, modified work environment. The FCE may require performance-based tests using job-specific equipment in a simulated or real environment. An additional Job Site Evaluation (JSE) can be obtained by using a specially trained therapist to assess the functions of the job and the physical demands required. [18]"}
+{"id": "article-100713_23", "title": "Disability Evaluation -- Clinical Significance", "content": "Documentation and key components. A thorough history and physical is important at the first evaluation for a disability claim. In addition to noting the precise details of the injury and body parts affected, it is also important to note the functional limitations caused by the impairment. The functional history should include various environments (home, work, social, community, etc.) and different activities (ADLs and iADLs).", "contents": "Disability Evaluation -- Clinical Significance. Documentation and key components. A thorough history and physical is important at the first evaluation for a disability claim. In addition to noting the precise details of the injury and body parts affected, it is also important to note the functional limitations caused by the impairment. The functional history should include various environments (home, work, social, community, etc.) and different activities (ADLs and iADLs)."}
+{"id": "article-100713_24", "title": "Disability Evaluation -- Clinical Significance", "content": "An important standardized scale is the Functional Independence Measure (FIM), which quantifies the patient\u2019s level of independence.\u00a0 The physical examination should use techniques and maneuvers that are standardized. These may include Manual Muscle Testing (MMT), Range of Motion evaluation with a goniometer, Modified Ashworth Scale for spasticity, and other special tests designed to identify the presence or specific injuries. These tests should be repeated at each visit to show progression or digression of the patient\u2019s progress with therapy. [19] [20]", "contents": "Disability Evaluation -- Clinical Significance. An important standardized scale is the Functional Independence Measure (FIM), which quantifies the patient\u2019s level of independence.\u00a0 The physical examination should use techniques and maneuvers that are standardized. These may include Manual Muscle Testing (MMT), Range of Motion evaluation with a goniometer, Modified Ashworth Scale for spasticity, and other special tests designed to identify the presence or specific injuries. These tests should be repeated at each visit to show progression or digression of the patient\u2019s progress with therapy. [19] [20]"}
+{"id": "article-100713_25", "title": "Disability Evaluation -- Other Issues", "content": "Independent Medical Examiner and litigation. The IME can be asked to provide witness testimony in the court of law. Previously, expert witnesses were exempt from medical malpractice claims and other lawsuits. However, there have been Supreme Court rulings that held expert witnesses liable to traditional malpractice. IMEs must be up to date on current medical-legal terminology and also the current legal standards.", "contents": "Disability Evaluation -- Other Issues. Independent Medical Examiner and litigation. The IME can be asked to provide witness testimony in the court of law. Previously, expert witnesses were exempt from medical malpractice claims and other lawsuits. However, there have been Supreme Court rulings that held expert witnesses liable to traditional malpractice. IMEs must be up to date on current medical-legal terminology and also the current legal standards."}
+{"id": "article-100713_26", "title": "Disability Evaluation -- Enhancing Healthcare Team Outcomes", "content": "An impairment that causes disability is an injury that extends beyond the physical body part. Patients who become disabled are transitioning into life with a different set of circumstances. The patients are affected personally, socially, professionally, and spiritually. Fortunately, due to progressive movements and increased awareness, the amount of funding and resources available to these patients has increased astronomically.\u00a0 The recent legislation approved mandates accessibility to all public spaces and appropriate accommodation in workplaces so that these individuals can continue to participate in the community in ways similar to how they had previously.", "contents": "Disability Evaluation -- Enhancing Healthcare Team Outcomes. An impairment that causes disability is an injury that extends beyond the physical body part. Patients who become disabled are transitioning into life with a different set of circumstances. The patients are affected personally, socially, professionally, and spiritually. Fortunately, due to progressive movements and increased awareness, the amount of funding and resources available to these patients has increased astronomically.\u00a0 The recent legislation approved mandates accessibility to all public spaces and appropriate accommodation in workplaces so that these individuals can continue to participate in the community in ways similar to how they had previously."}
+{"id": "article-100713_27", "title": "Disability Evaluation -- Enhancing Healthcare Team Outcomes", "content": "It is paramount for the physician and all providers participating in the care of a patient with a disability to understand and be familiar with the resources available. The care team should include, but not be limited to, the physician, physical therapist, and/or occupational therapist, and/or speech therapist, psychologist, and case manager. Further, when a patient is on disability from work, it should be the care team's responsibility to return the patient to work as quickly and as safely as possible.", "contents": "Disability Evaluation -- Enhancing Healthcare Team Outcomes. It is paramount for the physician and all providers participating in the care of a patient with a disability to understand and be familiar with the resources available. The care team should include, but not be limited to, the physician, physical therapist, and/or occupational therapist, and/or speech therapist, psychologist, and case manager. Further, when a patient is on disability from work, it should be the care team's responsibility to return the patient to work as quickly and as safely as possible."}
+{"id": "article-100713_28", "title": "Disability Evaluation -- Enhancing Healthcare Team Outcomes", "content": "Studies presented by the\u00a0 American College of Occupational and Environmental Medicine and the Canadia Institue for Work and Health have identified factors that promote a patient's return to work and further discuss the consequences of prolonged time off from work. [Level 5] For these reasons, it is important to have an interprofessional\u00a0team approach to patients with disabilities.", "contents": "Disability Evaluation -- Enhancing Healthcare Team Outcomes. Studies presented by the\u00a0 American College of Occupational and Environmental Medicine and the Canadia Institue for Work and Health have identified factors that promote a patient's return to work and further discuss the consequences of prolonged time off from work. [Level 5] For these reasons, it is important to have an interprofessional\u00a0team approach to patients with disabilities."}
+{"id": "article-100713_29", "title": "Disability Evaluation -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Disability Evaluation -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

statpearls/chunk/article-101263.jsonl

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+{"id": "article-101263_0", "title": "Cancer Antigen 125 -- Introduction", "content": "Cancer antigen 125 (CA125) is an antigenic tumor marker expressed by epithelial ovarian neoplasms and cells lining various organs such as the endometrium, fallopian tubes, pleura, peritoneum, and pericardium. [1] [2] CA125 is used as one of the serological tests in cases when an ovarian neoplasm is suspected and\u00a0for monitoring patients who have already been diagnosed with epithelial ovarian cancers. [2] [3] However, due to its low sensitivity, the test has limited use in diagnosing early ovarian cancer. The specificity is particularly low in premenopausal women; thus,\u00a0it is most useful\u00a0in postmenopausal women. [4]", "contents": "Cancer Antigen 125 -- Introduction. Cancer antigen 125 (CA125) is an antigenic tumor marker expressed by epithelial ovarian neoplasms and cells lining various organs such as the endometrium, fallopian tubes, pleura, peritoneum, and pericardium. [1] [2] CA125 is used as one of the serological tests in cases when an ovarian neoplasm is suspected and\u00a0for monitoring patients who have already been diagnosed with epithelial ovarian cancers. [2] [3] However, due to its low sensitivity, the test has limited use in diagnosing early ovarian cancer. The specificity is particularly low in premenopausal women; thus,\u00a0it is most useful\u00a0in postmenopausal women. [4]"}
+{"id": "article-101263_1", "title": "Cancer Antigen 125 -- Etiology and Epidemiology", "content": "CA125 is an epitope found on mucin 16 (MUC16), a  glycoprotein antigen present on the  cell surface.\u00a0This antigen is normally expressed in tissues derived from coelomic epithelia, such as the ovary, fallopian tube, peritoneum, pleura, pericardium, colon, kidney, and stomach. [2] [5] Currently, 3 antibodies can help identify\u00a0the CA125 antigen, and all 3 groups recognize nonoverlapping epitopes. [2] The first group involves OC125-like antibodies, the second involves M11-like antibodies, and the third involves OV197-like antibodies. [3] [6]", "contents": "Cancer Antigen 125 -- Etiology and Epidemiology. CA125 is an epitope found on mucin 16 (MUC16), a  glycoprotein antigen present on the  cell surface.\u00a0This antigen is normally expressed in tissues derived from coelomic epithelia, such as the ovary, fallopian tube, peritoneum, pleura, pericardium, colon, kidney, and stomach. [2] [5] Currently, 3 antibodies can help identify\u00a0the CA125 antigen, and all 3 groups recognize nonoverlapping epitopes. [2] The first group involves OC125-like antibodies, the second involves M11-like antibodies, and the third involves OV197-like antibodies. [3] [6]"}
+{"id": "article-101263_2", "title": "Cancer Antigen 125 -- Etiology and Epidemiology", "content": "In a study carried out by Bast et al in 1983, elevated levels of serum CA125 (>35 U/mL) were present in 82% of patients with epithelial ovarian cancer, 28.5% of patients with non-gynecological cancers such as pancreatic, lung, breast, and colorectal, and 6% of the patients with benign diseases such as an ovarian cyst. [7] Among gynecologic malignancies, elevated levels of CA125 correlate with adenocarcinoma of the endometrium and endocervix. [8] CA125 also becomes elevated\u00a0under\u00a0certain physiological conditions, such as during menstruation,\u00a0the\u00a0first trimester of pregnancy, the postpartum period, fibroids, and pelvic endometriosis. [3] [9] [10] [11]", "contents": "Cancer Antigen 125 -- Etiology and Epidemiology. In a study carried out by Bast et al in 1983, elevated levels of serum CA125 (>35 U/mL) were present in 82% of patients with epithelial ovarian cancer, 28.5% of patients with non-gynecological cancers such as pancreatic, lung, breast, and colorectal, and 6% of the patients with benign diseases such as an ovarian cyst. [7] Among gynecologic malignancies, elevated levels of CA125 correlate with adenocarcinoma of the endometrium and endocervix. [8] CA125 also becomes elevated\u00a0under\u00a0certain physiological conditions, such as during menstruation,\u00a0the\u00a0first trimester of pregnancy, the postpartum period, fibroids, and pelvic endometriosis. [3] [9] [10] [11]"}
+{"id": "article-101263_3", "title": "Cancer Antigen 125 -- Pathophysiology", "content": "The inherent function of CA125 membrane protein is still not completely clear. The latest studies suspect that the oligosaccharides associated with CA125 might play a role in cell-mediated immunity. [12] CA125 may have a role in inhibiting cytotoxic responses of the natural killer cells. [13] [14] Under physiological conditions, CA125 is expressed on the cell membrane. However, due to the presence of the cells' junctional complexes, it cannot cross into the bloodstream. Pathological states associated with the disruption of this membrane barrier lead to the antigen being shed into the blood and a consequent serological rise in the levels of CA125. [1] CA125 has been considered to play a role in promoting tumorigenesis and metastasis. This mechanism is\u00a0believed to occur\u00a0due to the\u00a0binding between CA125\u00a0and mesothelin, a glycoprotein expressed on the mesothelial cells of the peritoneum. [15] Elucidating this role of CA125 in oncogenesis has proposed a potential therapeutic avenue through the creation of monoclonal antibodies targeting CA125. [15] [16]", "contents": "Cancer Antigen 125 -- Pathophysiology. The inherent function of CA125 membrane protein is still not completely clear. The latest studies suspect that the oligosaccharides associated with CA125 might play a role in cell-mediated immunity. [12] CA125 may have a role in inhibiting cytotoxic responses of the natural killer cells. [13] [14] Under physiological conditions, CA125 is expressed on the cell membrane. However, due to the presence of the cells' junctional complexes, it cannot cross into the bloodstream. Pathological states associated with the disruption of this membrane barrier lead to the antigen being shed into the blood and a consequent serological rise in the levels of CA125. [1] CA125 has been considered to play a role in promoting tumorigenesis and metastasis. This mechanism is\u00a0believed to occur\u00a0due to the\u00a0binding between CA125\u00a0and mesothelin, a glycoprotein expressed on the mesothelial cells of the peritoneum. [15] Elucidating this role of CA125 in oncogenesis has proposed a potential therapeutic avenue through the creation of monoclonal antibodies targeting CA125. [15] [16]"}
+{"id": "article-101263_4", "title": "Cancer Antigen 125 -- Pathophysiology", "content": "In the case of ovaries, it appears that CA125 expresses when the ovarian epithelium undergoes metaplasia into a M\u00fcllerian-type endothelium or a neoplastic transformation. [1] [2] Upon their malignant transformation, the tumor cells invade and disrupt the architecture to enter the bloodstream. [17] In benign ovarian cysts, although the antigen may be shed into the cystic fluid, it is not present in the bloodstream. [8]", "contents": "Cancer Antigen 125 -- Pathophysiology. In the case of ovaries, it appears that CA125 expresses when the ovarian epithelium undergoes metaplasia into a M\u00fcllerian-type endothelium or a neoplastic transformation. [1] [2] Upon their malignant transformation, the tumor cells invade and disrupt the architecture to enter the bloodstream. [17] In benign ovarian cysts, although the antigen may be shed into the cystic fluid, it is not present in the bloodstream. [8]"}
+{"id": "article-101263_5", "title": "Cancer Antigen 125 -- Specimen Requirements and Procedure", "content": "CA125 is detectable through serological-based tests or tissue-based studies of malignant ovarian or endometrial tissue specimens. [18] In addition, it may\u00a0be present in body fluids such as pleural fluid, peritoneal fluid in benign or malignant conditions, and ovarian cystic fluid. [8] Serological assays on serum or plasma samples are the most commonly used quantitative analysis method for analyzing CA125 levels in the blood. To maintain the stability of the specimen, the serum must be separated from the clot and stored at \u221230 \u00b0C\u00a0(long term) or 4 \u00b0C\u00a0(short term). [19]", "contents": "Cancer Antigen 125 -- Specimen Requirements and Procedure. CA125 is detectable through serological-based tests or tissue-based studies of malignant ovarian or endometrial tissue specimens. [18] In addition, it may\u00a0be present in body fluids such as pleural fluid, peritoneal fluid in benign or malignant conditions, and ovarian cystic fluid. [8] Serological assays on serum or plasma samples are the most commonly used quantitative analysis method for analyzing CA125 levels in the blood. To maintain the stability of the specimen, the serum must be separated from the clot and stored at \u221230 \u00b0C\u00a0(long term) or 4 \u00b0C\u00a0(short term). [19]"}
+{"id": "article-101263_6", "title": "Cancer Antigen 125 -- Specimen Requirements and Procedure", "content": "When the CA125 assay is used for cancer diagnosis, sampling should not be conducted immediately before or during menstruation because the physiological elevation of the CA125 levels may provide false-positive results. [9] [20] The serum samples for CA125 should not be collected within 2 weeks of surgery, as the levels may become falsely elevated secondary to tissue damage. CA125 levels have a half-life of 6 days and may require a few weeks to return to normal levels after surgery. A pre-treatment sample should be used as a reference for evaluating CA125 levels postoperatively. [21]", "contents": "Cancer Antigen 125 -- Specimen Requirements and Procedure. When the CA125 assay is used for cancer diagnosis, sampling should not be conducted immediately before or during menstruation because the physiological elevation of the CA125 levels may provide false-positive results. [9] [20] The serum samples for CA125 should not be collected within 2 weeks of surgery, as the levels may become falsely elevated secondary to tissue damage. CA125 levels have a half-life of 6 days and may require a few weeks to return to normal levels after surgery. A pre-treatment sample should be used as a reference for evaluating CA125 levels postoperatively. [21]"}
+{"id": "article-101263_7", "title": "Cancer Antigen 125 -- Diagnostic Tests", "content": "Two tests are available to\u00a0measure the levels of CA125. The original test is a radioimmunoassay using OC125 monoclonal antibody, which recognizes the antigenic determinants on the CA125 glycoprotein. The second-generation CA125 test uses two antibodies, OC125 and M11. [22] This test has shown a higher level of precision and improved sensitivity with a lower number of false-positive results.\u00a0However, subsequent research comparing the two tests did not indicate the superiority of one over the other. [23]", "contents": "Cancer Antigen 125 -- Diagnostic Tests. Two tests are available to\u00a0measure the levels of CA125. The original test is a radioimmunoassay using OC125 monoclonal antibody, which recognizes the antigenic determinants on the CA125 glycoprotein. The second-generation CA125 test uses two antibodies, OC125 and M11. [22] This test has shown a higher level of precision and improved sensitivity with a lower number of false-positive results.\u00a0However, subsequent research comparing the two tests did not indicate the superiority of one over the other. [23]"}
+{"id": "article-101263_8", "title": "Cancer Antigen 125 -- Diagnostic Tests", "content": "These tests are made available by different commercial manufacturers in different versions, such as immunoradiometric assay (IRMA) and enzyme immunoassay (EIA). When using these tests to monitor patients longitudinally, the tests should preferably be from the same manufacturer and the same version, as different kits and versions can result in different absolute values and test sensitivity. [8]", "contents": "Cancer Antigen 125 -- Diagnostic Tests. These tests are made available by different commercial manufacturers in different versions, such as immunoradiometric assay (IRMA) and enzyme immunoassay (EIA). When using these tests to monitor patients longitudinally, the tests should preferably be from the same manufacturer and the same version, as different kits and versions can result in different absolute values and test sensitivity. [8]"}
+{"id": "article-101263_9", "title": "Cancer Antigen 125 -- Diagnostic Tests", "content": "Efforts have been made to enhance the specificity of the CA125 test by testing for CA125 glycoforms\u00a0more strongly associated with ovarian malignancy. For instance, the CA125-Tn ELISA-based test demonstrated almost a two-fold increase in specificity with no change in sensitivity. [24] Similarly, Other studies have shown an improved performance of certain CA125 glycoforms over the conventional CA125 test. [25]", "contents": "Cancer Antigen 125 -- Diagnostic Tests. Efforts have been made to enhance the specificity of the CA125 test by testing for CA125 glycoforms\u00a0more strongly associated with ovarian malignancy. For instance, the CA125-Tn ELISA-based test demonstrated almost a two-fold increase in specificity with no change in sensitivity. [24] Similarly, Other studies have shown an improved performance of certain CA125 glycoforms over the conventional CA125 test. [25]"}
+{"id": "article-101263_10", "title": "Cancer Antigen 125 -- Testing Procedures", "content": "The original CA125 test is a homologous double-determinant assay with the same capture and tracer antibodies. The OC125 antibody\u00a0is adsorbed onto the solid phase (capture antibody), followed by the addition of the serum. The OC125 moieties on the CA125 antigen\u00a0then bind to the antibody. Finally, a second radiolabeled (IRMA) or an enzyme-labeled (EIA) antibody (tracer antibody)\u00a0is added, which binds to the antigen-antibody complexes. [8] The second-generation CA125 test is a heterologous double-determinant assay, where the capture antibody is a monoclonal M11 antibody, and the tracer antibody is the OC125 antibody. Since the two antibodies do not have to bind to the same epitope, there is no competition for the same binding site, thus allowing for potentially higher sensitivity. [26]", "contents": "Cancer Antigen 125 -- Testing Procedures. The original CA125 test is a homologous double-determinant assay with the same capture and tracer antibodies. The OC125 antibody\u00a0is adsorbed onto the solid phase (capture antibody), followed by the addition of the serum. The OC125 moieties on the CA125 antigen\u00a0then bind to the antibody. Finally, a second radiolabeled (IRMA) or an enzyme-labeled (EIA) antibody (tracer antibody)\u00a0is added, which binds to the antigen-antibody complexes. [8] The second-generation CA125 test is a heterologous double-determinant assay, where the capture antibody is a monoclonal M11 antibody, and the tracer antibody is the OC125 antibody. Since the two antibodies do not have to bind to the same epitope, there is no competition for the same binding site, thus allowing for potentially higher sensitivity. [26]"}
+{"id": "article-101263_11", "title": "Cancer Antigen 125 -- Interfering Factors", "content": "The original CA125 assay uses murine monoclonal OC125 antibody as both the capture and the tracer antibodies.\u00a0Although it should bind to the corresponding epitope on the CA125 antigen, some individuals demonstrate the presence of the human anti-mouse antibody or human anti-murine antibody. [26] These antibodies may interfere with the test by binding to the capture and tracer antibodies, leading to falsely elevated CA125 levels. Human anti-murine antibodies are observed in patients exposed to murine monoclonal antibodies for therapeutic or diagnostic purposes. This interference is less observable in the newer assays. [27]", "contents": "Cancer Antigen 125 -- Interfering Factors. The original CA125 assay uses murine monoclonal OC125 antibody as both the capture and the tracer antibodies.\u00a0Although it should bind to the corresponding epitope on the CA125 antigen, some individuals demonstrate the presence of the human anti-mouse antibody or human anti-murine antibody. [26] These antibodies may interfere with the test by binding to the capture and tracer antibodies, leading to falsely elevated CA125 levels. Human anti-murine antibodies are observed in patients exposed to murine monoclonal antibodies for therapeutic or diagnostic purposes. This interference is less observable in the newer assays. [27]"}
+{"id": "article-101263_12", "title": "Cancer Antigen 125 -- Interfering Factors", "content": "Pre-analytical errors while testing for tumor markers such as CA125 are related to simple specimen-related errors such as incorrect sample processing, an insufficient sample, and inappropriate handling. When conducting tests involving CA125, specific attention should be paid to the timing of specimen collection. [19] Blood collection should be avoided during menstruation, which can lead to falsely elevated levels (up to three-fold).\u00a0Caution is needed when interpreting elevated CA125 results in women with suspected endometriosis, pregnancy, and ascites. [28] [29]", "contents": "Cancer Antigen 125 -- Interfering Factors. Pre-analytical errors while testing for tumor markers such as CA125 are related to simple specimen-related errors such as incorrect sample processing, an insufficient sample, and inappropriate handling. When conducting tests involving CA125, specific attention should be paid to the timing of specimen collection. [19] Blood collection should be avoided during menstruation, which can lead to falsely elevated levels (up to three-fold).\u00a0Caution is needed when interpreting elevated CA125 results in women with suspected endometriosis, pregnancy, and ascites. [28] [29]"}
+{"id": "article-101263_13", "title": "Cancer Antigen 125 -- Interfering Factors", "content": "Human anti-murine antibodies are known to interfere with the test, and adding non-immune murine serum can neutralize this interference. [23] [26] For patients undergoing monitoring with serial CA125 levels,\u00a0it is important\u00a0to use the same manufacturer and laboratory, preferably. If a different manufacturer or testing method needs to be employed, the recommendation is to carry out parallel testing by both methods to establish a new baseline for the patient. [30]", "contents": "Cancer Antigen 125 -- Interfering Factors. Human anti-murine antibodies are known to interfere with the test, and adding non-immune murine serum can neutralize this interference. [23] [26] For patients undergoing monitoring with serial CA125 levels,\u00a0it is important\u00a0to use the same manufacturer and laboratory, preferably. If a different manufacturer or testing method needs to be employed, the recommendation is to carry out parallel testing by both methods to establish a new baseline for the patient. [30]"}
+{"id": "article-101263_14", "title": "Cancer Antigen 125 -- Results, Reporting, and Critical Findings", "content": "In the original CA125 IRMA test, the cut-off point for the upper limit of normal was arbitrarily set at 35 U/mL.\u00a0This threshold was chosen because only 1% of the healthy population had CA125 levels greater than 35 U/mL. However, this was reduced to 0.2% of the healthy population when the cut-off point for the upper limit was raised to 65 U/mL. [7] The second-generation CA125 has shown to be more clinically reliable with greater precision in values less than 35 U/mL, leading to higher values\u00a0compared to the original CA125 test. [22] A meta-analysis comparing various studies using a CA125 threshold of greater than 35 U/mL for preoperative identification of an adnexal mass suspicious for ovarian cancer revealed an overall sensitivity and specificity of 78.7% and 77.9%, respectively. [31]", "contents": "Cancer Antigen 125 -- Results, Reporting, and Critical Findings. In the original CA125 IRMA test, the cut-off point for the upper limit of normal was arbitrarily set at 35 U/mL.\u00a0This threshold was chosen because only 1% of the healthy population had CA125 levels greater than 35 U/mL. However, this was reduced to 0.2% of the healthy population when the cut-off point for the upper limit was raised to 65 U/mL. [7] The second-generation CA125 has shown to be more clinically reliable with greater precision in values less than 35 U/mL, leading to higher values\u00a0compared to the original CA125 test. [22] A meta-analysis comparing various studies using a CA125 threshold of greater than 35 U/mL for preoperative identification of an adnexal mass suspicious for ovarian cancer revealed an overall sensitivity and specificity of 78.7% and 77.9%, respectively. [31]"}
+{"id": "article-101263_15", "title": "Cancer Antigen 125 -- Results, Reporting, and Critical Findings", "content": "Study results have shown that the test exhibits a higher sensitivity and specificity in\u00a0postmenopausal women compared to premenopausal women. [32] [33] The low sensitivity is due in part to the fact that CA125 is elevated only in half of the patients with early-stage epithelial ovarian cancer and rarely elevated in patients with mucinous carcinomas of the ovary. The low specificity, especially among premenopausal women, is due to the\u00a0elevation caused by\u00a0benign conditions such as fibroids, endometriosis, and pregnancy. [4] However, the test is relatively sensitive and specific among patients who have completed treatment for ovarian cancer. Patients\u00a0who appear to be clinically free of the tumor with elevations in CA125 (>35 U/mL) almost always have a tumor in second-look surgery. [8]", "contents": "Cancer Antigen 125 -- Results, Reporting, and Critical Findings. Study results have shown that the test exhibits a higher sensitivity and specificity in\u00a0postmenopausal women compared to premenopausal women. [32] [33] The low sensitivity is due in part to the fact that CA125 is elevated only in half of the patients with early-stage epithelial ovarian cancer and rarely elevated in patients with mucinous carcinomas of the ovary. The low specificity, especially among premenopausal women, is due to the\u00a0elevation caused by\u00a0benign conditions such as fibroids, endometriosis, and pregnancy. [4] However, the test is relatively sensitive and specific among patients who have completed treatment for ovarian cancer. Patients\u00a0who appear to be clinically free of the tumor with elevations in CA125 (>35 U/mL) almost always have a tumor in second-look surgery. [8]"}
+{"id": "article-101263_16", "title": "Cancer Antigen 125 -- Clinical Significance", "content": "CA125 plays a significant role as a tumor marker, particularly in the preoperative assessment of patients with an adnexal mass and suspected to have an ovarian malignancy. [31] Around 80% of the patients diagnosed with ovarian epithelial carcinoma show elevated CA125 levels, and levels are monitored post-treatment to assess the progression of the disease. [34] The use of CA125 for preoperative assessment is more valuable among postmenopausal\u00a0women compared to its use among premenopausal women. [4] Although an elevated CA125 level above 35 U/mL is utilized in assessing postmenopausal women, earlier guidelines from the American College of Obstetricians and Gynecologists had recommended using an arbitrary cutoff of 200 U/mL; this was, however, not supported by any research evidence. [35]", "contents": "Cancer Antigen 125 -- Clinical Significance. CA125 plays a significant role as a tumor marker, particularly in the preoperative assessment of patients with an adnexal mass and suspected to have an ovarian malignancy. [31] Around 80% of the patients diagnosed with ovarian epithelial carcinoma show elevated CA125 levels, and levels are monitored post-treatment to assess the progression of the disease. [34] The use of CA125 for preoperative assessment is more valuable among postmenopausal\u00a0women compared to its use among premenopausal women. [4] Although an elevated CA125 level above 35 U/mL is utilized in assessing postmenopausal women, earlier guidelines from the American College of Obstetricians and Gynecologists had recommended using an arbitrary cutoff of 200 U/mL; this was, however, not supported by any research evidence. [35]"}
+{"id": "article-101263_17", "title": "Cancer Antigen 125 -- Clinical Significance", "content": "Current guidelines suggest using formal risk assessment tests such as the risk of malignancy index or the risk of ovarian malignancy algorithm while assessing the need for gynecological referral in premenopausal women. [4] CA125 is successfully used for disease monitoring and evaluating the progression of the disease. A significant correlation exists between the disease progression and serum CA125 levels, with doubling or halving serum values considered clinically significant. [8]", "contents": "Cancer Antigen 125 -- Clinical Significance. Current guidelines suggest using formal risk assessment tests such as the risk of malignancy index or the risk of ovarian malignancy algorithm while assessing the need for gynecological referral in premenopausal women. [4] CA125 is successfully used for disease monitoring and evaluating the progression of the disease. A significant correlation exists between the disease progression and serum CA125 levels, with doubling or halving serum values considered clinically significant. [8]"}
+{"id": "article-101263_18", "title": "Cancer Antigen 125 -- Clinical Significance", "content": "CA125 levels also indicate the tumor status. Most patients with CA125\u00a0levels greater than 35 U/mL demonstrate disease recurrence on second-look surgery, and those with\u00a0CA125 levels less than 35 U/mL have minimal residual disease among half of the patients. [8] CA125 levels also act as an early predictor of outcomes where a deviation from the ideal CA125 regression curve suggests a poor outcome. Among patients who had undergone complete remission, elevation in CA125 occurred before the tumor recurrence in 75% of the patients. [2] However, using CA125 as a screening test for patients with ovarian cancer is not feasible. In subsequent studies evaluating the benefit of using multimodal screening combined with transvaginal ultrasound for ovarian cancer screening, no benefit in improving mortality was found. [36]", "contents": "Cancer Antigen 125 -- Clinical Significance. CA125 levels also indicate the tumor status. Most patients with CA125\u00a0levels greater than 35 U/mL demonstrate disease recurrence on second-look surgery, and those with\u00a0CA125 levels less than 35 U/mL have minimal residual disease among half of the patients. [8] CA125 levels also act as an early predictor of outcomes where a deviation from the ideal CA125 regression curve suggests a poor outcome. Among patients who had undergone complete remission, elevation in CA125 occurred before the tumor recurrence in 75% of the patients. [2] However, using CA125 as a screening test for patients with ovarian cancer is not feasible. In subsequent studies evaluating the benefit of using multimodal screening combined with transvaginal ultrasound for ovarian cancer screening, no benefit in improving mortality was found. [36]"}
+{"id": "article-101263_19", "title": "Cancer Antigen 125 -- Clinical Significance", "content": "CA125 may also have a role in monitoring response to chemotherapy. Serial measurements of CA125 are\u00a0found to correlate with clinical disease outcomes in 89% of 531 patients. [21] There is a consensus among current guidelines to use CA125 to monitor the response to chemotherapy. The Gynecologic Cancer Intergroup defines response as a 50% reduction in CA125 concentration compared to a pretreatment sample. [37] [38] The response should be confirmed and sustained for at least 20 days. Patients can only be diagnosed if\u00a0they have a CA125 concentration in a pretreatment sample that is twice the upper reference limit and taken 2 weeks before initiation of therapy. Additional samples are recommended at 2 to 4 weeks during treatment and at intervals of 2 to 3 weeks during follow-up. The same method should be used to monitor the patient throughout, and patients who receive immunotherapy (mouse antibodies) cannot be diagnosed. [39] The Food and Drug Administration approved the serial measurement of CA125 to aid in monitoring therapeutic response. [40]", "contents": "Cancer Antigen 125 -- Clinical Significance. CA125 may also have a role in monitoring response to chemotherapy. Serial measurements of CA125 are\u00a0found to correlate with clinical disease outcomes in 89% of 531 patients. [21] There is a consensus among current guidelines to use CA125 to monitor the response to chemotherapy. The Gynecologic Cancer Intergroup defines response as a 50% reduction in CA125 concentration compared to a pretreatment sample. [37] [38] The response should be confirmed and sustained for at least 20 days. Patients can only be diagnosed if\u00a0they have a CA125 concentration in a pretreatment sample that is twice the upper reference limit and taken 2 weeks before initiation of therapy. Additional samples are recommended at 2 to 4 weeks during treatment and at intervals of 2 to 3 weeks during follow-up. The same method should be used to monitor the patient throughout, and patients who receive immunotherapy (mouse antibodies) cannot be diagnosed. [39] The Food and Drug Administration approved the serial measurement of CA125 to aid in monitoring therapeutic response. [40]"}
+{"id": "article-101263_20", "title": "Cancer Antigen 125 -- Clinical Significance", "content": "Preoperative and postoperative CA125 concentrations may be of prognostic significance. [41] After primary surgery and chemotherapy, persistent elevations of CA125 concentrations are associated with poor prognosis. Patients with preoperative CA125 concentrations greater than 65\u00a0U/mL are reported to have a lower 5-year survival rate and a 6.37-fold risk of death compared to patients with CA125 levels less than 65\u00a0U/mL. [21] The half-life of the CA125 antigen is reported to have an additional prognostic value. A half-life of less than 20 days is associated with improved survival compared to a half-life of more than 20 days. [26] Normalization of CA125 levels after\u00a03 cycles of combination therapy also correlates with improved survival. Importantly,\u00a0CA125 concentration is not elevated in 10% to 20% of patients with advanced ovarian cancer. For these patients, using radiological imaging techniques and monitoring other tumor markers\u00a0are necessary. [42]", "contents": "Cancer Antigen 125 -- Clinical Significance. Preoperative and postoperative CA125 concentrations may be of prognostic significance. [41] After primary surgery and chemotherapy, persistent elevations of CA125 concentrations are associated with poor prognosis. Patients with preoperative CA125 concentrations greater than 65\u00a0U/mL are reported to have a lower 5-year survival rate and a 6.37-fold risk of death compared to patients with CA125 levels less than 65\u00a0U/mL. [21] The half-life of the CA125 antigen is reported to have an additional prognostic value. A half-life of less than 20 days is associated with improved survival compared to a half-life of more than 20 days. [26] Normalization of CA125 levels after\u00a03 cycles of combination therapy also correlates with improved survival. Importantly,\u00a0CA125 concentration is not elevated in 10% to 20% of patients with advanced ovarian cancer. For these patients, using radiological imaging techniques and monitoring other tumor markers\u00a0are necessary. [42]"}
+{"id": "article-101263_21", "title": "Cancer Antigen 125 -- Quality Control and Lab Safety", "content": "For non-waived tests, laboratory regulations require, at the minimum, analysis of at least\u00a02 levels of control materials once every 24 hours. If necessary, laboratories can more frequently assay quality control (QC) samples to ensure accurate results. QC samples should be assayed after calibration or maintenance of an analyzer to verify the correct method performance. [43] To minimize QC when performing tests for which manufacturers\u2019 recommendations are less than those required by the regulatory agency, such as once per month, the labs can develop an individualized quality control plan. This plan involves performing a risk assessment of potential sources of error in all testing phases and putting in place a QC plan to reduce the likelihood of mistakes. [44] Westgard multi-rules are used to evaluate the\u00a0QC runs. In case of a rule violation, proper corrective and preventive action should be taken before patient testing. [45]", "contents": "Cancer Antigen 125 -- Quality Control and Lab Safety. For non-waived tests, laboratory regulations require, at the minimum, analysis of at least\u00a02 levels of control materials once every 24 hours. If necessary, laboratories can more frequently assay quality control (QC) samples to ensure accurate results. QC samples should be assayed after calibration or maintenance of an analyzer to verify the correct method performance. [43] To minimize QC when performing tests for which manufacturers\u2019 recommendations are less than those required by the regulatory agency, such as once per month, the labs can develop an individualized quality control plan. This plan involves performing a risk assessment of potential sources of error in all testing phases and putting in place a QC plan to reduce the likelihood of mistakes. [44] Westgard multi-rules are used to evaluate the\u00a0QC runs. In case of a rule violation, proper corrective and preventive action should be taken before patient testing. [45]"}
+{"id": "article-101263_22", "title": "Cancer Antigen 125 -- Quality Control and Lab Safety", "content": "The laboratory must participate in the external\u00a0QC or proficiency testing program because it is a regulatory requirement published by the Centers for Medicare and Medicaid Services in the Clinical Laboratory Improvement Amendments regulations. This practice is helpful\u00a0to ensure the accuracy and reliability of the laboratory compared to other laboratories performing the same or comparable assays. [46] The PT plan should be included in the quality assessment plan and the laboratory's overall quality program. [47]", "contents": "Cancer Antigen 125 -- Quality Control and Lab Safety. The laboratory must participate in the external\u00a0QC or proficiency testing program because it is a regulatory requirement published by the Centers for Medicare and Medicaid Services in the Clinical Laboratory Improvement Amendments regulations. This practice is helpful\u00a0to ensure the accuracy and reliability of the laboratory compared to other laboratories performing the same or comparable assays. [46] The PT plan should be included in the quality assessment plan and the laboratory's overall quality program. [47]"}
+{"id": "article-101263_23", "title": "Cancer Antigen 125 -- Quality Control and Lab Safety", "content": "The intricate tests conducted in clinical laboratories are the cornerstone of patient diagnosis and treatment. However, this crucial work does not come without risks. These facilities handle various potentially hazardous materials, from infectious agents to toxic chemicals. Strict adherence to safety protocols is essential to prevent accidental exposure or contamination, which includes proper handling, storing, and disposing of these materials to safeguard laboratory personnel, minimizing patient transmission risks, and ensuring the integrity of diagnostic tests. [48]", "contents": "Cancer Antigen 125 -- Quality Control and Lab Safety. The intricate tests conducted in clinical laboratories are the cornerstone of patient diagnosis and treatment. However, this crucial work does not come without risks. These facilities handle various potentially hazardous materials, from infectious agents to toxic chemicals. Strict adherence to safety protocols is essential to prevent accidental exposure or contamination, which includes proper handling, storing, and disposing of these materials to safeguard laboratory personnel, minimizing patient transmission risks, and ensuring the integrity of diagnostic tests. [48]"}
+{"id": "article-101263_24", "title": "Cancer Antigen 125 -- Quality Control and Lab Safety", "content": "Beyond material safety, meticulous equipment maintenance plays a critical role. Keeping laboratory instruments and safety devices, such as eyewash stations and fume hoods, in top condition is crucial for optimal functionality and mitigating potential hazards. Equally important are established and practiced emergency response plans. These plans enable staff to react swiftly and effectively in the event of accidents or incidents. [49]", "contents": "Cancer Antigen 125 -- Quality Control and Lab Safety. Beyond material safety, meticulous equipment maintenance plays a critical role. Keeping laboratory instruments and safety devices, such as eyewash stations and fume hoods, in top condition is crucial for optimal functionality and mitigating potential hazards. Equally important are established and practiced emergency response plans. These plans enable staff to react swiftly and effectively in the event of accidents or incidents. [49]"}
+{"id": "article-101263_25", "title": "Cancer Antigen 125 -- Quality Control and Lab Safety", "content": "Continuous education and training are vital for the laboratory staff to stay abreast of evolving safety procedures and best practices. In addition, this fosters a culture of safety consciousness and accountability within the institution. Prioritizing lab safety does not just protect the workforce; it also strengthens the overall quality and trustworthiness of healthcare delivery. This comprehensive approach to safety includes employing appropriate personal protective equipment such as gloves, lab coats, and respirators, adhering to biosafety levels for specific infectious agents, following a dedicated chemical hygiene plan for safe chemical handling, and ensuring the proper segregation and disposal of biohazardous and chemical waste. [50]", "contents": "Cancer Antigen 125 -- Quality Control and Lab Safety. Continuous education and training are vital for the laboratory staff to stay abreast of evolving safety procedures and best practices. In addition, this fosters a culture of safety consciousness and accountability within the institution. Prioritizing lab safety does not just protect the workforce; it also strengthens the overall quality and trustworthiness of healthcare delivery. This comprehensive approach to safety includes employing appropriate personal protective equipment such as gloves, lab coats, and respirators, adhering to biosafety levels for specific infectious agents, following a dedicated chemical hygiene plan for safe chemical handling, and ensuring the proper segregation and disposal of biohazardous and chemical waste. [50]"}
+{"id": "article-101263_26", "title": "Cancer Antigen 125 -- Enhancing Healthcare Team Outcomes", "content": "CA125 serves a crucial role as a tumor marker\u00a0in diagnosing patients suspected of having ovarian cancer and monitoring disease progression. According to guidelines, it is an essential\u00a0criterion for referring patients with an adnexal mass suspicious of malignancy to a gynecological oncologist.\u00a0Although it has a higher specificity when used\u00a0in postmenopausal women, very high levels\u00a0in premenopausal women require referral. In addition, patient outcomes have been observed to improve\u00a0when treatment is provided by specialized gynecological oncologists and conducted\u00a0in hospitals with necessary consult services and multidisciplinary collaboration. [51]", "contents": "Cancer Antigen 125 -- Enhancing Healthcare Team Outcomes. CA125 serves a crucial role as a tumor marker\u00a0in diagnosing patients suspected of having ovarian cancer and monitoring disease progression. According to guidelines, it is an essential\u00a0criterion for referring patients with an adnexal mass suspicious of malignancy to a gynecological oncologist.\u00a0Although it has a higher specificity when used\u00a0in postmenopausal women, very high levels\u00a0in premenopausal women require referral. In addition, patient outcomes have been observed to improve\u00a0when treatment is provided by specialized gynecological oncologists and conducted\u00a0in hospitals with necessary consult services and multidisciplinary collaboration. [51]"}
+{"id": "article-101263_27", "title": "Cancer Antigen 125 -- Enhancing Healthcare Team Outcomes", "content": "Interprofessional team care involves multiple disciplines, such as primary care physicians, gynecological oncologists, nurses, and pathologists. Each of them has an essential role in providing care for individuals with suspected ovarian cancer or monitoring the disease status, thus influencing disease management. Clinicopathologic meetings involving\u00a0discussions between pathologists and clinicians are a form of interprofessional care. Interprofessional team care has been shown to improve the accuracy of the diagnosis, achieve accurate staging and grading of the disease, and thus improve the management of the patient's disease. In addition to improving patient care, it provides a learning opportunity for the team members. [52]", "contents": "Cancer Antigen 125 -- Enhancing Healthcare Team Outcomes. Interprofessional team care involves multiple disciplines, such as primary care physicians, gynecological oncologists, nurses, and pathologists. Each of them has an essential role in providing care for individuals with suspected ovarian cancer or monitoring the disease status, thus influencing disease management. Clinicopathologic meetings involving\u00a0discussions between pathologists and clinicians are a form of interprofessional care. Interprofessional team care has been shown to improve the accuracy of the diagnosis, achieve accurate staging and grading of the disease, and thus improve the management of the patient's disease. In addition to improving patient care, it provides a learning opportunity for the team members. [52]"}
+{"id": "article-101263_28", "title": "Cancer Antigen 125 -- Enhancing Healthcare Team Outcomes", "content": "Nurses involved in the care of a patient with ovarian cancer are in a unique position to provide information and education to the patient and their family about the disease. In addition, they may be able to identify patients needing psychological support and counseling,\u00a0thereby improving the quality of life for their patients by coordinating referrals with nutritionists, physiotherapists, and psychologists. [53] Evidence shows that patients treated under\u00a0interprofessional team care involving clinicians and physicians from different specialties had a significant survival advantage. [54]", "contents": "Cancer Antigen 125 -- Enhancing Healthcare Team Outcomes. Nurses involved in the care of a patient with ovarian cancer are in a unique position to provide information and education to the patient and their family about the disease. In addition, they may be able to identify patients needing psychological support and counseling,\u00a0thereby improving the quality of life for their patients by coordinating referrals with nutritionists, physiotherapists, and psychologists. [53] Evidence shows that patients treated under\u00a0interprofessional team care involving clinicians and physicians from different specialties had a significant survival advantage. [54]"}
+{"id": "article-101263_29", "title": "Cancer Antigen 125 -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Cancer Antigen 125 -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

statpearls/chunk/article-101401.jsonl

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+{"id": "article-101401_0", "title": "Epithelial Downgrowth -- Continuing Education Activity", "content": "Epithelial downgrowth is a potentially visually devastating complication of intraocular surgery or trauma characterized by the invasion of epithelial cells and growth into intraocular structures. This activity\u00a0reviews\u00a0etiological factors, clinical presentation, diagnostic nuances, and comprehensive management strategies of epithelial downgrowth. Various forms of epithelialization are discussed, and the clinical significance of its aggressive nature is emphasized, particularly the sheet-like invasion culminating in secondary glaucoma and potential vision loss.", "contents": "Epithelial Downgrowth -- Continuing Education Activity. Epithelial downgrowth is a potentially visually devastating complication of intraocular surgery or trauma characterized by the invasion of epithelial cells and growth into intraocular structures. This activity\u00a0reviews\u00a0etiological factors, clinical presentation, diagnostic nuances, and comprehensive management strategies of epithelial downgrowth. Various forms of epithelialization are discussed, and the clinical significance of its aggressive nature is emphasized, particularly the sheet-like invasion culminating in secondary glaucoma and potential vision loss."}
+{"id": "article-101401_1", "title": "Epithelial Downgrowth -- Continuing Education Activity", "content": "This session also covers the diverse diagnostic methodologies and treatment modalities available for epithelial downgrowth, weighing their pros and cons.\u00a0Insights into differentiating epithelial downgrowth from fibrous downgrowth are provided, elucidating subtle yet pivotal distinctions critical for accurate diagnosis and management planning. Finally, the role of the interprofessional team is emphasized,\u00a0as is the need for\u00a0a collaborative approach to ensure optimal patient outcomes in managing this visually threatening condition.", "contents": "Epithelial Downgrowth -- Continuing Education Activity. This session also covers the diverse diagnostic methodologies and treatment modalities available for epithelial downgrowth, weighing their pros and cons.\u00a0Insights into differentiating epithelial downgrowth from fibrous downgrowth are provided, elucidating subtle yet pivotal distinctions critical for accurate diagnosis and management planning. Finally, the role of the interprofessional team is emphasized,\u00a0as is the need for\u00a0a collaborative approach to ensure optimal patient outcomes in managing this visually threatening condition."}
+{"id": "article-101401_2", "title": "Epithelial Downgrowth -- Continuing Education Activity", "content": "Objectives: Identify the primary etiology of epithelial downgrowth involving intraocular surgery or penetrating ocular trauma, leading to the migration of epithelial cells into the anterior chamber and subsequent proliferation into intraocular structures. Apply knowledge of various diagnostic studies for epithelial downgrowth to guide treatment plans and establish surveillance protocols, ensuring timely interventions and improved patient outcomes. Apply evidence-based management\u00a0approaches for epithelial downgrowth, from noninvasive measures to complete surgical excision, considering their risks\u00a0and limitations. Collaborate with\u00a0various healthcare professionals involved in the care of patients with epithelial downgrowth, promoting a shared decision-making process and mutual understanding of treatment goals\u00a0to improve outcomes and reduce complications. Access free multiple choice questions on this topic.", "contents": "Epithelial Downgrowth -- Continuing Education Activity. Objectives: Identify the primary etiology of epithelial downgrowth involving intraocular surgery or penetrating ocular trauma, leading to the migration of epithelial cells into the anterior chamber and subsequent proliferation into intraocular structures. Apply knowledge of various diagnostic studies for epithelial downgrowth to guide treatment plans and establish surveillance protocols, ensuring timely interventions and improved patient outcomes. Apply evidence-based management\u00a0approaches for epithelial downgrowth, from noninvasive measures to complete surgical excision, considering their risks\u00a0and limitations. Collaborate with\u00a0various healthcare professionals involved in the care of patients with epithelial downgrowth, promoting a shared decision-making process and mutual understanding of treatment goals\u00a0to improve outcomes and reduce complications. Access free multiple choice questions on this topic."}
+{"id": "article-101401_3", "title": "Epithelial Downgrowth -- Introduction", "content": "Epithelial downgrowth is a rare but vision-threatening complication of penetrating ocular trauma or intraocular surgery. In this disease, epithelial cells enter the anterior chamber and proliferate into intraocular structures. Stratified squamous epithelium is not ordinarily present in the interior of the eye\u00a0but can\u00a0grow into nearly any intraocular structure. Epithelialization can appear in\u00a03 forms: pearls, cysts, and sheets. [1]", "contents": "Epithelial Downgrowth -- Introduction. Epithelial downgrowth is a rare but vision-threatening complication of penetrating ocular trauma or intraocular surgery. In this disease, epithelial cells enter the anterior chamber and proliferate into intraocular structures. Stratified squamous epithelium is not ordinarily present in the interior of the eye\u00a0but can\u00a0grow into nearly any intraocular structure. Epithelialization can appear in\u00a03 forms: pearls, cysts, and sheets. [1]"}
+{"id": "article-101401_4", "title": "Epithelial Downgrowth -- Introduction", "content": "The sheet-like, diffuse form is the most common and most aggressive and more frequently leads to complications like secondary glaucoma. The cystic form, on the other hand, has a more benign course. [2] However, the natural course of epithelial downgrowth leads to extensive epithelial invasion, resulting in inflammation, secondary glaucoma, hemorrhage, and ultimately permanent vision loss or loss of the eye. [3]", "contents": "Epithelial Downgrowth -- Introduction. The sheet-like, diffuse form is the most common and most aggressive and more frequently leads to complications like secondary glaucoma. The cystic form, on the other hand, has a more benign course. [2] However, the natural course of epithelial downgrowth leads to extensive epithelial invasion, resulting in inflammation, secondary glaucoma, hemorrhage, and ultimately permanent vision loss or loss of the eye. [3]"}
+{"id": "article-101401_5", "title": "Epithelial Downgrowth -- Introduction", "content": "This article presents a brief overview of the etiology, pathophysiology, and risk factors for epithelial downgrowth with a broader discussion of the many diagnostic and therapeutic options, along with the advantages and disadvantages of each. The terms epithelial downgrowth and epithelial ingrowth are sometimes used interchangeably in the literature. However, this article will not discuss epithelial ingrowth that occurs after procedures such as laser-assisted in situ keratomileusis (LASIK), where there is ingrowth of epithelium into the corneal flap interface.", "contents": "Epithelial Downgrowth -- Introduction. This article presents a brief overview of the etiology, pathophysiology, and risk factors for epithelial downgrowth with a broader discussion of the many diagnostic and therapeutic options, along with the advantages and disadvantages of each. The terms epithelial downgrowth and epithelial ingrowth are sometimes used interchangeably in the literature. However, this article will not discuss epithelial ingrowth that occurs after procedures such as laser-assisted in situ keratomileusis (LASIK), where there is ingrowth of epithelium into the corneal flap interface."}
+{"id": "article-101401_6", "title": "Epithelial Downgrowth -- Introduction", "content": "Epithelial downgrowth should also be distinguished from fibrous downgrowth. These\u00a02 conditions are quite similar in terms of etiology, risk factors, and complications and are often managed in the same way. However, there are subtle but important differences between the two that will be further discussed in the Differential Diagnosis\u00a0section.", "contents": "Epithelial Downgrowth -- Introduction. Epithelial downgrowth should also be distinguished from fibrous downgrowth. These\u00a02 conditions are quite similar in terms of etiology, risk factors, and complications and are often managed in the same way. However, there are subtle but important differences between the two that will be further discussed in the Differential Diagnosis\u00a0section."}
+{"id": "article-101401_7", "title": "Epithelial Downgrowth -- Etiology", "content": "Epithelial invasion was first described in 1832 by Dr. William Mackenzie as a semitransparent cyst in the anterior chamber of a patient after a perforating intraocular injury. [4] Since then, epithelial downgrowth has mostly been reported following ocular trauma and cataract surgery, though it has been associated with other procedures such as penetrating keratoplasty, pterygium excision, aspiration of aqueous, and retinal detachment surgery. [5] [6] Although modern surgical techniques have reduced the risk, epithelial downgrowth has been reported after clear cornea phacoemulsification [2] ,\u00a0Descemet's stripping automated endothelial keratoplasty (DSAEK), [7] Descemet's membrane endothelial keratoplasty (DMEK), [1] glaucoma implant surgery, [8] and type 1 Boston keratoprosthesis (KPro). [9]", "contents": "Epithelial Downgrowth -- Etiology. Epithelial invasion was first described in 1832 by Dr. William Mackenzie as a semitransparent cyst in the anterior chamber of a patient after a perforating intraocular injury. [4] Since then, epithelial downgrowth has mostly been reported following ocular trauma and cataract surgery, though it has been associated with other procedures such as penetrating keratoplasty, pterygium excision, aspiration of aqueous, and retinal detachment surgery. [5] [6] Although modern surgical techniques have reduced the risk, epithelial downgrowth has been reported after clear cornea phacoemulsification [2] ,\u00a0Descemet's stripping automated endothelial keratoplasty (DSAEK), [7] Descemet's membrane endothelial keratoplasty (DMEK), [1] glaucoma implant surgery, [8] and type 1 Boston keratoprosthesis (KPro). [9]"}
+{"id": "article-101401_8", "title": "Epithelial Downgrowth -- Epidemiology", "content": "Intracapsular and extracapsular cataract surgery have been reported in the literature as the most common cause of epithelial downgrowth with an average reported incidence of 0.076% to 0.12%, [5] but with ranges from 0% to 1.1%. [10] The incidence of this condition after penetrating keratoplasty has been reported as 0.25%. [11] Most cases of epithelial downgrowth present within the first year following intraocular surgery, but there have been reports of cases presenting decades after surgery or trauma. [5] [12] [13]", "contents": "Epithelial Downgrowth -- Epidemiology. Intracapsular and extracapsular cataract surgery have been reported in the literature as the most common cause of epithelial downgrowth with an average reported incidence of 0.076% to 0.12%, [5] but with ranges from 0% to 1.1%. [10] The incidence of this condition after penetrating keratoplasty has been reported as 0.25%. [11] Most cases of epithelial downgrowth present within the first year following intraocular surgery, but there have been reports of cases presenting decades after surgery or trauma. [5] [12] [13]"}
+{"id": "article-101401_9", "title": "Epithelial Downgrowth -- Pathophysiology", "content": "Epithelial downgrowth occurs when nonkeratinized epithelial cells are introduced through a traumatic or surgical wound and proliferate in the inner structures of the eye.\u00a0Proposed pathophysiologic mechanisms include implantation of the epithelium, the introduction of a conjunctival flap into a wound, or delayed closure. [14] These cells can come from the conjunctiva or cornea and grow over the cornea, iris, trabecular meshwork, ciliary body, crystalline, artificial lens, and retina.", "contents": "Epithelial Downgrowth -- Pathophysiology. Epithelial downgrowth occurs when nonkeratinized epithelial cells are introduced through a traumatic or surgical wound and proliferate in the inner structures of the eye.\u00a0Proposed pathophysiologic mechanisms include implantation of the epithelium, the introduction of a conjunctival flap into a wound, or delayed closure. [14] These cells can come from the conjunctiva or cornea and grow over the cornea, iris, trabecular meshwork, ciliary body, crystalline, artificial lens, and retina."}
+{"id": "article-101401_10", "title": "Epithelial Downgrowth -- Pathophysiology", "content": "Risk factors potentially allowing for epithelial entry and proliferation include multiple intraocular surgeries, delayed wound healing, gaping wound edges, wound fistulas, iris or vitreous incarceration, and full-thickness sutures. [2] [5] Additionally, damaged or denuded endothelium may pose a risk for epithelial migration secondary to loss of contact inhibition. [15] This invasion of epithelium leads to an inflammatory reaction and tissue damage.", "contents": "Epithelial Downgrowth -- Pathophysiology. Risk factors potentially allowing for epithelial entry and proliferation include multiple intraocular surgeries, delayed wound healing, gaping wound edges, wound fistulas, iris or vitreous incarceration, and full-thickness sutures. [2] [5] Additionally, damaged or denuded endothelium may pose a risk for epithelial migration secondary to loss of contact inhibition. [15] This invasion of epithelium leads to an inflammatory reaction and tissue damage."}
+{"id": "article-101401_11", "title": "Epithelial Downgrowth -- History and Physical", "content": "Patients with epithelial downgrowth will usually present within a year of the inciting event with a variety of symptoms, including decreasing visual acuity, redness, pain, tearing, and photophobia. [5] [16] The sheet-like form more commonly presents with marked inflammation and pain. [2] These findings are nonspecific, making the clinical diagnosis of epithelial downgrowth challenging. Slit-lamp examination classically reveals a translucent growth with a scalloped, advancing margin on the posterior surface of the cornea or anterior iris, or a cyst emanating from a wound site. [17] Gonioscopy may reveal epithelium covering the iris and angle, often resulting in glaucoma. [3] However, intraocular pressure is variable and is normal in many cases due to the presence of a fistula. [18]", "contents": "Epithelial Downgrowth -- History and Physical. Patients with epithelial downgrowth will usually present within a year of the inciting event with a variety of symptoms, including decreasing visual acuity, redness, pain, tearing, and photophobia. [5] [16] The sheet-like form more commonly presents with marked inflammation and pain. [2] These findings are nonspecific, making the clinical diagnosis of epithelial downgrowth challenging. Slit-lamp examination classically reveals a translucent growth with a scalloped, advancing margin on the posterior surface of the cornea or anterior iris, or a cyst emanating from a wound site. [17] Gonioscopy may reveal epithelium covering the iris and angle, often resulting in glaucoma. [3] However, intraocular pressure is variable and is normal in many cases due to the presence of a fistula. [18]"}
+{"id": "article-101401_12", "title": "Epithelial Downgrowth -- Evaluation", "content": "Many diagnostic tools for detecting epithelial downgrowth have been reported in the literature. Certain modalities may be more useful when specific risk factors or anatomical involvement are suspected. For example, Seidel testing may help identify fistulas, which are commonly cited risk factors for epithelial downgrowth. [5] For suspected iris involvement, argon laser photocoagulation (100-200 micrometers, 0.1\u00a0to 0.2 s, 100\u00a0to 200 mW) can detect epithelium. [19] A normal iris usually turns dark upon photocoagulation, but the presence of epithelial cells will produce a pathognomonic fluffy white reaction. [8] This method is only helpful in diagnosing iris involvement. Cytology can be performed from an anterior chamber aspirate if free-floating cells are present. Papanicolaou staining may reveal cells of epithelial origin. [20]", "contents": "Epithelial Downgrowth -- Evaluation. Many diagnostic tools for detecting epithelial downgrowth have been reported in the literature. Certain modalities may be more useful when specific risk factors or anatomical involvement are suspected. For example, Seidel testing may help identify fistulas, which are commonly cited risk factors for epithelial downgrowth. [5] For suspected iris involvement, argon laser photocoagulation (100-200 micrometers, 0.1\u00a0to 0.2 s, 100\u00a0to 200 mW) can detect epithelium. [19] A normal iris usually turns dark upon photocoagulation, but the presence of epithelial cells will produce a pathognomonic fluffy white reaction. [8] This method is only helpful in diagnosing iris involvement. Cytology can be performed from an anterior chamber aspirate if free-floating cells are present. Papanicolaou staining may reveal cells of epithelial origin. [20]"}
+{"id": "article-101401_13", "title": "Epithelial Downgrowth -- Evaluation -- Specular Microscopy", "content": "This\u00a0noninvasive diagnostic test reveals a pattern consisting of a sharply defined border between endothelium and epithelial downgrowth. [3] When adjusted to focus on a deeper plane, the microscope will also show a pattern of interlacing borders representing the cell margins of the epithelium. [3] However, this test may be ineffective in the presence of corneal edema. [21]", "contents": "Epithelial Downgrowth -- Evaluation -- Specular Microscopy. This\u00a0noninvasive diagnostic test reveals a pattern consisting of a sharply defined border between endothelium and epithelial downgrowth. [3] When adjusted to focus on a deeper plane, the microscope will also show a pattern of interlacing borders representing the cell margins of the epithelium. [3] However, this test may be ineffective in the presence of corneal edema. [21]"}
+{"id": "article-101401_14", "title": "Epithelial Downgrowth -- Evaluation -- Confocal Microscopy", "content": "This noninvasive modality allows the observer to image living tissue at higher resolutions than specular microscopy and is less affected by corneal edema. [21] Visualization of round, hyperreflective nuclei is characteristic of epithelial cell invasion. Confocal microscopy can also help distinguish between fibrous and epithelial downgrowth in the presence of a retrocorneal membrane. It may be able to detect changes in the appearance of epithelium after treatment, which could be helpful in following the clinical course of epithelial downgrowth. Confocal microscopy may be more sensitive than light microscopy in detecting residual epithelial downgrowth. [21]", "contents": "Epithelial Downgrowth -- Evaluation -- Confocal Microscopy. This noninvasive modality allows the observer to image living tissue at higher resolutions than specular microscopy and is less affected by corneal edema. [21] Visualization of round, hyperreflective nuclei is characteristic of epithelial cell invasion. Confocal microscopy can also help distinguish between fibrous and epithelial downgrowth in the presence of a retrocorneal membrane. It may be able to detect changes in the appearance of epithelium after treatment, which could be helpful in following the clinical course of epithelial downgrowth. Confocal microscopy may be more sensitive than light microscopy in detecting residual epithelial downgrowth. [21]"}
+{"id": "article-101401_15", "title": "Epithelial Downgrowth -- Evaluation -- Anterior Segment Optical Coherence Tomography", "content": "Anterior segment optical coherence tomography (AS-OCT) is another noninvasive imaging modality that has been shown to aid in diagnosing epithelial downgrowth after DSAEK\u00a0and penetrating keratoplasty. [22] [23] Epithelial downgrowth will appear as a hyperreflective layer.", "contents": "Epithelial Downgrowth -- Evaluation -- Anterior Segment Optical Coherence Tomography. Anterior segment optical coherence tomography (AS-OCT) is another noninvasive imaging modality that has been shown to aid in diagnosing epithelial downgrowth after DSAEK\u00a0and penetrating keratoplasty. [22] [23] Epithelial downgrowth will appear as a hyperreflective layer."}
+{"id": "article-101401_16", "title": "Epithelial Downgrowth -- Evaluation -- Histopathologic Analysis", "content": "Histopathologic analysis is the gold standard to confirm epithelial downgrowth. Diagnosis is based on the classic finding of\u00a01 to\u00a03 layers of stratified, nonkeratinized squamous epithelium on the posterior cornea and anterior iris; however, any intraocular structure can be involved. [5] The source of the epithelium may also be distinguished. If the epithelium contains goblet cells, this indicates conjunctival rather than corneal origin. [16]", "contents": "Epithelial Downgrowth -- Evaluation -- Histopathologic Analysis. Histopathologic analysis is the gold standard to confirm epithelial downgrowth. Diagnosis is based on the classic finding of\u00a01 to\u00a03 layers of stratified, nonkeratinized squamous epithelium on the posterior cornea and anterior iris; however, any intraocular structure can be involved. [5] The source of the epithelium may also be distinguished. If the epithelium contains goblet cells, this indicates conjunctival rather than corneal origin. [16]"}
+{"id": "article-101401_17", "title": "Epithelial Downgrowth -- Evaluation -- Immunohistochemistry", "content": "Immunohistochemistry may also be used, but the evidence is limited. Cornea and conjunctival cells can be located by the expression of AE1/AE3, which are anticytokeratin antibodies found in almost all epithelia. [20] However, corneal endothelium may also express cytokeratins, making it difficult to distinguish between attenuated squamous epithelium and a single layer of corneal endothelium using this method alone. [16]", "contents": "Epithelial Downgrowth -- Evaluation -- Immunohistochemistry. Immunohistochemistry may also be used, but the evidence is limited. Cornea and conjunctival cells can be located by the expression of AE1/AE3, which are anticytokeratin antibodies found in almost all epithelia. [20] However, corneal endothelium may also express cytokeratins, making it difficult to distinguish between attenuated squamous epithelium and a single layer of corneal endothelium using this method alone. [16]"}
+{"id": "article-101401_18", "title": "Epithelial Downgrowth -- Treatment / Management", "content": "Historically, many therapeutic modalities have been used to treat epithelial downgrowth. These include surgical interventions such as iridectomy, vitrectomy, cautery, penetrating keratoplasty, cryotherapy, photocoagulation, and mechanical debridement. Medical treatments historically include radiation, alcohol, steroids, and antibiotics. Many of these are no longer used due to complications or high recurrence rates. [2] Regardless, the management of epithelial downgrowth depends on the extent of the involvement and whether it is the cystic or the diffuse, sheet-like form. Aggressive surgical management is often required; however, some of the more conservative approaches listed below may be used alone or in conjunction with others.", "contents": "Epithelial Downgrowth -- Treatment / Management. Historically, many therapeutic modalities have been used to treat epithelial downgrowth. These include surgical interventions such as iridectomy, vitrectomy, cautery, penetrating keratoplasty, cryotherapy, photocoagulation, and mechanical debridement. Medical treatments historically include radiation, alcohol, steroids, and antibiotics. Many of these are no longer used due to complications or high recurrence rates. [2] Regardless, the management of epithelial downgrowth depends on the extent of the involvement and whether it is the cystic or the diffuse, sheet-like form. Aggressive surgical management is often required; however, some of the more conservative approaches listed below may be used alone or in conjunction with others."}
+{"id": "article-101401_19", "title": "Epithelial Downgrowth -- Treatment / Management -- Cryotherapy", "content": "Cryotherapy can be used to eliminate epithelium if localized to the posterior cornea, drainage angle, or ciliary body. [19] This approach can be combined with other surgical techniques, such as penetrating keratoplasty (PKP), fistula resection, or DMEK, to restore clarity and vision. [2] [24] Although cryotherapy typically spares other intraocular structures, different success rates have been reported, and endothelial loss should be anticipated, possibly necessitating corneal transplantation later. [2]", "contents": "Epithelial Downgrowth -- Treatment / Management -- Cryotherapy. Cryotherapy can be used to eliminate epithelium if localized to the posterior cornea, drainage angle, or ciliary body. [19] This approach can be combined with other surgical techniques, such as penetrating keratoplasty (PKP), fistula resection, or DMEK, to restore clarity and vision. [2] [24] Although cryotherapy typically spares other intraocular structures, different success rates have been reported, and endothelial loss should be anticipated, possibly necessitating corneal transplantation later. [2]"}
+{"id": "article-101401_20", "title": "Epithelial Downgrowth -- Treatment / Management -- Transcorneal Photocoagulation", "content": "Transcorneal photocoagulation with an argon laser is typically used for the cystic form of epithelial downgrowth but, in rare cases, has shown effectiveness in treating the diffuse form. [25] This procedure is less invasive than cryotherapy, leading to less inflammation. However, several disadvantages exist, including the need for multiple sessions and a rise in intraocular pressure caused by the release of cyst contents, subsequently blocking the trabecular meshwork. [26] Applying photocoagulation to the posterior surface of the iris or in the angle can also be technically difficult. [2] Endoscopic photocoagulation with a diode laser has been shown to allow for better visualization and precision and, thus, complete treatment, especially in the setting of corneal opacification. [27] [28] However, all forms of photocoagulation reportedly risk rupturing the cyst, potentially leading to the development of the diffuse, sheet-like form.", "contents": "Epithelial Downgrowth -- Treatment / Management -- Transcorneal Photocoagulation. Transcorneal photocoagulation with an argon laser is typically used for the cystic form of epithelial downgrowth but, in rare cases, has shown effectiveness in treating the diffuse form. [25] This procedure is less invasive than cryotherapy, leading to less inflammation. However, several disadvantages exist, including the need for multiple sessions and a rise in intraocular pressure caused by the release of cyst contents, subsequently blocking the trabecular meshwork. [26] Applying photocoagulation to the posterior surface of the iris or in the angle can also be technically difficult. [2] Endoscopic photocoagulation with a diode laser has been shown to allow for better visualization and precision and, thus, complete treatment, especially in the setting of corneal opacification. [27] [28] However, all forms of photocoagulation reportedly risk rupturing the cyst, potentially leading to the development of the diffuse, sheet-like form."}
+{"id": "article-101401_21", "title": "Epithelial Downgrowth -- Treatment / Management -- Intracameral Injections", "content": "Intracameral injections of antimetabolites such as 5-fluorouracil (5-FU) and Mitomycin-C (MMC) have also been reported as potentially effective treatments for epithelial downgrowth. [28] [29] [30] These injections offer an alternative to more aggressive surgical management. The pyrimidine analog 5-FU inhibits cell proliferation and may alter the appearance of epithelial cells on histopathology. [21] Reported dosages range from 40 to 1000 mcg in single or sequential doses. [29] [30] One protocol described an initial injection of 1000 mcg/0.1mL of 5-FU combined with 0.1 mL viscoelastic, followed\u00a03 weeks later by another injection of 5-FU at 500 mcg/0.1mL with 0.1mL of viscoelastic. [30]", "contents": "Epithelial Downgrowth -- Treatment / Management -- Intracameral Injections. Intracameral injections of antimetabolites such as 5-fluorouracil (5-FU) and Mitomycin-C (MMC) have also been reported as potentially effective treatments for epithelial downgrowth. [28] [29] [30] These injections offer an alternative to more aggressive surgical management. The pyrimidine analog 5-FU inhibits cell proliferation and may alter the appearance of epithelial cells on histopathology. [21] Reported dosages range from 40 to 1000 mcg in single or sequential doses. [29] [30] One protocol described an initial injection of 1000 mcg/0.1mL of 5-FU combined with 0.1 mL viscoelastic, followed\u00a03 weeks later by another injection of 5-FU at 500 mcg/0.1mL with 0.1mL of viscoelastic. [30]"}
+{"id": "article-101401_22", "title": "Epithelial Downgrowth -- Treatment / Management -- Intracameral Injections", "content": "This sequential dose pattern was designed to eradicate rapidly proliferating cells with the first injection. The second injection targets cells in the rest phase that may have proliferated after the drug had cleared. This is similar to a protocol used by Lai and Haller in which 500 mcg of 5-FU was injected into the anterior chamber after a fluid-gas exchange, followed by a second injection of 500 mcg\u00a02 weeks later without gas. [31]", "contents": "Epithelial Downgrowth -- Treatment / Management -- Intracameral Injections. This sequential dose pattern was designed to eradicate rapidly proliferating cells with the first injection. The second injection targets cells in the rest phase that may have proliferated after the drug had cleared. This is similar to a protocol used by Lai and Haller in which 500 mcg of 5-FU was injected into the anterior chamber after a fluid-gas exchange, followed by a second injection of 500 mcg\u00a02 weeks later without gas. [31]"}
+{"id": "article-101401_23", "title": "Epithelial Downgrowth -- Treatment / Management -- Intracameral Injections", "content": "Intraocular injections offer several potential advantages over subconjunctival injections, including the ability to use smaller doses with decreased risk of toxic side effects to the cornea. [32] In some cases, these injections completely resolve epithelial downgrowth, but complications include epithelial defect and corneal decompensation. [29] [30]", "contents": "Epithelial Downgrowth -- Treatment / Management -- Intracameral Injections. Intraocular injections offer several potential advantages over subconjunctival injections, including the ability to use smaller doses with decreased risk of toxic side effects to the cornea. [32] In some cases, these injections completely resolve epithelial downgrowth, but complications include epithelial defect and corneal decompensation. [29] [30]"}
+{"id": "article-101401_24", "title": "Epithelial Downgrowth -- Treatment / Management -- MMC", "content": "MMC is a DNA cross-linking antineoplastic agent which also inhibits RNA and protein synthesis. It has been hypothesized that applying MMC in the cystic form of epithelial downgrowth damages the epithelial cells that secrete cyst fluid, leading to regression of the cyst. [26] Yu et al described a protocol beginning with aspirating an epithelial cyst with a 30-gauge needle followed by an injection of MMC at a concentration of 0.0002 mg/mL into the drained cyst. [26] However, MMC can have devastating effects if it leaks into the anterior chamber, so this procedure must be performed with caution.", "contents": "Epithelial Downgrowth -- Treatment / Management -- MMC. MMC is a DNA cross-linking antineoplastic agent which also inhibits RNA and protein synthesis. It has been hypothesized that applying MMC in the cystic form of epithelial downgrowth damages the epithelial cells that secrete cyst fluid, leading to regression of the cyst. [26] Yu et al described a protocol beginning with aspirating an epithelial cyst with a 30-gauge needle followed by an injection of MMC at a concentration of 0.0002 mg/mL into the drained cyst. [26] However, MMC can have devastating effects if it leaks into the anterior chamber, so this procedure must be performed with caution."}
+{"id": "article-101401_25", "title": "Epithelial Downgrowth -- Treatment / Management -- Intravitreal Methotrexate", "content": "Lambert et al.\u00a0reported a case of recurrent epithelial downgrowth refractory to membrane peeling, endolaser photocoagulation, and 5-FU injection that was treated successfully with intravitreal methotrexate (400 mcg/0.1mL). [33] The protocol was derived from the treatment of intraocular lymphoma. The first injection was performed with an additional membrane peel and endolaser treatment, followed by injections weekly for 4 weeks and then every other week for a total of 12 injections.", "contents": "Epithelial Downgrowth -- Treatment / Management -- Intravitreal Methotrexate. Lambert et al.\u00a0reported a case of recurrent epithelial downgrowth refractory to membrane peeling, endolaser photocoagulation, and 5-FU injection that was treated successfully with intravitreal methotrexate (400 mcg/0.1mL). [33] The protocol was derived from the treatment of intraocular lymphoma. The first injection was performed with an additional membrane peel and endolaser treatment, followed by injections weekly for 4 weeks and then every other week for a total of 12 injections."}
+{"id": "article-101401_26", "title": "Epithelial Downgrowth -- Treatment / Management -- Surgical Procedures", "content": "More aggressive surgical procedures for epithelial downgrowth vary greatly in technique and success rates and depend on the location and structures affected. In some situations, epithelial cysts can be treated more conservatively, which may be recommended in children to preserve intraocular structures\u00a0and manage amblyopia. One such technique consists\u00a0of the viscodissection of the cyst with the aspiration of cyst contents and photocoagulation. [34] These procedures still run the risk of recurrence or converting a cyst into the diffuse form. Therefore, complete excision of cysts along with affected intraocular structures with full-thickness corneoscleral grafting may provide the most definitive surgical management. [17] [35] [36]", "contents": "Epithelial Downgrowth -- Treatment / Management -- Surgical Procedures. More aggressive surgical procedures for epithelial downgrowth vary greatly in technique and success rates and depend on the location and structures affected. In some situations, epithelial cysts can be treated more conservatively, which may be recommended in children to preserve intraocular structures\u00a0and manage amblyopia. One such technique consists\u00a0of the viscodissection of the cyst with the aspiration of cyst contents and photocoagulation. [34] These procedures still run the risk of recurrence or converting a cyst into the diffuse form. Therefore, complete excision of cysts along with affected intraocular structures with full-thickness corneoscleral grafting may provide the most definitive surgical management. [17] [35] [36]"}
+{"id": "article-101401_27", "title": "Epithelial Downgrowth -- Treatment / Management -- Surgical Procedures", "content": "Although the diffuse, sheet-like form may be effectively treated conservatively in rare cases with photocoagulation\u00a0or epithelial membrane peeling, a more aggressive surgical approach is also usually necessary. [25] [37] [25] Surgical removal of the cystic form is more likely to be successful due to implanted cells being circumscribed within the cyst. These approaches seek to completely remove the epithelium and the intraocular structures involved but run the risk of collateral damage to ocular structures.", "contents": "Epithelial Downgrowth -- Treatment / Management -- Surgical Procedures. Although the diffuse, sheet-like form may be effectively treated conservatively in rare cases with photocoagulation\u00a0or epithelial membrane peeling, a more aggressive surgical approach is also usually necessary. [25] [37] [25] Surgical removal of the cystic form is more likely to be successful due to implanted cells being circumscribed within the cyst. These approaches seek to completely remove the epithelium and the intraocular structures involved but run the risk of collateral damage to ocular structures."}
+{"id": "article-101401_28", "title": "Epithelial Downgrowth -- Treatment / Management -- Surgical Procedures", "content": "To prevent epithelial downgrowth, a meticulous approximation of wound edges and attention to incisions intraoperatively and postoperatively are crucial. Wound leaks should also be evaluated and repaired when applicable.", "contents": "Epithelial Downgrowth -- Treatment / Management -- Surgical Procedures. To prevent epithelial downgrowth, a meticulous approximation of wound edges and attention to incisions intraoperatively and postoperatively are crucial. Wound leaks should also be evaluated and repaired when applicable."}
+{"id": "article-101401_29", "title": "Epithelial Downgrowth -- Differential Diagnosis -- Fibrovascular Downgrowth", "content": "The term retrocorneal membrane can encompass both epithelial downgrowth and fibrous downgrowth. Both can be a result of trauma or intraocular surgery; for example, fibrous downgrowth has been reported after cataract surgery, [38] rigid Schreck anterior chamber lens implantation, [39] intraocular telescope implantation, [40] and traumatic corneoscleral wound dehiscence. [41] Risk factors appear similar, including prolonged inflammation, wound dehiscence, and delayed wound closure. Symptoms in each are nonspecific, and both appear as translucent retrocorneal membranes.", "contents": "Epithelial Downgrowth -- Differential Diagnosis -- Fibrovascular Downgrowth. The term retrocorneal membrane can encompass both epithelial downgrowth and fibrous downgrowth. Both can be a result of trauma or intraocular surgery; for example, fibrous downgrowth has been reported after cataract surgery, [38] rigid Schreck anterior chamber lens implantation, [39] intraocular telescope implantation, [40] and traumatic corneoscleral wound dehiscence. [41] Risk factors appear similar, including prolonged inflammation, wound dehiscence, and delayed wound closure. Symptoms in each are nonspecific, and both appear as translucent retrocorneal membranes."}
+{"id": "article-101401_30", "title": "Epithelial Downgrowth -- Differential Diagnosis -- Fibrovascular Downgrowth", "content": "Complications of fibrous downgrowth are like that of epithelial downgrowth, including glaucoma. [42] However, there are a few distinctions. The membrane in fibrous downgrowth may be vascular and is predominately fibrous instead of cellular. [14] [19] Fibrous downgrowth is also more common than epithelial downgrowth and tends to progress more slowly. There are few adjunctive tests to confirm the presence of fibrous downgrowth. However, there are reports that immunohistochemical positive staining for \u03b1-smooth muscle actin can help sway the diagnosis toward fibrous downgrowth. [43]", "contents": "Epithelial Downgrowth -- Differential Diagnosis -- Fibrovascular Downgrowth. Complications of fibrous downgrowth are like that of epithelial downgrowth, including glaucoma. [42] However, there are a few distinctions. The membrane in fibrous downgrowth may be vascular and is predominately fibrous instead of cellular. [14] [19] Fibrous downgrowth is also more common than epithelial downgrowth and tends to progress more slowly. There are few adjunctive tests to confirm the presence of fibrous downgrowth. However, there are reports that immunohistochemical positive staining for \u03b1-smooth muscle actin can help sway the diagnosis toward fibrous downgrowth. [43]"}
+{"id": "article-101401_31", "title": "Epithelial Downgrowth -- Differential Diagnosis -- Fibrovascular Downgrowth", "content": "Management mainly appears to be similar between epithelial and fibrous downgrowth using photocoagulation, surgical excision, and intracameral metabolites. Bevacizumab has been suggested as a unique treatment for fibrous downgrowth. Mansour\u00a0reports using combined intracorneal (0.05 mL; 1.25 mg) and subconjunctival (0.1 mL; 2.5 mg) injections of bevacizumab in a patient to halt vascularization within the fibrous membrane to reduce intraocular bleeding. [14] Intracorneal and subconjunctival routes of injection were chosen instead of intracameral due to the presence of glaucoma and intravitreal silicone oil.", "contents": "Epithelial Downgrowth -- Differential Diagnosis -- Fibrovascular Downgrowth. Management mainly appears to be similar between epithelial and fibrous downgrowth using photocoagulation, surgical excision, and intracameral metabolites. Bevacizumab has been suggested as a unique treatment for fibrous downgrowth. Mansour\u00a0reports using combined intracorneal (0.05 mL; 1.25 mg) and subconjunctival (0.1 mL; 2.5 mg) injections of bevacizumab in a patient to halt vascularization within the fibrous membrane to reduce intraocular bleeding. [14] Intracorneal and subconjunctival routes of injection were chosen instead of intracameral due to the presence of glaucoma and intravitreal silicone oil."}
+{"id": "article-101401_32", "title": "Epithelial Downgrowth -- Differential Diagnosis -- Pseudophakic Bullous Keratopathy", "content": "Pseudophakic bullous keratopathy (PBK) is the development of irreversible corneal edema after cataract surgery and postoperative inflammation. This corneal edema occurs due to the loss of corneal endothelium secondary to surgical trauma. PBK can clinically resemble epithelial downgrowth with reduced visual acuity, tearing, and pain. However, signs of PBK include stromal edema and subepithelial bullae. Epithelial downgrowth should be considered in patients undergoing penetrating keratoplasty for presumed diagnoses of PBK, and these may be distinguished immunohistochemically with the presence of anticytokeratin antibodies in epithelial downgrowth. [20]", "contents": "Epithelial Downgrowth -- Differential Diagnosis -- Pseudophakic Bullous Keratopathy. Pseudophakic bullous keratopathy (PBK) is the development of irreversible corneal edema after cataract surgery and postoperative inflammation. This corneal edema occurs due to the loss of corneal endothelium secondary to surgical trauma. PBK can clinically resemble epithelial downgrowth with reduced visual acuity, tearing, and pain. However, signs of PBK include stromal edema and subepithelial bullae. Epithelial downgrowth should be considered in patients undergoing penetrating keratoplasty for presumed diagnoses of PBK, and these may be distinguished immunohistochemically with the presence of anticytokeratin antibodies in epithelial downgrowth. [20]"}
+{"id": "article-101401_33", "title": "Epithelial Downgrowth -- Differential Diagnosis -- Secondary Endothelial Proliferation", "content": "Secondary endothelization usually arises from ischemia and can also present after multiple intraocular surgeries. The endothelial cells can proliferate in the angle and anterior surface of the iris. This can be considered a precursor to rubeosis iridis (neovascularization of the iris), which can lead to neovascular glaucoma, a form of secondary glaucoma. Clinically, this can appear as neovascularization of the iris. Histologically, this can be differentiated from epithelial downgrowth by a lack of stratification. [16]", "contents": "Epithelial Downgrowth -- Differential Diagnosis -- Secondary Endothelial Proliferation. Secondary endothelization usually arises from ischemia and can also present after multiple intraocular surgeries. The endothelial cells can proliferate in the angle and anterior surface of the iris. This can be considered a precursor to rubeosis iridis (neovascularization of the iris), which can lead to neovascular glaucoma, a form of secondary glaucoma. Clinically, this can appear as neovascularization of the iris. Histologically, this can be differentiated from epithelial downgrowth by a lack of stratification. [16]"}
+{"id": "article-101401_34", "title": "Epithelial Downgrowth -- Prognosis", "content": "Visual outcome after a diagnosis of epithelial\u00a0downgrowth\u00a0is generally poor due to recurrence, refractory glaucoma, and corneal decompensation. [15] Prognosis tends to be worse in the diffuse, sheet-like form because it is more difficult to identify and requires more extensive surgical procedures. [2] Many cases have historically ended in enucleation, most commonly due to severe secondary glaucoma. [5] In one retrospective study from 1953 to 1983, enucleation occurred in 52% of patients treated with surgery and 95% of those without surgery. [5]", "contents": "Epithelial Downgrowth -- Prognosis. Visual outcome after a diagnosis of epithelial\u00a0downgrowth\u00a0is generally poor due to recurrence, refractory glaucoma, and corneal decompensation. [15] Prognosis tends to be worse in the diffuse, sheet-like form because it is more difficult to identify and requires more extensive surgical procedures. [2] Many cases have historically ended in enucleation, most commonly due to severe secondary glaucoma. [5] In one retrospective study from 1953 to 1983, enucleation occurred in 52% of patients treated with surgery and 95% of those without surgery. [5]"}
+{"id": "article-101401_35", "title": "Epithelial Downgrowth -- Prognosis", "content": "In a series of 52 patients from 1980\u00a0to 1996 treated with en bloc excision and corneoscleral grafting, the mean visual acuity at the final follow-up visit was 20/100 in the cystic-type cases and 20/200 in the diffuse-type cases. [44] In this study, there were no reported cases of recurrence or enucleation.\u00a0Although many cases require early and aggressive intervention to prevent permanent vision loss, there are rare case reports of epithelial downgrowth spontaneously regressing. [45]", "contents": "Epithelial Downgrowth -- Prognosis. In a series of 52 patients from 1980\u00a0to 1996 treated with en bloc excision and corneoscleral grafting, the mean visual acuity at the final follow-up visit was 20/100 in the cystic-type cases and 20/200 in the diffuse-type cases. [44] In this study, there were no reported cases of recurrence or enucleation.\u00a0Although many cases require early and aggressive intervention to prevent permanent vision loss, there are rare case reports of epithelial downgrowth spontaneously regressing. [45]"}
+{"id": "article-101401_36", "title": "Epithelial Downgrowth -- Complications", "content": "Complications include chronic inflammation, secondary glaucoma, corneal decompensation, and, in severe cases, phthisis bulbi. Glaucoma is common with the diffuse sheet-like form and may occur due to blockage of the trabecular meshwork by the epithelium directly or by mucin from conjunctival goblet cells. [42] Inflammation can also lead to peripheral anterior synechiae and trabeculitis, worsening aqueous drainage. This secondary glaucoma is often refractory to medical management and is a major cause of irreversible vision loss in epithelial downgrowth.", "contents": "Epithelial Downgrowth -- Complications. Complications include chronic inflammation, secondary glaucoma, corneal decompensation, and, in severe cases, phthisis bulbi. Glaucoma is common with the diffuse sheet-like form and may occur due to blockage of the trabecular meshwork by the epithelium directly or by mucin from conjunctival goblet cells. [42] Inflammation can also lead to peripheral anterior synechiae and trabeculitis, worsening aqueous drainage. This secondary glaucoma is often refractory to medical management and is a major cause of irreversible vision loss in epithelial downgrowth."}
+{"id": "article-101401_37", "title": "Epithelial Downgrowth -- Complications", "content": "Management usually centers around combining topical intraocular pressure\u2013lowering medications with a glaucoma drainage device and possibly cryoablation procedures. Epithelium can also progress to the posterior chamber in the setting of aphakia, lens luxation, trauma, or scleral buckle insertion. [9] This can lead to proliferation onto the inner retina, causing tractional retinal detachment and epiretinal membranes. [46]", "contents": "Epithelial Downgrowth -- Complications. Management usually centers around combining topical intraocular pressure\u2013lowering medications with a glaucoma drainage device and possibly cryoablation procedures. Epithelium can also progress to the posterior chamber in the setting of aphakia, lens luxation, trauma, or scleral buckle insertion. [9] This can lead to proliferation onto the inner retina, causing tractional retinal detachment and epiretinal membranes. [46]"}
+{"id": "article-101401_38", "title": "Epithelial Downgrowth -- Deterrence and Patient Education", "content": "Patients should be informed of treatment options for epithelial downgrowth and that recurrence is common.\u00a0They should also be educated that, depending on the extent of the disease, the goal of treatment may not be to restore visual acuity and function completely but rather to achieve stability and comfort. If surgery is pursued, patients should be encouraged to follow postoperative safety measures to improve outcomes.", "contents": "Epithelial Downgrowth -- Deterrence and Patient Education. Patients should be informed of treatment options for epithelial downgrowth and that recurrence is common.\u00a0They should also be educated that, depending on the extent of the disease, the goal of treatment may not be to restore visual acuity and function completely but rather to achieve stability and comfort. If surgery is pursued, patients should be encouraged to follow postoperative safety measures to improve outcomes."}
+{"id": "article-101401_39", "title": "Epithelial Downgrowth -- Pearls and Other Issues", "content": "Epithelial downgrowth is a rare but vision-threatening complication of penetrating ocular trauma or intraocular surgery. It\u00a0ranges in the severity of presentation but can include decreasing visual acuity, redness, pain, tearing, and photophobia. A thorough history and physical examination, in addition to supplemental studies like imaging and histopathology, is crucial to diagnose epithelial downgrowth accurately. Treatment options depend on the extent of involvement and growth pattern and vary from conservative measures to surgical excision with corneoscleral transplantation.", "contents": "Epithelial Downgrowth -- Pearls and Other Issues. Epithelial downgrowth is a rare but vision-threatening complication of penetrating ocular trauma or intraocular surgery. It\u00a0ranges in the severity of presentation but can include decreasing visual acuity, redness, pain, tearing, and photophobia. A thorough history and physical examination, in addition to supplemental studies like imaging and histopathology, is crucial to diagnose epithelial downgrowth accurately. Treatment options depend on the extent of involvement and growth pattern and vary from conservative measures to surgical excision with corneoscleral transplantation."}
+{"id": "article-101401_40", "title": "Epithelial Downgrowth -- Enhancing Healthcare Team Outcomes", "content": "Epithelial downgrowth is a rare pathology, but clinicians should be able to identify it promptly to minimize severe complications. [2] Managing epithelial downgrowth requires a team of medical professionals. Physicians, eye care specialists, nurses, technicians, and medical assistants should be thorough when performing the history and physical, paying particular attention to previous intraocular surgeries or trauma. Clinicians should be aware of relevant testing to expedite the diagnosis of epithelial downgrowth, as it is progressive and carries a poor prognosis. Patients\u00a0should be adequately informed of the diagnosis, treatment options, and complications.", "contents": "Epithelial Downgrowth -- Enhancing Healthcare Team Outcomes. Epithelial downgrowth is a rare pathology, but clinicians should be able to identify it promptly to minimize severe complications. [2] Managing epithelial downgrowth requires a team of medical professionals. Physicians, eye care specialists, nurses, technicians, and medical assistants should be thorough when performing the history and physical, paying particular attention to previous intraocular surgeries or trauma. Clinicians should be aware of relevant testing to expedite the diagnosis of epithelial downgrowth, as it is progressive and carries a poor prognosis. Patients\u00a0should be adequately informed of the diagnosis, treatment options, and complications."}
+{"id": "article-101401_41", "title": "Epithelial Downgrowth -- Review Questions", "content": "Access free multiple choice questions on this topic. Click here for a simplified version. Comment on this article.", "contents": "Epithelial Downgrowth -- Review Questions. Access free multiple choice questions on this topic. Click here for a simplified version. Comment on this article."}

statpearls/chunk/article-101404.jsonl

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+{"id": "article-101404_0", "title": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Introduction", "content": "The elbow is a hinge joint comprised of bony and ligamentous stabilizers. Specifically, the elbow contains two\u00a0collateral\u00a0ligaments:\u00a0the medial\u00a0collateral ligament (MCL, also known as ulnar\u00a0collateral ligament, or UCL) and the lateral collateral ligament (LCL). Each of these two ligaments is made up of smaller ligamentous portions. These structures provide stability for the elbow joint and constant tension through elbow motion. The constant tension and torque experienced by these ligaments leave them prone to injury, especially the MCL. [1]", "contents": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Introduction. The elbow is a hinge joint comprised of bony and ligamentous stabilizers. Specifically, the elbow contains two\u00a0collateral\u00a0ligaments:\u00a0the medial\u00a0collateral ligament (MCL, also known as ulnar\u00a0collateral ligament, or UCL) and the lateral collateral ligament (LCL). Each of these two ligaments is made up of smaller ligamentous portions. These structures provide stability for the elbow joint and constant tension through elbow motion. The constant tension and torque experienced by these ligaments leave them prone to injury, especially the MCL. [1]"}
+{"id": "article-101404_1", "title": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Structure and Function", "content": "The elbow's ranges of motion (ROM)\u00a0are\u00a0flexion, extension, pronation, and supination. In healthy individuals, flexion lies between 130\u00a0to 154\u00a0degrees, extension from -6\u00a0to 11\u00a0degrees, pronation from 75\u00a0to 85\u00a0degrees, and supination from 80\u00a0to 104\u00a0degrees. [2]", "contents": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Structure and Function. The elbow's ranges of motion (ROM)\u00a0are\u00a0flexion, extension, pronation, and supination. In healthy individuals, flexion lies between 130\u00a0to 154\u00a0degrees, extension from -6\u00a0to 11\u00a0degrees, pronation from 75\u00a0to 85\u00a0degrees, and supination from 80\u00a0to 104\u00a0degrees. [2]"}
+{"id": "article-101404_2", "title": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Structure and Function", "content": "The bony anatomy of the elbow joint requires a brief description\u00a0to lay the framework for the collateral ligaments of the elbow. Three bony structures create multiple articulations within the elbow complex. The three bony structures include the distal humerus, proximal radius, and proximal ulna. The distal humerus contains two\u00a0main\u00a0structures, the trochlea, and the capitellum. The medial epicondyle of the humerus\u00a0provides a\u00a0site of connection for ligamentous and muscular structures.", "contents": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Structure and Function. The bony anatomy of the elbow joint requires a brief description\u00a0to lay the framework for the collateral ligaments of the elbow. Three bony structures create multiple articulations within the elbow complex. The three bony structures include the distal humerus, proximal radius, and proximal ulna. The distal humerus contains two\u00a0main\u00a0structures, the trochlea, and the capitellum. The medial epicondyle of the humerus\u00a0provides a\u00a0site of connection for ligamentous and muscular structures."}
+{"id": "article-101404_3", "title": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Structure and Function", "content": "The proximal ulna also has two articulations, the greater and lesser sigmoid notches. The trochlea and greater sigmoid notch have 180 degrees of articular contact during the elbow range of motion (ROM). The lesser sigmoid notch\u00a0articulates with the radius at the proximal radioulnar joint. The radial head and capitellum form the raidiocapitellar joint. The radial head allows for pronation and supination of the elbow. [1]", "contents": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Structure and Function. The proximal ulna also has two articulations, the greater and lesser sigmoid notches. The trochlea and greater sigmoid notch have 180 degrees of articular contact during the elbow range of motion (ROM). The lesser sigmoid notch\u00a0articulates with the radius at the proximal radioulnar joint. The radial head and capitellum form the raidiocapitellar joint. The radial head allows for pronation and supination of the elbow. [1]"}
+{"id": "article-101404_4", "title": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Structure and Function", "content": "The MCL has three ligamentous portions: the anterior bundle (AMCL), the posterior bundle, and the transverse ligament (Cooper ligament). The AMCL and posterior bundle originate from the medial epicondyle of the distal humerus, on the posterior side of the elbow; this creates ligamentous tension with elbow flexion. The insertion site of the AMCL is the sublime tubercle on the coronoid process of the ulna, and the posterior bundle inserts on at the medial olecranon of the ulna. [1]", "contents": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Structure and Function. The MCL has three ligamentous portions: the anterior bundle (AMCL), the posterior bundle, and the transverse ligament (Cooper ligament). The AMCL and posterior bundle originate from the medial epicondyle of the distal humerus, on the posterior side of the elbow; this creates ligamentous tension with elbow flexion. The insertion site of the AMCL is the sublime tubercle on the coronoid process of the ulna, and the posterior bundle inserts on at the medial olecranon of the ulna. [1]"}
+{"id": "article-101404_5", "title": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Structure and Function", "content": "The transverse ligament originates from the olecranon process inserts on the sublime tubercle of the ulna. [3] As mentioned, the MCL acts as a primary stabilizer of the elbow, but specifically during valgus stress. For this reason, the MCL is the most commonly\u00a0injured ligament in overhead throwing athletes; this is due to\u00a0the mechanics of throwing motion that cause extreme valgus stress at high velocities.\u00a0The anterior and posterior bundles\u00a0provide reciprocal function, as the anterior portion is tight in extension, and the posterior portion is tight in flexion. During flexion of the elbow, the MCL also limits internal rotation. [4]", "contents": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Structure and Function. The transverse ligament originates from the olecranon process inserts on the sublime tubercle of the ulna. [3] As mentioned, the MCL acts as a primary stabilizer of the elbow, but specifically during valgus stress. For this reason, the MCL is the most commonly\u00a0injured ligament in overhead throwing athletes; this is due to\u00a0the mechanics of throwing motion that cause extreme valgus stress at high velocities.\u00a0The anterior and posterior bundles\u00a0provide reciprocal function, as the anterior portion is tight in extension, and the posterior portion is tight in flexion. During flexion of the elbow, the MCL also limits internal rotation. [4]"}
+{"id": "article-101404_6", "title": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Structure and Function", "content": "The MCL also functions as a restraint in posteromedial rotatory instability, specifically the AMCL. Further evaluating the MCL and the specifics of valgus stress, the MCL provides\u00a0one-third of the valgus restraint in extension, and one half in 90\u00a0degrees of elbow flexion. The MCL coincides with the flexor and pronator forearm musculature in dynamic stability. [1]", "contents": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Structure and Function. The MCL also functions as a restraint in posteromedial rotatory instability, specifically the AMCL. Further evaluating the MCL and the specifics of valgus stress, the MCL provides\u00a0one-third of the valgus restraint in extension, and one half in 90\u00a0degrees of elbow flexion. The MCL coincides with the flexor and pronator forearm musculature in dynamic stability. [1]"}
+{"id": "article-101404_7", "title": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Structure and Function", "content": "The LCL contains four ligamentous portions: the lateral ulnar collateral ligament (LUCL), radial collateral ligament (RCL), annular ligament, and accessory collateral ligament. The LUCL and RCL originate from the inferior surface of the lateral epicondyle of the humerus. These two ligaments provide consistent tension through elbow ROM. The LUCL inserts at the proximal ulna and the RCL attached to the annular ligament. The annular ligament wraps around the radial head and attaches to the anterior snd posterior margins of the lesser sigmoid notch of the proximal ulna. The RCL and annular ligaments provide stabilization for the radial head. [1]", "contents": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Structure and Function. The LCL contains four ligamentous portions: the lateral ulnar collateral ligament (LUCL), radial collateral ligament (RCL), annular ligament, and accessory collateral ligament. The LUCL and RCL originate from the inferior surface of the lateral epicondyle of the humerus. These two ligaments provide consistent tension through elbow ROM. The LUCL inserts at the proximal ulna and the RCL attached to the annular ligament. The annular ligament wraps around the radial head and attaches to the anterior snd posterior margins of the lesser sigmoid notch of the proximal ulna. The RCL and annular ligaments provide stabilization for the radial head. [1]"}
+{"id": "article-101404_8", "title": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Structure and Function", "content": "The accessory collateral ligament runs from the medial portion of the\u00a0supinator crest (on the proximal ulna) and attaches to the inferior portion of the annular ligament. [5] The LCL functions to\u00a0primarily resist posterolateral rotatory instability, and to a lesser extent, the LCL resists varus stress. The ulnohumeral joint provides the majority of stability when the elbow is under varus stress application; the LCL resists just 10% of varus stress. Within the LCL unit, the LUCL appears to be the\u00a0primary stabilizer, but the entire four-ligament complex is required to provide radiohumeral, radioulnar, and ulnohumeral joint stability. The extensor forearm musculature coincides with the LCL ligament to provide stability with dynamic motion. the LCL is most vulnerable in the supinated position. [1]", "contents": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Structure and Function. The accessory collateral ligament runs from the medial portion of the\u00a0supinator crest (on the proximal ulna) and attaches to the inferior portion of the annular ligament. [5] The LCL functions to\u00a0primarily resist posterolateral rotatory instability, and to a lesser extent, the LCL resists varus stress. The ulnohumeral joint provides the majority of stability when the elbow is under varus stress application; the LCL resists just 10% of varus stress. Within the LCL unit, the LUCL appears to be the\u00a0primary stabilizer, but the entire four-ligament complex is required to provide radiohumeral, radioulnar, and ulnohumeral joint stability. The extensor forearm musculature coincides with the LCL ligament to provide stability with dynamic motion. the LCL is most vulnerable in the supinated position. [1]"}
+{"id": "article-101404_9", "title": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Embryology", "content": "The elbow joint develops in three phases, the homogenous interzone, three-layered interzones, and cavitation. Chondrogenic areas are termed homogenous interzone around six weeks, and cartilaginous development increase via appositional growth. Homogenous zones convert into three-layered interzones at seven weeks. Mesenchymal tissue will condense into a fibrous capsule, and vascular mesenchyme becomes incorporated into the joint as synovial mesenchyme. This synovial\u00a0mesenchyme will form the synovial tissue as well as the intracapsular ligaments. Cavitation, occurring at eight weeks, is when the articular cavity will form. Cavitation is initially independent of movement, but articular motion is necessary for full differentiation and development of the cavity. [6]", "contents": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Embryology. The elbow joint develops in three phases, the homogenous interzone, three-layered interzones, and cavitation. Chondrogenic areas are termed homogenous interzone around six weeks, and cartilaginous development increase via appositional growth. Homogenous zones convert into three-layered interzones at seven weeks. Mesenchymal tissue will condense into a fibrous capsule, and vascular mesenchyme becomes incorporated into the joint as synovial mesenchyme. This synovial\u00a0mesenchyme will form the synovial tissue as well as the intracapsular ligaments. Cavitation, occurring at eight weeks, is when the articular cavity will form. Cavitation is initially independent of movement, but articular motion is necessary for full differentiation and development of the cavity. [6]"}
+{"id": "article-101404_10", "title": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Embryology", "content": "There is a discrepancy when the collateral ligaments are first visible. Studies have demonstrated visualization of the collateral ligaments in as early as 56 days in a 31 mm fetus. Yet other studies mention requiring fetuses of 270mm or larger for visualization of the collateral ligaments. Merida-Velasco et al. found that during week 12, vascular canals became apparent in the humerus, trochlear notch of the ulna, and radial head. It was at this time that the lateral ligaments began to develop into small densities of the outer aspect of the articular capsule. [6]", "contents": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Embryology. There is a discrepancy when the collateral ligaments are first visible. Studies have demonstrated visualization of the collateral ligaments in as early as 56 days in a 31 mm fetus. Yet other studies mention requiring fetuses of 270mm or larger for visualization of the collateral ligaments. Merida-Velasco et al. found that during week 12, vascular canals became apparent in the humerus, trochlear notch of the ulna, and radial head. It was at this time that the lateral ligaments began to develop into small densities of the outer aspect of the articular capsule. [6]"}
+{"id": "article-101404_11", "title": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Blood Supply and Lymphatics", "content": "The elbow joint receives its blood supply from peri-articular anastomoses. Specifically, the brachial, deep brachial, ulnar, and radial arteries have collateral and recurrent branches to provide continuous blood flow. Superior collateral branches include superior collateral, inferior ulnar, and radial collateral arteries. The inferior collateral branches include the anterior and posterior ulnar recurrent arteries, the recurrent interosseous artery, and the radial recurrent artery. The venous outflow is provided by the radial, ulnar, basilic, and brachial veins. [7] [8]", "contents": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Blood Supply and Lymphatics. The elbow joint receives its blood supply from peri-articular anastomoses. Specifically, the brachial, deep brachial, ulnar, and radial arteries have collateral and recurrent branches to provide continuous blood flow. Superior collateral branches include superior collateral, inferior ulnar, and radial collateral arteries. The inferior collateral branches include the anterior and posterior ulnar recurrent arteries, the recurrent interosseous artery, and the radial recurrent artery. The venous outflow is provided by the radial, ulnar, basilic, and brachial veins. [7] [8]"}
+{"id": "article-101404_12", "title": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Blood Supply and Lymphatics", "content": "Specifically, the blood supply to the medial\u00a0collateral ligament is unknown. A descriptive laboratory study utilizing 18 fresh-frozen male cadaveric elbows\u00a0injected 60 mL of India ink into the brachial artery of each elbow.\u00a0The proximal MCL consistently exhibited dense blood supply, while the distal MCL was hypovascular. The authors also found a possible contribution to the proximal MCL\u00a0from the medial epicondyle. An artery from the flexor/pronator musculature also consistently provided blood to the proximal MCL. The average length of vascular penetration\u00a0was 49% for the entire MCL. The study concluded there is a difference in vascular supply between the proximal and distal MCL. They suggested that the hypovascularity of the distal MCL may result in a lack of appropriate healing capacity, and MCL\u00a0injuries may differ in a progression based on the location of the injury (proximal vs. distal). [9]", "contents": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Blood Supply and Lymphatics. Specifically, the blood supply to the medial\u00a0collateral ligament is unknown. A descriptive laboratory study utilizing 18 fresh-frozen male cadaveric elbows\u00a0injected 60 mL of India ink into the brachial artery of each elbow.\u00a0The proximal MCL consistently exhibited dense blood supply, while the distal MCL was hypovascular. The authors also found a possible contribution to the proximal MCL\u00a0from the medial epicondyle. An artery from the flexor/pronator musculature also consistently provided blood to the proximal MCL. The average length of vascular penetration\u00a0was 49% for the entire MCL. The study concluded there is a difference in vascular supply between the proximal and distal MCL. They suggested that the hypovascularity of the distal MCL may result in a lack of appropriate healing capacity, and MCL\u00a0injuries may differ in a progression based on the location of the injury (proximal vs. distal). [9]"}
+{"id": "article-101404_13", "title": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Blood Supply and Lymphatics", "content": "Superficial cubital lymph nodes and deep cubital lymph nodes are located above the medial epicondyle at the elbow. The superficial cubital nodes receive lymph from the medial side of the hand and forearm, while the deep cubital nodes drain the elbow joint itself. The lymph from these nodes eventually reaches the axillary lymph nodes bilaterally. The lymph from the left will enter the thoracic duct and lymph from the right will enter the right lymphatic duct. [7]", "contents": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Blood Supply and Lymphatics. Superficial cubital lymph nodes and deep cubital lymph nodes are located above the medial epicondyle at the elbow. The superficial cubital nodes receive lymph from the medial side of the hand and forearm, while the deep cubital nodes drain the elbow joint itself. The lymph from these nodes eventually reaches the axillary lymph nodes bilaterally. The lymph from the left will enter the thoracic duct and lymph from the right will enter the right lymphatic duct. [7]"}
+{"id": "article-101404_14", "title": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Nerves", "content": "The elbow joint receives branches of the median, radial, and musculocutaneous nerves anteriorly. Posteriorly the elbow joint is supplied by the ulnar nerve. [7] The median nerve branches into small sections that innervate\u00a0the anteromedial epicondyle, where the MCL originates. The ulnar nerve supplies the posteromedial part of the elbow capsules, also in the neighborhood of the medial epicondyle and the olecranon. Branches from the radial nerve supply the posterolateral region of the elbow capsule, which is the location of the LCL. [10]", "contents": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Nerves. The elbow joint receives branches of the median, radial, and musculocutaneous nerves anteriorly. Posteriorly the elbow joint is supplied by the ulnar nerve. [7] The median nerve branches into small sections that innervate\u00a0the anteromedial epicondyle, where the MCL originates. The ulnar nerve supplies the posteromedial part of the elbow capsules, also in the neighborhood of the medial epicondyle and the olecranon. Branches from the radial nerve supply the posterolateral region of the elbow capsule, which is the location of the LCL. [10]"}
+{"id": "article-101404_15", "title": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Muscles", "content": "The MCL works with the medial\u00a0flexor musculature to resist valgus stress. Medial flexor musculature includes the flexor carpi ulnaris, flexor carpi radialis, flexor digitorum superficialis, and pronator teres. The LCL works with the extensor forearm musculature to resist varus forces. The extensor muscles include the extensor carpi ulnaris, extensor digitorum communis, extensor carpi radialis brevis and longus, and the anconeus. The anconeus is of significant importance\u00a0because it provides major dynamic constraint to posterolateral rotatory instability and varus stresses, two functions\u00a0that are also provided by the LCL. [1]", "contents": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Muscles. The MCL works with the medial\u00a0flexor musculature to resist valgus stress. Medial flexor musculature includes the flexor carpi ulnaris, flexor carpi radialis, flexor digitorum superficialis, and pronator teres. The LCL works with the extensor forearm musculature to resist varus forces. The extensor muscles include the extensor carpi ulnaris, extensor digitorum communis, extensor carpi radialis brevis and longus, and the anconeus. The anconeus is of significant importance\u00a0because it provides major dynamic constraint to posterolateral rotatory instability and varus stresses, two functions\u00a0that are also provided by the LCL. [1]"}
+{"id": "article-101404_16", "title": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Physiologic Variants", "content": "A study examining cadaveric specimens looked at specific ligaments of the MCL (anterior bundle, posterior bundle, and transverse ligament). Specifically, they focused on the transverse ligament and its relationship with the anterior ligament. The majority of the transverse ligament continues to the distal half of the anterior ligament, and less common\u00a0variants included transverse ligaments that traveled\u00a0the entire anterior ligament. [3]", "contents": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Physiologic Variants. A study examining cadaveric specimens looked at specific ligaments of the MCL (anterior bundle, posterior bundle, and transverse ligament). Specifically, they focused on the transverse ligament and its relationship with the anterior ligament. The majority of the transverse ligament continues to the distal half of the anterior ligament, and less common\u00a0variants included transverse ligaments that traveled\u00a0the entire anterior ligament. [3]"}
+{"id": "article-101404_17", "title": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Physiologic Variants", "content": "There is\u00a0minimal variation with the anterior and posterior bundles. Of note, while the most common insertion site for the anterior bundle of the MCL is the sublime tubercle, variations have been found. Studies have found anterior bundle insertion only 1 mm away from the joint line. Other studies have found the insertion of the anterior bundle to be 3 mm more distal. This distal insertion has clinical relevance because it creates a small recess on arthrograms, which simulates a partial undersurface tear of the anterior bundle. [11]", "contents": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Physiologic Variants. There is\u00a0minimal variation with the anterior and posterior bundles. Of note, while the most common insertion site for the anterior bundle of the MCL is the sublime tubercle, variations have been found. Studies have found anterior bundle insertion only 1 mm away from the joint line. Other studies have found the insertion of the anterior bundle to be 3 mm more distal. This distal insertion has clinical relevance because it creates a small recess on arthrograms, which simulates a partial undersurface tear of the anterior bundle. [11]"}
+{"id": "article-101404_18", "title": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Physiologic Variants", "content": "An accessory or \"extra bundle\" ligament belonging to the MCL was also present in a quarter of examined specimens found in one study. The addition of this ligament creates an MCL comprised of four ligaments. The extra-bundle ligament originates from the posteromedial aspect of the capsule and inserts on the transverse\u00a0bundle. The transverse bundle itself has a variation of a fanlike distribution with insertions onto the anterior bundle and coronoid; this creates a strong oblique pattern on imaging. [11]", "contents": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Physiologic Variants. An accessory or \"extra bundle\" ligament belonging to the MCL was also present in a quarter of examined specimens found in one study. The addition of this ligament creates an MCL comprised of four ligaments. The extra-bundle ligament originates from the posteromedial aspect of the capsule and inserts on the transverse\u00a0bundle. The transverse bundle itself has a variation of a fanlike distribution with insertions onto the anterior bundle and coronoid; this creates a strong oblique pattern on imaging. [11]"}
+{"id": "article-101404_19", "title": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Surgical Considerations", "content": "Posterolateral rotatory instability (PLRI) occurs secondary to a traumatic or iatrogenic injury to the LCL, which is the most common recurrent instability of the elbow. The radial head frequently subluxes, which creates lateral elbow pain and mechanical issues while the elbow is in flexion and supination, and a load is applied. [1]", "contents": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Surgical Considerations. Posterolateral rotatory instability (PLRI) occurs secondary to a traumatic or iatrogenic injury to the LCL, which is the most common recurrent instability of the elbow. The radial head frequently subluxes, which creates lateral elbow pain and mechanical issues while the elbow is in flexion and supination, and a load is applied. [1]"}
+{"id": "article-101404_20", "title": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Surgical Considerations", "content": "While conservative treatment such as physical therapy and activity modification should be trialed, nonoperative management of PLRI is typically ineffective. Surgical treatment is necessary to restabilize the joint in patients with persistent and symptomatic instability that causes pain or functional impairment. In acute, simple dislocation, closed reduction under general anesthesia is suggested. If the lateral elbow is stable past 30 degrees of extension, the patient wears a dynamic brace for six weeks. However, if after the closed reduction, the lateral elbow is still unstable before 30 degrees extension, ligament repair is necessary.", "contents": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Surgical Considerations. While conservative treatment such as physical therapy and activity modification should be trialed, nonoperative management of PLRI is typically ineffective. Surgical treatment is necessary to restabilize the joint in patients with persistent and symptomatic instability that causes pain or functional impairment. In acute, simple dislocation, closed reduction under general anesthesia is suggested. If the lateral elbow is stable past 30 degrees of extension, the patient wears a dynamic brace for six weeks. However, if after the closed reduction, the lateral elbow is still unstable before 30 degrees extension, ligament repair is necessary."}
+{"id": "article-101404_21", "title": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Surgical Considerations", "content": "Chronic and symptomatic PLRI requires surgical intervention, as mentioned. The pivot shift test is performed on a supine patient, with the forearm hypersupinated. Valgus stress, along with an axial load, is then applied to the elbow while moving the elbow form extension to flexion. A positive-shift test on a conscious patient is with patient apprehension. In a sedated patient (under general anesthesia), this test is positive with subluxation or dislocation of the elbow, typically occurring between 30\u00a0to 45\u00a0degrees of flexion.", "contents": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Surgical Considerations. Chronic and symptomatic PLRI requires surgical intervention, as mentioned. The pivot shift test is performed on a supine patient, with the forearm hypersupinated. Valgus stress, along with an axial load, is then applied to the elbow while moving the elbow form extension to flexion. A positive-shift test on a conscious patient is with patient apprehension. In a sedated patient (under general anesthesia), this test is positive with subluxation or dislocation of the elbow, typically occurring between 30\u00a0to 45\u00a0degrees of flexion."}
+{"id": "article-101404_22", "title": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Surgical Considerations", "content": "Low-grade PLRI (subluxation) is treated with LCL imbrication via arthroscopic or open technique. Severe PLRI (dislocation) requires LCL reconstruction with graft use. Results after reconstruction show good to excellent results in 85% of patients. Recurrent instability has been seen even after surgical intervention, in up to as many of 25% of patients after medium to long-term follow-up. [12]", "contents": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Surgical Considerations. Low-grade PLRI (subluxation) is treated with LCL imbrication via arthroscopic or open technique. Severe PLRI (dislocation) requires LCL reconstruction with graft use. Results after reconstruction show good to excellent results in 85% of patients. Recurrent instability has been seen even after surgical intervention, in up to as many of 25% of patients after medium to long-term follow-up. [12]"}
+{"id": "article-101404_23", "title": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Surgical Considerations", "content": "MCL\u00a0injury is more common, and especially seen in overhead throwers such as pitchers. For painful, symptomatic MCL\u00a0injuries, reconstruction is a reliable treatment method for correction. Surgery is indicated after nonoperative treatment has been exhausted. Surgical treatment for the MCL is one of the most well known in the sports world and is dubbed \"Tommy John surgery\" after pitcher Tommy John was successfully treated using the following technique. The docking technique is most commonly performed. Advantages include minimizing injury to the flexor/pronator musculature, avoidance of the ulnar nerve, providing an optimal location for graft tensioning, and minimizing the amount of bone removed from the medial epicondyle. [13]", "contents": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Surgical Considerations. MCL\u00a0injury is more common, and especially seen in overhead throwers such as pitchers. For painful, symptomatic MCL\u00a0injuries, reconstruction is a reliable treatment method for correction. Surgery is indicated after nonoperative treatment has been exhausted. Surgical treatment for the MCL is one of the most well known in the sports world and is dubbed \"Tommy John surgery\" after pitcher Tommy John was successfully treated using the following technique. The docking technique is most commonly performed. Advantages include minimizing injury to the flexor/pronator musculature, avoidance of the ulnar nerve, providing an optimal location for graft tensioning, and minimizing the amount of bone removed from the medial epicondyle. [13]"}
+{"id": "article-101404_24", "title": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Surgical Considerations", "content": "Surgical treatment utilizes autograft, most commonly\u00a0from the palmaris longus. Other graft options include gracilis, semitendinosus, toe extensor, plantaris, patellar tendon, and Achilles autografts.\u00a0This injury that was once deemed a career-ending injury for major league baseball pitchers now shows an astounding 83% return to sport after UCL reconstruction. [14]", "contents": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Surgical Considerations. Surgical treatment utilizes autograft, most commonly\u00a0from the palmaris longus. Other graft options include gracilis, semitendinosus, toe extensor, plantaris, patellar tendon, and Achilles autografts.\u00a0This injury that was once deemed a career-ending injury for major league baseball pitchers now shows an astounding 83% return to sport after UCL reconstruction. [14]"}
+{"id": "article-101404_25", "title": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Clinical Significance", "content": "The collateral ligaments and their significant responsibility in maintaining elbow function make it pivotal for physicians to diagnose injuries properly. Whether the MCL or LCL injury at the elbow, a history, physical exam, imaging, and exhausted conservative treatments\u00a0prior to surgery is the generalized outline of patient care.", "contents": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Clinical Significance. The collateral ligaments and their significant responsibility in maintaining elbow function make it pivotal for physicians to diagnose injuries properly. Whether the MCL or LCL injury at the elbow, a history, physical exam, imaging, and exhausted conservative treatments\u00a0prior to surgery is the generalized outline of patient care."}
+{"id": "article-101404_26", "title": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Clinical Significance", "content": "Medial elbow injuries are amongst the most common in sports. Elbow injuries are the most common cause of time loss (over ten days) in collegiate pitchers, Upper extremity injuries account for 45% of all injuries in the NCAA, and 7-8% of these injuries belong to the elbow. Specifically pertaining\u00a0to baseball, 97% of pitchers elbow pain is on the medial side of the elbow [14] .", "contents": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Clinical Significance. Medial elbow injuries are amongst the most common in sports. Elbow injuries are the most common cause of time loss (over ten days) in collegiate pitchers, Upper extremity injuries account for 45% of all injuries in the NCAA, and 7-8% of these injuries belong to the elbow. Specifically pertaining\u00a0to baseball, 97% of pitchers elbow pain is on the medial side of the elbow [14] ."}
+{"id": "article-101404_27", "title": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Clinical Significance", "content": "A patient history determining the location of the pain, how long the pain has been present, the exact point\u00a0in motion where the patient experiences the injury is imperative in diagnosing MCL injury. If present in an athlete, they may complain of decreased performance, such as throwing velocity or stamina. Patients might also site issues of numbness and tingling in the ulnar distribution pattern since the chronic UCL injuries are associated with ulnar neuropathy. Physical exam should check for the palmaris longus muscle if surgery is required; this requires the patient to flex the wrist with opposing the first and fifth digits.", "contents": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Clinical Significance. A patient history determining the location of the pain, how long the pain has been present, the exact point\u00a0in motion where the patient experiences the injury is imperative in diagnosing MCL injury. If present in an athlete, they may complain of decreased performance, such as throwing velocity or stamina. Patients might also site issues of numbness and tingling in the ulnar distribution pattern since the chronic UCL injuries are associated with ulnar neuropathy. Physical exam should check for the palmaris longus muscle if surgery is required; this requires the patient to flex the wrist with opposing the first and fifth digits."}
+{"id": "article-101404_28", "title": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Clinical Significance", "content": "Special tests, including the valgus stress test, milking maneuver, and moving valgus stress test, can be performed to facilitate the diagnosis of UCL injury.\u00a0Imaging such as MRI, MRA, and US provide the best visualization for the UCL. The MRA has the highest sensitivity and specificity, along with superior interobserver reliability. Imaging can also provide prognostic factors. One study demonstrated that MRI of UCL with a higher T2 signal intensity is less likely to benefit from conservative treatment. [14]", "contents": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Clinical Significance. Special tests, including the valgus stress test, milking maneuver, and moving valgus stress test, can be performed to facilitate the diagnosis of UCL injury.\u00a0Imaging such as MRI, MRA, and US provide the best visualization for the UCL. The MRA has the highest sensitivity and specificity, along with superior interobserver reliability. Imaging can also provide prognostic factors. One study demonstrated that MRI of UCL with a higher T2 signal intensity is less likely to benefit from conservative treatment. [14]"}
+{"id": "article-101404_29", "title": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Clinical Significance", "content": "While not as common as MCL injuries, PLRI due to LCL damage can occur. Similar to that of MCL, history is a critical portion in evaluation, although injury to the LCL may not be as apparent as is with the MCL. The physical exam can include special tests, such as the pivot-shift test (mentioned above), posterolateral rotatory drawer test, chair push-up test, prone push-up test, and table-top relocation test. All of these are examining for radial head subluxation or apprehension in conscious patients. [1]", "contents": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Clinical Significance. While not as common as MCL injuries, PLRI due to LCL damage can occur. Similar to that of MCL, history is a critical portion in evaluation, although injury to the LCL may not be as apparent as is with the MCL. The physical exam can include special tests, such as the pivot-shift test (mentioned above), posterolateral rotatory drawer test, chair push-up test, prone push-up test, and table-top relocation test. All of these are examining for radial head subluxation or apprehension in conscious patients. [1]"}
+{"id": "article-101404_30", "title": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Clinical Significance", "content": "Varus posteromedial rotatory instability occurs when axial and valgus stress is applied to the forearm, which is in a pronated position. This stress results in a fracture to the anteromedial facet of the coronoid, and LCL rupture. This injury typically occurs in an acute, traumatic setting. In a subacute setting, the gravity-assisted varus stress test is an option, where the patient flexes and extends their elbow at 90 degrees of shoulder abduction, allowing gravity to apply the varus stress. This technique has shown to be the most sensitive and specific in diagnosing varus posteromedial rotatory instability. [1]", "contents": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Clinical Significance. Varus posteromedial rotatory instability occurs when axial and valgus stress is applied to the forearm, which is in a pronated position. This stress results in a fracture to the anteromedial facet of the coronoid, and LCL rupture. This injury typically occurs in an acute, traumatic setting. In a subacute setting, the gravity-assisted varus stress test is an option, where the patient flexes and extends their elbow at 90 degrees of shoulder abduction, allowing gravity to apply the varus stress. This technique has shown to be the most sensitive and specific in diagnosing varus posteromedial rotatory instability. [1]"}
+{"id": "article-101404_31", "title": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Other Issues", "content": "While UCL surgical intervention has progressed over\u00a0the years, the tracking of patient outcomes in a quantitative manner is lacking relative to other musculoskeletal injuries such as ACL tears and its reconstruction. The function of the UCL and the stresses put on this ligament need to be analyzed in various settings, especially the athletic setting such as baseball. Functional screening and quantitative measures regarding injury progression, proper postsurgical therapy, and the timeline for return to sport still need to be accounted for in the literature regarding UCL injuries. [15]", "contents": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Other Issues. While UCL surgical intervention has progressed over\u00a0the years, the tracking of patient outcomes in a quantitative manner is lacking relative to other musculoskeletal injuries such as ACL tears and its reconstruction. The function of the UCL and the stresses put on this ligament need to be analyzed in various settings, especially the athletic setting such as baseball. Functional screening and quantitative measures regarding injury progression, proper postsurgical therapy, and the timeline for return to sport still need to be accounted for in the literature regarding UCL injuries. [15]"}
+{"id": "article-101404_32", "title": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Anatomy, Shoulder and Upper Limb, Elbow Collateral Ligaments -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

statpearls/chunk/article-101481.jsonl

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+{"id": "article-101481_0", "title": "Spirometry -- Continuing Education Activity", "content": "Spirometry is one of the most commonly used approaches to test pulmonary function. It measures the volume of exhaled air vs. time. This activity highlights its role in the evaluation of pulmonary disease by the interprofessional team. Objectives: Identify the indications of spirometry. Describe the technique of spirometry. Outline the clinical significance of spirometry. Access free multiple choice questions on this topic.", "contents": "Spirometry -- Continuing Education Activity. Spirometry is one of the most commonly used approaches to test pulmonary function. It measures the volume of exhaled air vs. time. This activity highlights its role in the evaluation of pulmonary disease by the interprofessional team. Objectives: Identify the indications of spirometry. Describe the technique of spirometry. Outline the clinical significance of spirometry. Access free multiple choice questions on this topic."}
+{"id": "article-101481_1", "title": "Spirometry -- Introduction", "content": "Spirometry is one of the most readily available and useful tests for pulmonary function. It measures the volume of air exhaled at specific time points during complete exhalation by force, which is preceded by a maximal inhalation.", "contents": "Spirometry -- Introduction. Spirometry is one of the most readily available and useful tests for pulmonary function. It measures the volume of air exhaled at specific time points during complete exhalation by force, which is preceded by a maximal inhalation."}
+{"id": "article-101481_2", "title": "Spirometry -- Introduction", "content": "The most important variables reported include total exhaled volume, known as the forced vital capacity (FVC), the volume exhaled in the first second, known as the forced expiratory volume in one second (FEV1), and their ratio (FEV1/FVC). [1] These results are represented on a graph as volumes and combinations of these volumes termed capacities and can be used as a diagnostic tool, as a means to monitor patients with pulmonary diseases, and to improve the rate of smoking cessation, according to some reports. [2]", "contents": "Spirometry -- Introduction. The most important variables reported include total exhaled volume, known as the forced vital capacity (FVC), the volume exhaled in the first second, known as the forced expiratory volume in one second (FEV1), and their ratio (FEV1/FVC). [1] These results are represented on a graph as volumes and combinations of these volumes termed capacities and can be used as a diagnostic tool, as a means to monitor patients with pulmonary diseases, and to improve the rate of smoking cessation, according to some reports. [2]"}
+{"id": "article-101481_3", "title": "Spirometry -- Anatomy and Physiology", "content": "Lungs provide life-sustaining gas exchange by way of introducing oxygen for metabolism and eliminating the by-product carbon dioxide. Air-inspired will pass through the oropharynx to the trachea, which is a membranous tube covered by cartilage bifurcating at the carina as two bronchi at the level of C6. After passing the trachea, the air enters the right and left bronchi, which divide to give several million terminal bronchioles that end in alveoli. The alveoli and surrounding vessels provide a surface where the gas exchange takes place. [3]", "contents": "Spirometry -- Anatomy and Physiology. Lungs provide life-sustaining gas exchange by way of introducing oxygen for metabolism and eliminating the by-product carbon dioxide. Air-inspired will pass through the oropharynx to the trachea, which is a membranous tube covered by cartilage bifurcating at the carina as two bronchi at the level of C6. After passing the trachea, the air enters the right and left bronchi, which divide to give several million terminal bronchioles that end in alveoli. The alveoli and surrounding vessels provide a surface where the gas exchange takes place. [3]"}
+{"id": "article-101481_4", "title": "Spirometry -- Indications", "content": "Apart from being a key diagnostic test for asthma and chronic obstructive pulmonary disease, spirometry is indicated in several other places, as listed below:", "contents": "Spirometry -- Indications. Apart from being a key diagnostic test for asthma and chronic obstructive pulmonary disease, spirometry is indicated in several other places, as listed below:"}
+{"id": "article-101481_5", "title": "Spirometry -- Indications -- Diagnostic Indications", "content": "Evaluation of the signs and symptoms of a patient or their abnormal investigations and lab tests Evaluation of the effect a certain disease has on pulmonary function Screening and early detection of individuals who are at risk of pulmonary disease Assessing surgical patients for preoperative risk Assessing the severity and the prognosis of a pulmonary disease [4]", "contents": "Spirometry -- Indications -- Diagnostic Indications. Evaluation of the signs and symptoms of a patient or their abnormal investigations and lab tests Evaluation of the effect a certain disease has on pulmonary function Screening and early detection of individuals who are at risk of pulmonary disease Assessing surgical patients for preoperative risk Assessing the severity and the prognosis of a pulmonary disease [4]"}
+{"id": "article-101481_6", "title": "Spirometry -- Indications -- Monitoring Indications", "content": "Assessment of the efficiency of a therapeutic intervention such as bronchodilator therapy Describing the course and progression of a disease that is affecting pulmonary function, such as interstitial lung disease or obstructive lung disease Monitoring pulmonary function in individuals with high-risk jobs Sampling data that can be used for epidemiologic surveys [5]", "contents": "Spirometry -- Indications -- Monitoring Indications. Assessment of the efficiency of a therapeutic intervention such as bronchodilator therapy Describing the course and progression of a disease that is affecting pulmonary function, such as interstitial lung disease or obstructive lung disease Monitoring pulmonary function in individuals with high-risk jobs Sampling data that can be used for epidemiologic surveys [5]"}
+{"id": "article-101481_7", "title": "Spirometry -- Contraindications", "content": "Spirometry has proved itself as an accessible utility to assess lung function. However, it may not be for every patient, and care must be taken in some cases where it may be absolutely or relatively contraindicated.", "contents": "Spirometry -- Contraindications. Spirometry has proved itself as an accessible utility to assess lung function. However, it may not be for every patient, and care must be taken in some cases where it may be absolutely or relatively contraindicated."}
+{"id": "article-101481_8", "title": "Spirometry -- Contraindications -- Absolute Contraindications", "content": "Hemodynamic instability Recent myocardial infarction or acute coronary syndrome Respiratory infection, a recent pneumothorax, or a pulmonary embolism A growing or large (>6 cm) aneurysm of the thoracic, abdominal aorta Hemoptysis of acute onset Intracranial hypertension Retinal detachment", "contents": "Spirometry -- Contraindications -- Absolute Contraindications. Hemodynamic instability Recent myocardial infarction or acute coronary syndrome Respiratory infection, a recent pneumothorax, or a pulmonary embolism A growing or large (>6 cm) aneurysm of the thoracic, abdominal aorta Hemoptysis of acute onset Intracranial hypertension Retinal detachment"}
+{"id": "article-101481_9", "title": "Spirometry -- Contraindications -- Relative Contraindications", "content": "Patients who cannot be instructed to use the device properly and are at risk of using the device inappropriately, such as children and patients with dementia Conditions that make it difficult to hold the mouthpiece, such as facial pain Recent abdominal, thoracic, brain, eye, ear, nose, or throat surgeries Hypertensive crisis [2] [3] [6]", "contents": "Spirometry -- Contraindications -- Relative Contraindications. Patients who cannot be instructed to use the device properly and are at risk of using the device inappropriately, such as children and patients with dementia Conditions that make it difficult to hold the mouthpiece, such as facial pain Recent abdominal, thoracic, brain, eye, ear, nose, or throat surgeries Hypertensive crisis [2] [3] [6]"}
+{"id": "article-101481_10", "title": "Spirometry -- Equipment", "content": "The first requirement for spirometry is physical space in order for the patient to be positioned comfortably. The minimum space recommended is a 2.5* 3m room with 120 cm side doors.", "contents": "Spirometry -- Equipment. The first requirement for spirometry is physical space in order for the patient to be positioned comfortably. The minimum space recommended is a 2.5* 3m room with 120 cm side doors."}
+{"id": "article-101481_11", "title": "Spirometry -- Equipment", "content": "Spirometers are classified into closed-circuit and open-circuit spirometers. Closed-circuit spirometers are further sub-classified into wet and dry spirometers, which consist of a piston or a bellow acting as an air collecting system and a supported recording system that moves at the desired rate.", "contents": "Spirometry -- Equipment. Spirometers are classified into closed-circuit and open-circuit spirometers. Closed-circuit spirometers are further sub-classified into wet and dry spirometers, which consist of a piston or a bellow acting as an air collecting system and a supported recording system that moves at the desired rate."}
+{"id": "article-101481_12", "title": "Spirometry -- Equipment", "content": "Open-circuit spirometers , which are more commonly used at present, do not have an air-collecting system and instead measure the airflow, integrate the results, and calculate the volume. The most commonly used open-circuit spirometer is the turbine flow meter, which records the rate at which turbines turn and derives the flow measurement based on proportionality. Pneumotachographs are another example, which measure the airflow by measuring the pressure difference generated as the laminar flow passes through a certain resistance. Hotwire spirometers, in which a hot metal wire is heated, and the air used to cool it is used to calculate the flow, are also an example of open-circuit spirometers. Ultrasound spirometers can be based on any of the aforementioned open-circuit spirometer principles. [7]", "contents": "Spirometry -- Equipment. Open-circuit spirometers , which are more commonly used at present, do not have an air-collecting system and instead measure the airflow, integrate the results, and calculate the volume. The most commonly used open-circuit spirometer is the turbine flow meter, which records the rate at which turbines turn and derives the flow measurement based on proportionality. Pneumotachographs are another example, which measure the airflow by measuring the pressure difference generated as the laminar flow passes through a certain resistance. Hotwire spirometers, in which a hot metal wire is heated, and the air used to cool it is used to calculate the flow, are also an example of open-circuit spirometers. Ultrasound spirometers can be based on any of the aforementioned open-circuit spirometer principles. [7]"}
+{"id": "article-101481_13", "title": "Spirometry -- Equipment", "content": "The minimum specifications for a spirometer are the ability to measure a volume of 8L with an accuracy of \u00b13% or \u00b150ml with a flow measurement range of \u00b1141 and a sensitivity of 200ml/s. It is recommended that the spirometer record at 15 s of the expiration time for the forced maneuver. [8] [9]", "contents": "Spirometry -- Equipment. The minimum specifications for a spirometer are the ability to measure a volume of 8L with an accuracy of \u00b13% or \u00b150ml with a flow measurement range of \u00b1141 and a sensitivity of 200ml/s. It is recommended that the spirometer record at 15 s of the expiration time for the forced maneuver. [8] [9]"}
+{"id": "article-101481_14", "title": "Spirometry -- Personnel", "content": "The personnel performing the procedure must be familiar with respiratory symptoms and signs. They have to undergo training to understand the technical and physiological background of the tests in order to be competent in performing the techniques of the operation of the device, be able to apply the universal precautions, instruct the patients properly to avoid complications, and act accordingly if any of the complications arise. The personnel should be able to identify responses to therapy, the need for initiating therapy, or discontinuing an inefficient one. Continuity of training and periodic retraining is a must for staff in charge of spirometry. [10]", "contents": "Spirometry -- Personnel. The personnel performing the procedure must be familiar with respiratory symptoms and signs. They have to undergo training to understand the technical and physiological background of the tests in order to be competent in performing the techniques of the operation of the device, be able to apply the universal precautions, instruct the patients properly to avoid complications, and act accordingly if any of the complications arise. The personnel should be able to identify responses to therapy, the need for initiating therapy, or discontinuing an inefficient one. Continuity of training and periodic retraining is a must for staff in charge of spirometry. [10]"}
+{"id": "article-101481_15", "title": "Spirometry -- Preparation", "content": "All patients must be informed that they must abstain from smoking and physical exercise in the hours before the procedure. Any bronchodilator therapy must also be stopped beforehand.", "contents": "Spirometry -- Preparation. All patients must be informed that they must abstain from smoking and physical exercise in the hours before the procedure. Any bronchodilator therapy must also be stopped beforehand."}
+{"id": "article-101481_16", "title": "Spirometry -- Preparation", "content": "The procedure must be carefully explained to the patient focusing on the importance of the patient\u2019s cooperation to provide the most accurate results. The patient\u2019s weight and height must be recorded with the patient barefoot and wearing only light clothing. In the case of chest deformities such as kyphoscoliosis, the span should be measured from the tip of one middle finger to the tip of the other middle finger with the hands crossed, and the height can be estimated from the formula: height = span/1.06. The patient\u2019s age must be recorded. The procedure should be performed with the patient sitting upright, wearing light clothing, and without crossing their legs. Children can perform the test sitting or standing, but the same procedure should be done for the same individual every time.", "contents": "Spirometry -- Preparation. The procedure must be carefully explained to the patient focusing on the importance of the patient\u2019s cooperation to provide the most accurate results. The patient\u2019s weight and height must be recorded with the patient barefoot and wearing only light clothing. In the case of chest deformities such as kyphoscoliosis, the span should be measured from the tip of one middle finger to the tip of the other middle finger with the hands crossed, and the height can be estimated from the formula: height = span/1.06. The patient\u2019s age must be recorded. The procedure should be performed with the patient sitting upright, wearing light clothing, and without crossing their legs. Children can perform the test sitting or standing, but the same procedure should be done for the same individual every time."}
+{"id": "article-101481_17", "title": "Spirometry -- Preparation", "content": "During the procedure, the back must be supported by a backrest and not lead forward. Dentures have to be removed if they interfere with the procedure.\u00a0Manual occlusion of the nares with the help of nose clips helps to prevent air leakage through the nasal passages, although it is not mandatory to occlude nasal passage. The calibration of the spirometer has to be confirmed on the day of the test. Any contraindications or infectious diseases that require special measures will lead to a delay in the procedure. [8] [9] [10]", "contents": "Spirometry -- Preparation. During the procedure, the back must be supported by a backrest and not lead forward. Dentures have to be removed if they interfere with the procedure.\u00a0Manual occlusion of the nares with the help of nose clips helps to prevent air leakage through the nasal passages, although it is not mandatory to occlude nasal passage. The calibration of the spirometer has to be confirmed on the day of the test. Any contraindications or infectious diseases that require special measures will lead to a delay in the procedure. [8] [9] [10]"}
+{"id": "article-101481_18", "title": "Spirometry -- Technique or Treatment", "content": "The patient must place the mouthpiece in their mouth, and the technician must ensure that there are no leaks, and the patient is not obstructing the mouthpiece. The procedure is carried out as follows:", "contents": "Spirometry -- Technique or Treatment. The patient must place the mouthpiece in their mouth, and the technician must ensure that there are no leaks, and the patient is not obstructing the mouthpiece. The procedure is carried out as follows:"}
+{"id": "article-101481_19", "title": "Spirometry -- Technique or Treatment", "content": "The patient must breathe in as much air as they can with a pause lasting for less than 1s at the total lung capacity. The mouthpiece is placed just inside the mouth between the teeth soon after the deep inhalation. The lips should be sealed tightly around the mouthpiece to prevent air leakage. Exhalation should last at least 6 seconds or as long as advised by the instructor. If only the forced expiratory volume is to be measured, the patient must insert the mouthpiece after performing step 1 and must not breathe from the tube. If any of the maneuvers are incorrectly performed, the technician must stop the patient in order to avoid fatigue and re-explain the procedure to the patient. The procedure is repeated in intervals separated by 1 minute until two matching and acceptable results are acquired. [11] [12]", "contents": "Spirometry -- Technique or Treatment. The patient must breathe in as much air as they can with a pause lasting for less than 1s at the total lung capacity. The mouthpiece is placed just inside the mouth between the teeth soon after the deep inhalation. The lips should be sealed tightly around the mouthpiece to prevent air leakage. Exhalation should last at least 6 seconds or as long as advised by the instructor. If only the forced expiratory volume is to be measured, the patient must insert the mouthpiece after performing step 1 and must not breathe from the tube. If any of the maneuvers are incorrectly performed, the technician must stop the patient in order to avoid fatigue and re-explain the procedure to the patient. The procedure is repeated in intervals separated by 1 minute until two matching and acceptable results are acquired. [11] [12]"}
+{"id": "article-101481_20", "title": "Spirometry -- Complications", "content": "The complications of spirometry are fairly limited and will render the procedure inaccurate or ineffective once they occur. They include: [10] [11] [12] Respiratory alkalosis as a result of hyperventilation Hypoxemia in a patient whose oxygen therapy has been interrupted Chest pain Fatigue Paroxysmal coughing Bronchospasm Dizziness Urinary incontinence Increased intracranial pressure Syncopal symptoms", "contents": "Spirometry -- Complications. The complications of spirometry are fairly limited and will render the procedure inaccurate or ineffective once they occur. They include: [10] [11] [12] Respiratory alkalosis as a result of hyperventilation Hypoxemia in a patient whose oxygen therapy has been interrupted Chest pain Fatigue Paroxysmal coughing Bronchospasm Dizziness Urinary incontinence Increased intracranial pressure Syncopal symptoms"}
+{"id": "article-101481_21", "title": "Spirometry -- Clinical Significance", "content": "Spirometry has proved crucial in diagnosing lung disease, monitoring patients' pulmonary function, and assessing their fitness for various procedures. With further research, solid evidence can arise for the role of spirometry in assisting\u00a0patients in quitting smoking. The American College of Physicians guidelines do not recommend spirometry testing for patients undergoing nonthoracic surgery. There, of course, are exceptions if the patient has preoperative asthma or COPD.", "contents": "Spirometry -- Clinical Significance. Spirometry has proved crucial in diagnosing lung disease, monitoring patients' pulmonary function, and assessing their fitness for various procedures. With further research, solid evidence can arise for the role of spirometry in assisting\u00a0patients in quitting smoking. The American College of Physicians guidelines do not recommend spirometry testing for patients undergoing nonthoracic surgery. There, of course, are exceptions if the patient has preoperative asthma or COPD."}
+{"id": "article-101481_22", "title": "Spirometry -- Clinical Significance", "content": "Recent evidence also supports the use of spirometry in nonthoracic surgeries. A recent\u00a0retrospective observational study found that\u00a0lower preoperative spirometry FVC may predict postoperative pulmonary complications in high-risk patients undergoing abdominal surgery. [13] In another\u00a0retrospective observational study, the authors found that %VC (FVC/predicted VC) may be a predictor for postoperative pneumonia in patients undergoing colorectal cancer surgery. [14] More studies are needed, but spirometry may be an important tool in identifying nonthoracic surgical patients who are at high risk of postoperative pulmonary complications.", "contents": "Spirometry -- Clinical Significance. Recent evidence also supports the use of spirometry in nonthoracic surgeries. A recent\u00a0retrospective observational study found that\u00a0lower preoperative spirometry FVC may predict postoperative pulmonary complications in high-risk patients undergoing abdominal surgery. [13] In another\u00a0retrospective observational study, the authors found that %VC (FVC/predicted VC) may be a predictor for postoperative pneumonia in patients undergoing colorectal cancer surgery. [14] More studies are needed, but spirometry may be an important tool in identifying nonthoracic surgical patients who are at high risk of postoperative pulmonary complications."}
+{"id": "article-101481_23", "title": "Spirometry -- Clinical Significance", "content": "Lung volumes are essential to understand when evaluating a patient for surgery or evaluating a patient with preexisting lung disease. Tidal volume (TV) is the amount of air that can be exhaled or inhaled in one respiratory cycle. Normal tidal volume ranges from 6 to 8 ml/kg. Inspiratory reserve volume (IRV) is the forcible amount of air inhaled after normal TV. Expiratory reserve volume (ERV) is the amount of forcible air exhaled after exhalation of a normal TV. Residual Volume (RV) is the amount of air in the lungs after maximum exhalation. Both RV and functional residual volume (FRC) can not be\u00a0measured directly by spirometry. RV can be indirectly calculated from the FRC and ERV.", "contents": "Spirometry -- Clinical Significance. Lung volumes are essential to understand when evaluating a patient for surgery or evaluating a patient with preexisting lung disease. Tidal volume (TV) is the amount of air that can be exhaled or inhaled in one respiratory cycle. Normal tidal volume ranges from 6 to 8 ml/kg. Inspiratory reserve volume (IRV) is the forcible amount of air inhaled after normal TV. Expiratory reserve volume (ERV) is the amount of forcible air exhaled after exhalation of a normal TV. Residual Volume (RV) is the amount of air in the lungs after maximum exhalation. Both RV and functional residual volume (FRC) can not be\u00a0measured directly by spirometry. RV can be indirectly calculated from the FRC and ERV."}
+{"id": "article-101481_24", "title": "Spirometry -- Clinical Significance", "content": "Lung capacities are the summation of lung volumes. Total lung capacity (TLC) is the summation of TV, IRV, ERV, and RV. This represents the maximum volume the lungs can accommodate. Vital capacity (VC) is the summation of\u00a0TV, IR, and ERV. It represents the total air exhaled after maximum inhalation. Functional residual capacity (FRC) is the residual volume plus expiratory reserve volume. It is the volume of air remaining in the lungs after normal exhalation.", "contents": "Spirometry -- Clinical Significance. Lung capacities are the summation of lung volumes. Total lung capacity (TLC) is the summation of TV, IRV, ERV, and RV. This represents the maximum volume the lungs can accommodate. Vital capacity (VC) is the summation of\u00a0TV, IR, and ERV. It represents the total air exhaled after maximum inhalation. Functional residual capacity (FRC) is the residual volume plus expiratory reserve volume. It is the volume of air remaining in the lungs after normal exhalation."}
+{"id": "article-101481_25", "title": "Spirometry -- Clinical Significance", "content": "These static lung volumes and capacities can diagnose obstructive and restrictive lung patterns. Restrictive lung disease results in reduced lung compliance and a reduction in lung volumes and capacities. TLC is reduced greater than 80% or below the 5th percentile of the predicted value. Both FEV1 and FVC are reduced, but FVC is reduced more than FEV1. Therefore, the FEV1/FVC ratio is greater than 80%. [15]", "contents": "Spirometry -- Clinical Significance. These static lung volumes and capacities can diagnose obstructive and restrictive lung patterns. Restrictive lung disease results in reduced lung compliance and a reduction in lung volumes and capacities. TLC is reduced greater than 80% or below the 5th percentile of the predicted value. Both FEV1 and FVC are reduced, but FVC is reduced more than FEV1. Therefore, the FEV1/FVC ratio is greater than 80%. [15]"}
+{"id": "article-101481_26", "title": "Spirometry -- Clinical Significance", "content": "One of the most common causes of restrictive lung disease is obesity. Obese patients have a reduction in FRC, which becomes worse when moving from upright to a supine position. The weight of the chest wall pushes down on the lungs. The weight of the abdominal contents pushes against the diaphragm and base of the lungs, worsening the restrictive pattern. Other restrictive lung processes are chest wall diseases(scoliosis, chest trauma) and neuromuscular disorders (Myasthenia Gravis, Guillain-Barr\u00e9 syndrome). Obstructive lung disease is a disproportionate reduction in the maximum airflow from the lungs compared to the maximum air that can be displaced from the lungs. [15] This can be confirmed by an\u00a0FEV/VC ratio below\u00a0the 5th percentile of the predicted value. [15] The RV/TLC ratio will increase irrespective of whether VC increases or decreases. The TLC will either increase or stay the same.", "contents": "Spirometry -- Clinical Significance. One of the most common causes of restrictive lung disease is obesity. Obese patients have a reduction in FRC, which becomes worse when moving from upright to a supine position. The weight of the chest wall pushes down on the lungs. The weight of the abdominal contents pushes against the diaphragm and base of the lungs, worsening the restrictive pattern. Other restrictive lung processes are chest wall diseases(scoliosis, chest trauma) and neuromuscular disorders (Myasthenia Gravis, Guillain-Barr\u00e9 syndrome). Obstructive lung disease is a disproportionate reduction in the maximum airflow from the lungs compared to the maximum air that can be displaced from the lungs. [15] This can be confirmed by an\u00a0FEV/VC ratio below\u00a0the 5th percentile of the predicted value. [15] The RV/TLC ratio will increase irrespective of whether VC increases or decreases. The TLC will either increase or stay the same."}
+{"id": "article-101481_27", "title": "Spirometry -- Clinical Significance", "content": "Complete spirometry exams will identify FEV1,\u00a0forced vital capacity (FVC),\u00a0vital capacity (VC),\u00a0residual lung volume (RV),\u00a0maximum voluntary minute ventilation (MMV), and total lung capacity (TLC). One parameter highly indicative of postoperative complications is predicted postoperative FEV 1 (PPO FEV 1). [16] FEV1 measures the volume of air forcefully exhaled in the first second during a forced expiration maneuver. Small airway disease often results in obstruction or narrowing of the small airways, leading to difficulty rapidly expelling air. Predicted postoperative FEV1 <30% are at a higher risk of postoperative pulmonary complications after thoracic surgery.", "contents": "Spirometry -- Clinical Significance. Complete spirometry exams will identify FEV1,\u00a0forced vital capacity (FVC),\u00a0vital capacity (VC),\u00a0residual lung volume (RV),\u00a0maximum voluntary minute ventilation (MMV), and total lung capacity (TLC). One parameter highly indicative of postoperative complications is predicted postoperative FEV 1 (PPO FEV 1). [16] FEV1 measures the volume of air forcefully exhaled in the first second during a forced expiration maneuver. Small airway disease often results in obstruction or narrowing of the small airways, leading to difficulty rapidly expelling air. Predicted postoperative FEV1 <30% are at a higher risk of postoperative pulmonary complications after thoracic surgery."}
+{"id": "article-101481_28", "title": "Spirometry -- Enhancing Healthcare Team Outcomes", "content": "Spirometry is an apparatus used to assess pulmonary function for diagnostic or monitoring purposes. The procedure must be explained thoroughly to the subject patient by competent personnel who underwent training under supervision by a specialist mentor and will undergo periodic retraining in order to ensure that the results obtained are as accurate as possible and the complications are kept to a minimum. The results are interpreted by a pulmonologist, and the consultation of an interprofessional group of specialists is recommended. [11] [12]", "contents": "Spirometry -- Enhancing Healthcare Team Outcomes. Spirometry is an apparatus used to assess pulmonary function for diagnostic or monitoring purposes. The procedure must be explained thoroughly to the subject patient by competent personnel who underwent training under supervision by a specialist mentor and will undergo periodic retraining in order to ensure that the results obtained are as accurate as possible and the complications are kept to a minimum. The results are interpreted by a pulmonologist, and the consultation of an interprofessional group of specialists is recommended. [11] [12]"}
+{"id": "article-101481_29", "title": "Spirometry -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Spirometry -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

statpearls/chunk/article-101507.jsonl

@@ -0,0 +1,37 @@
+{"id": "article-101507_0", "title": "Fuchs Uveitis Syndrome -- Continuing Education Activity", "content": "Fuchs uveitis syndrome (FUS) is a chronic and typically unilateral form of mild anterior uveitis characterized by a distinctive clinical feature known as heterochromia, observed in approximately 13.9% of affected individuals. First described by Ernst Fuchs in 1906, its precise origin remains elusive, with various theories proposed over time, though the infectious theory\u00a0remains one of the more plausible explanations. This condition leads to changes in vision, primarily due to ensuing complications\u00a0(eg, cataracts and glaucoma), often affecting patient prognosis. Notably, heterochromia arises from anterior iris stromal atrophy, resulting in the lightening of the affected eye\u2014a phenomenon more pronounced in individuals with lighter-colored irises than those with darker irises, where the atrophy's visibility is reduced.", "contents": "Fuchs Uveitis Syndrome -- Continuing Education Activity. Fuchs uveitis syndrome (FUS) is a chronic and typically unilateral form of mild anterior uveitis characterized by a distinctive clinical feature known as heterochromia, observed in approximately 13.9% of affected individuals. First described by Ernst Fuchs in 1906, its precise origin remains elusive, with various theories proposed over time, though the infectious theory\u00a0remains one of the more plausible explanations. This condition leads to changes in vision, primarily due to ensuing complications\u00a0(eg, cataracts and glaucoma), often affecting patient prognosis. Notably, heterochromia arises from anterior iris stromal atrophy, resulting in the lightening of the affected eye\u2014a phenomenon more pronounced in individuals with lighter-colored irises than those with darker irises, where the atrophy's visibility is reduced."}
+{"id": "article-101507_1", "title": "Fuchs Uveitis Syndrome -- Continuing Education Activity", "content": "The demographics of FUS patients exhibit variability across geographic regions, showcasing differences in incidence rates, onset age, and complication frequencies among distinct subpopulations. This CME activity\u00a0reviews the\u00a0uncertain etiology of FUS, its diverse epidemiological patterns, proposed pathophysiological mechanisms, clinical manifestations, and the interprofessional team's management of both the syndrome and its associated complications. By exploring these facets, healthcare practitioners can enhance their understanding and approach to effectively address\u00a0FUS and its diverse clinical implications for patient care.", "contents": "Fuchs Uveitis Syndrome -- Continuing Education Activity. The demographics of FUS patients exhibit variability across geographic regions, showcasing differences in incidence rates, onset age, and complication frequencies among distinct subpopulations. This CME activity\u00a0reviews the\u00a0uncertain etiology of FUS, its diverse epidemiological patterns, proposed pathophysiological mechanisms, clinical manifestations, and the interprofessional team's management of both the syndrome and its associated complications. By exploring these facets, healthcare practitioners can enhance their understanding and approach to effectively address\u00a0FUS and its diverse clinical implications for patient care."}
+{"id": "article-101507_2", "title": "Fuchs Uveitis Syndrome -- Continuing Education Activity", "content": "Objectives: Identify the etiology of Fuchs uveitis syndrome (FUS). Assess\u00a0the theorized pathophysiology of FUS. Interpret the findings that differentiate\u00a0FUS from other common causes of uveitis. Collaborate with the interprofessional team to educate, treat, and monitor patients with\u00a0FUS to improve patient outcomes. Access free multiple choice questions on this topic.", "contents": "Fuchs Uveitis Syndrome -- Continuing Education Activity. Objectives: Identify the etiology of Fuchs uveitis syndrome (FUS). Assess\u00a0the theorized pathophysiology of FUS. Interpret the findings that differentiate\u00a0FUS from other common causes of uveitis. Collaborate with the interprofessional team to educate, treat, and monitor patients with\u00a0FUS to improve patient outcomes. Access free multiple choice questions on this topic."}
+{"id": "article-101507_3", "title": "Fuchs Uveitis Syndrome -- Introduction", "content": "Fuchs uveitis syndrome (FUS) is a chronic, typically unilateral, mild anterior uveitis that was first described by Ernst Fuchs in 1906. FUS is also referred to as Fuchs heterochromic uveitis and Fuchs heterochromic iridocyclitis. The exact etiology of FUS is unknown. Fuchs had many theories about what caused this unique pathology; however, these have been largely disproven over the years, with the infectious theory remaining one of the more probable causes.", "contents": "Fuchs Uveitis Syndrome -- Introduction. Fuchs uveitis syndrome (FUS) is a chronic, typically unilateral, mild anterior uveitis that was first described by Ernst Fuchs in 1906. FUS is also referred to as Fuchs heterochromic uveitis and Fuchs heterochromic iridocyclitis. The exact etiology of FUS is unknown. Fuchs had many theories about what caused this unique pathology; however, these have been largely disproven over the years, with the infectious theory remaining one of the more probable causes."}
+{"id": "article-101507_4", "title": "Fuchs Uveitis Syndrome -- Introduction", "content": "The patient population demographics vary by geographic location, with different incidence rates, symptom presentation age, and complication rates depending on the subpopulation studied. Most patients with FUS experience changes in vision mainly due to secondary complications, such as cataracts and glaucoma. Treatment of these complications leads to a good prognosis. [1] [2] [3] [4]", "contents": "Fuchs Uveitis Syndrome -- Introduction. The patient population demographics vary by geographic location, with different incidence rates, symptom presentation age, and complication rates depending on the subpopulation studied. Most patients with FUS experience changes in vision mainly due to secondary complications, such as cataracts and glaucoma. Treatment of these complications leads to a good prognosis. [1] [2] [3] [4]"}
+{"id": "article-101507_5", "title": "Fuchs Uveitis Syndrome -- Introduction", "content": "Nonhereditary heterochromia, present in about 13.9% of patients with FUS, is caused by anterior iris stromal atrophy. [4] [5] As a result, the patient will notice a lightening in the affected eye. Heterochromia is predominantly seen in patients with a lighter-colored iris. Patients with a darker-colored iris have more pigment cells in the anterior border layer of the iris, making the atrophy in the iris less apparent. Consequently, these patients are less likely to\u00a0develop heterochromia. [3] [4] [6] This article will discuss the etiology, epidemiology, proposed pathophysiology, clinical presentation, and management of FUS and its complications.", "contents": "Fuchs Uveitis Syndrome -- Introduction. Nonhereditary heterochromia, present in about 13.9% of patients with FUS, is caused by anterior iris stromal atrophy. [4] [5] As a result, the patient will notice a lightening in the affected eye. Heterochromia is predominantly seen in patients with a lighter-colored iris. Patients with a darker-colored iris have more pigment cells in the anterior border layer of the iris, making the atrophy in the iris less apparent. Consequently, these patients are less likely to\u00a0develop heterochromia. [3] [4] [6] This article will discuss the etiology, epidemiology, proposed pathophysiology, clinical presentation, and management of FUS and its complications."}
+{"id": "article-101507_6", "title": "Fuchs Uveitis Syndrome -- Etiology", "content": "The initial studies on FUS hypothesized its etiology ranging from adrenergic denervation, as in Horner syndrome, to infectious causes such as herpes simplex virus (HSV) and Toxoplasma gondii. One of the landmark studies by Quentin and Reiber proposed the now-predominant theory that FUS is caused by an inflammatory process involving rubella. The study analyzed the presence of intraocular antibody synthesis driven by rubella, HSV, varicella-zoster, measles, and toxoplasmosis. The results showed rubella oligoclonal antibodies in every sample of aqueous humor collected from patients with FUS, leading to a diagnostic criterion of 100% sensitivity. [7]", "contents": "Fuchs Uveitis Syndrome -- Etiology. The initial studies on FUS hypothesized its etiology ranging from adrenergic denervation, as in Horner syndrome, to infectious causes such as herpes simplex virus (HSV) and Toxoplasma gondii. One of the landmark studies by Quentin and Reiber proposed the now-predominant theory that FUS is caused by an inflammatory process involving rubella. The study analyzed the presence of intraocular antibody synthesis driven by rubella, HSV, varicella-zoster, measles, and toxoplasmosis. The results showed rubella oligoclonal antibodies in every sample of aqueous humor collected from patients with FUS, leading to a diagnostic criterion of 100% sensitivity. [7]"}
+{"id": "article-101507_7", "title": "Fuchs Uveitis Syndrome -- Etiology", "content": "Subsequently, multiple studies analyzed the presence of rubella RNA or rubella antibodies in the aqueous humor of patients with FUS. [5] [7] [8] These studies concluded that patients with FUS have the persistent presence of immunoglobulin G (IgG) oligoclonal rubella antibodies in the affected eye and that the presence of rubella viral RNA in the aqueous humor is not associated with the progression of FUS. [9] [10] [11] [12] [13]", "contents": "Fuchs Uveitis Syndrome -- Etiology. Subsequently, multiple studies analyzed the presence of rubella RNA or rubella antibodies in the aqueous humor of patients with FUS. [5] [7] [8] These studies concluded that patients with FUS have the persistent presence of immunoglobulin G (IgG) oligoclonal rubella antibodies in the affected eye and that the presence of rubella viral RNA in the aqueous humor is not associated with the progression of FUS. [9] [10] [11] [12] [13]"}
+{"id": "article-101507_8", "title": "Fuchs Uveitis Syndrome -- Etiology", "content": "The initially proposed mechanisms of FUS consisted of sympathetic nerve dysfunction, hereditary, ocular toxoplasmosis, vascular, and immunological theories, all of which have largely lost favor. [14] Other diseases theorized to manifest with FUS are retinitis pigmentosa, Usher syndrome, and chikungunya; however, other theories have limited support in the literature since the studies involve clinical diagnosis with no aqueous humor antibody analysis. No specific human leukocyte antigen (HLA) is associated with FUS. [15] [16] [17] [18]", "contents": "Fuchs Uveitis Syndrome -- Etiology. The initially proposed mechanisms of FUS consisted of sympathetic nerve dysfunction, hereditary, ocular toxoplasmosis, vascular, and immunological theories, all of which have largely lost favor. [14] Other diseases theorized to manifest with FUS are retinitis pigmentosa, Usher syndrome, and chikungunya; however, other theories have limited support in the literature since the studies involve clinical diagnosis with no aqueous humor antibody analysis. No specific human leukocyte antigen (HLA) is associated with FUS. [15] [16] [17] [18]"}
+{"id": "article-101507_9", "title": "Fuchs Uveitis Syndrome -- Epidemiology", "content": "In most studies conducted around the world, the age range of diagnosis is from 27 to 44.5 years, with\u00a0no significant difference between genders. [19] [20] [21] [22] [23] [24] [25] In a cohort of 131 patients at the University of Illinois Eye and Ear Infirmary, the mean age of patients diagnosed with\u00a0FUS was 43.9, plus or minus 14.3 years. [25]", "contents": "Fuchs Uveitis Syndrome -- Epidemiology. In most studies conducted around the world, the age range of diagnosis is from 27 to 44.5 years, with\u00a0no significant difference between genders. [19] [20] [21] [22] [23] [24] [25] In a cohort of 131 patients at the University of Illinois Eye and Ear Infirmary, the mean age of patients diagnosed with\u00a0FUS was 43.9, plus or minus 14.3 years. [25]"}
+{"id": "article-101507_10", "title": "Fuchs Uveitis Syndrome -- Epidemiology", "content": "In this study, 4.48% of patients presenting to the clinic from 1919\u00a0to 1958 had\u00a0FUS before and after rubella vaccination. [25] The decade after the rubella vaccination was introduced in 1969, only 1.18% of patients had FUS, with decreasing rates in the subsequent decades. [25] Even though the rubella vaccination decreased the overall incidence of FUS, the proportion of patients diagnosed with FUS born outside the United States has increased.", "contents": "Fuchs Uveitis Syndrome -- Epidemiology. In this study, 4.48% of patients presenting to the clinic from 1919\u00a0to 1958 had\u00a0FUS before and after rubella vaccination. [25] The decade after the rubella vaccination was introduced in 1969, only 1.18% of patients had FUS, with decreasing rates in the subsequent decades. [25] Even though the rubella vaccination decreased the overall incidence of FUS, the proportion of patients diagnosed with FUS born outside the United States has increased."}
+{"id": "article-101507_11", "title": "Fuchs Uveitis Syndrome -- Pathophysiology", "content": "New studies have led to the infectious pathway, which has gained increasing traction within the scientific community. It has been proposed that patients with FUS harbor rubella infection, leading to chronic inflammation manifested as chronic anterior or intermediate uveitis. [7] A study that focused on analyzing the cellular infiltrates identified the presence of mainly T-lymphocytes of CD8 + phenotype, further enforcing the theory of a viral pathological mechanism. [26] [27] Even though the exact mechanism of FUS is unknown, the relationship between rubella oligoclonal antibodies and CD8 + T-lymphocytes in the aqueous humor sheds light on the pathway. [7] [11] [12] [27]", "contents": "Fuchs Uveitis Syndrome -- Pathophysiology. New studies have led to the infectious pathway, which has gained increasing traction within the scientific community. It has been proposed that patients with FUS harbor rubella infection, leading to chronic inflammation manifested as chronic anterior or intermediate uveitis. [7] A study that focused on analyzing the cellular infiltrates identified the presence of mainly T-lymphocytes of CD8 + phenotype, further enforcing the theory of a viral pathological mechanism. [26] [27] Even though the exact mechanism of FUS is unknown, the relationship between rubella oligoclonal antibodies and CD8 + T-lymphocytes in the aqueous humor sheds light on the pathway. [7] [11] [12] [27]"}
+{"id": "article-101507_12", "title": "Fuchs Uveitis Syndrome -- History and Physical", "content": "FUS\u00a0usually occurs in the third to the fourth decade of life. Due to the insidious nature of this condition, coupled with a mild chronic course, most patients will be unaware of the subtle changes in their eyes. Patients are usually asymptomatic, with most FUS diagnoses detected during a routine ocular examination. Lightening of the iris of the affected eye is a unique complaint by patients. Occasionally, both eyes will be affected. Another pertinent finding in a patient\u2019s history is decreasing visual acuity primarily caused by cataract formation. Patients may also complain of floaters, one of the more common presenting symptoms. Some patients may also experience symptoms of increased intraocular pressure (IOP), such as blurry vision, mild pain, and colored haloes around lights. [5] [19]", "contents": "Fuchs Uveitis Syndrome -- History and Physical. FUS\u00a0usually occurs in the third to the fourth decade of life. Due to the insidious nature of this condition, coupled with a mild chronic course, most patients will be unaware of the subtle changes in their eyes. Patients are usually asymptomatic, with most FUS diagnoses detected during a routine ocular examination. Lightening of the iris of the affected eye is a unique complaint by patients. Occasionally, both eyes will be affected. Another pertinent finding in a patient\u2019s history is decreasing visual acuity primarily caused by cataract formation. Patients may also complain of floaters, one of the more common presenting symptoms. Some patients may also experience symptoms of increased intraocular pressure (IOP), such as blurry vision, mild pain, and colored haloes around lights. [5] [19]"}
+{"id": "article-101507_13", "title": "Fuchs Uveitis Syndrome -- History and Physical", "content": "On slit-lamp examination, minimal inflammatory signs are present, with quiet conjunctiva and no ciliary injection. Even though heterochromia is a unique feature in FUS, many factors affect this finding, including anterior stromal atrophy, iris color, and the amount of pigment in the iris\u2019s epithelium. This unique clinical finding is caused by the irreversible and progressive atrophy of the anterior stroma. Individuals with darker-colored irises may not manifest heterochromia,\u00a0whereas others may experience a lightening of the iris of the affected eye. However, those with a lighter iris will experience a deepening of the color. The more consistent finding\u00a0is\u00a0that white stellate keratic precipitates are distributed throughout the endothelium, described as sharply circumscribed and small to medium in size.", "contents": "Fuchs Uveitis Syndrome -- History and Physical. On slit-lamp examination, minimal inflammatory signs are present, with quiet conjunctiva and no ciliary injection. Even though heterochromia is a unique feature in FUS, many factors affect this finding, including anterior stromal atrophy, iris color, and the amount of pigment in the iris\u2019s epithelium. This unique clinical finding is caused by the irreversible and progressive atrophy of the anterior stroma. Individuals with darker-colored irises may not manifest heterochromia,\u00a0whereas others may experience a lightening of the iris of the affected eye. However, those with a lighter iris will experience a deepening of the color. The more consistent finding\u00a0is\u00a0that white stellate keratic precipitates are distributed throughout the endothelium, described as sharply circumscribed and small to medium in size."}
+{"id": "article-101507_14", "title": "Fuchs Uveitis Syndrome -- History and Physical", "content": "The trabecular meshwork and iris will display abnormal vessels with variable vitreous inflammation. In some cases, patients\u00a0have iris nodules in the pupillary margin, known as Koeppe\u2019s nodule, or on the iris\u2019s surface, known as Busacca nodules. The iris sphincter can also atrophy, leading to an irregularly shaped pupil exhibiting poor light reflex. Due to the insidious nature of the disease, many patients with FUS will present to the clinic with advanced disease. These patients often have a posterior subcapsular cataract, eventually evolving into total opacification and increased intraocular pressure. [5] [19]", "contents": "Fuchs Uveitis Syndrome -- History and Physical. The trabecular meshwork and iris will display abnormal vessels with variable vitreous inflammation. In some cases, patients\u00a0have iris nodules in the pupillary margin, known as Koeppe\u2019s nodule, or on the iris\u2019s surface, known as Busacca nodules. The iris sphincter can also atrophy, leading to an irregularly shaped pupil exhibiting poor light reflex. Due to the insidious nature of the disease, many patients with FUS will present to the clinic with advanced disease. These patients often have a posterior subcapsular cataract, eventually evolving into total opacification and increased intraocular pressure. [5] [19]"}
+{"id": "article-101507_15", "title": "Fuchs Uveitis Syndrome -- Evaluation", "content": "The diagnosis of\u00a0FUS is primarily clinical, based on history and complete eye examination. Alternative methods of examining the eye can prove useful with an atypical presentation. Anterior chamber paracentesis can be done to analyze the aqueous humor. Finding rubella-specific antibodies in the aqueous humor is nonspecific, but in their absence, it would decrease the probability of the patient having FUS. [7] [12]", "contents": "Fuchs Uveitis Syndrome -- Evaluation. The diagnosis of\u00a0FUS is primarily clinical, based on history and complete eye examination. Alternative methods of examining the eye can prove useful with an atypical presentation. Anterior chamber paracentesis can be done to analyze the aqueous humor. Finding rubella-specific antibodies in the aqueous humor is nonspecific, but in their absence, it would decrease the probability of the patient having FUS. [7] [12]"}
+{"id": "article-101507_16", "title": "Fuchs Uveitis Syndrome -- Evaluation", "content": "In vivo , confocal microscopy (IVCM) is a noninvasive procedure that can\u00a0help observe ocular structures on the cellular level. A study published in 2009 that focused on observing patients with FUS using IVCM provided high-resolution images of the cornea\u2019s endothelium and the consistent keratic precipitates that patients with FUS experience. The images were compared to those of uveitis caused by an infectious etiology, and both images shared various similarities, further enforcing\u00a0the infectious cause of FUS. Even though IVCM helped identify the possible etiology of FUS, this noninvasive procedure is not routinely used. [28]", "contents": "Fuchs Uveitis Syndrome -- Evaluation. In vivo , confocal microscopy (IVCM) is a noninvasive procedure that can\u00a0help observe ocular structures on the cellular level. A study published in 2009 that focused on observing patients with FUS using IVCM provided high-resolution images of the cornea\u2019s endothelium and the consistent keratic precipitates that patients with FUS experience. The images were compared to those of uveitis caused by an infectious etiology, and both images shared various similarities, further enforcing\u00a0the infectious cause of FUS. Even though IVCM helped identify the possible etiology of FUS, this noninvasive procedure is not routinely used. [28]"}
+{"id": "article-101507_17", "title": "Fuchs Uveitis Syndrome -- Evaluation", "content": "Further imaging studies such as enhanced-depth imaging optical coherence tomography (EDI-OCT) have also been used to evaluate the morphology present in FUS. FUS eyes had a decreased thickness of the iris compared\u00a0with eyes without pathology, as well as statistically significant extra-foveal and subfoveal choroidal thinning.\u00a0Although studies regarding different imaging modalities have primarily been used\u00a0in\u00a0an attempt to refine the knowledge concerning FUS, none have changed the diagnostic criteria. [29] [30] [31]", "contents": "Fuchs Uveitis Syndrome -- Evaluation. Further imaging studies such as enhanced-depth imaging optical coherence tomography (EDI-OCT) have also been used to evaluate the morphology present in FUS. FUS eyes had a decreased thickness of the iris compared\u00a0with eyes without pathology, as well as statistically significant extra-foveal and subfoveal choroidal thinning.\u00a0Although studies regarding different imaging modalities have primarily been used\u00a0in\u00a0an attempt to refine the knowledge concerning FUS, none have changed the diagnostic criteria. [29] [30] [31]"}
+{"id": "article-101507_18", "title": "Fuchs Uveitis Syndrome -- Treatment / Management", "content": "In FUS, a short course of corticosteroids can be used to treat symptomatic exacerbation of the patient\u2019s uveitis. Topical corticosteroids are typically preferred in patients with anterior uveitis exacerbation because the steroids can only penetrate the anterior segment of the patient\u2019s eyes. [32] Systemic corticosteroids are commonly used when the inflammation involves all uveal layers and, subsequently, the optic nerve. [32]", "contents": "Fuchs Uveitis Syndrome -- Treatment / Management. In FUS, a short course of corticosteroids can be used to treat symptomatic exacerbation of the patient\u2019s uveitis. Topical corticosteroids are typically preferred in patients with anterior uveitis exacerbation because the steroids can only penetrate the anterior segment of the patient\u2019s eyes. [32] Systemic corticosteroids are commonly used when the inflammation involves all uveal layers and, subsequently, the optic nerve. [32]"}
+{"id": "article-101507_19", "title": "Fuchs Uveitis Syndrome -- Treatment / Management", "content": "However, long-term use of anti-inflammatory therapy is not indicated. Patients still experience flares even with chronic corticosteroids, which can lead to cataract formation and glaucoma. Occasionally, since FUS has a similar clinical presentation to other uveitides of other etiologies, a trial of short-course topical corticosteroid therapy may be used to help differentiate the other inflammatory pathologies. The patient requires treatment for secondary complications such as cataracts or glaucoma, which occur in most patients leading to visual deterioration in this disease. [5] [14] [33]", "contents": "Fuchs Uveitis Syndrome -- Treatment / Management. However, long-term use of anti-inflammatory therapy is not indicated. Patients still experience flares even with chronic corticosteroids, which can lead to cataract formation and glaucoma. Occasionally, since FUS has a similar clinical presentation to other uveitides of other etiologies, a trial of short-course topical corticosteroid therapy may be used to help differentiate the other inflammatory pathologies. The patient requires treatment for secondary complications such as cataracts or glaucoma, which occur in most patients leading to visual deterioration in this disease. [5] [14] [33]"}
+{"id": "article-101507_20", "title": "Fuchs Uveitis Syndrome -- Differential Diagnosis", "content": "FUS\u00a0shares similar clinical features with other inflammatory processes, such as Posner-Schlossman syndrome (PSS). Both diagnoses are made clinically, with PSS having the characteristics of mild, nongranulomatous, anterior uveitis with recurrent attacks of increasing intraocular pressure. Patients with PSS may experience unilateral mild eye discomfort, pain, or blurred vision, but it can also be asymptomatic. Epithelial corneal edema and small keratic precipitates will be seen.", "contents": "Fuchs Uveitis Syndrome -- Differential Diagnosis. FUS\u00a0shares similar clinical features with other inflammatory processes, such as Posner-Schlossman syndrome (PSS). Both diagnoses are made clinically, with PSS having the characteristics of mild, nongranulomatous, anterior uveitis with recurrent attacks of increasing intraocular pressure. Patients with PSS may experience unilateral mild eye discomfort, pain, or blurred vision, but it can also be asymptomatic. Epithelial corneal edema and small keratic precipitates will be seen."}
+{"id": "article-101507_21", "title": "Fuchs Uveitis Syndrome -- Differential Diagnosis", "content": "FUS and PSS share the unique features of an atrophied iris and heterochromia. In between attacks, the patients will have open angles with normal IOP. PSS responds well to steroids, with most cases only resulting in surgery if refractory glaucoma develops. FUS can be differentiated from PSS through history, physical examination, and a trial of steroid medication. [34]", "contents": "Fuchs Uveitis Syndrome -- Differential Diagnosis. FUS and PSS share the unique features of an atrophied iris and heterochromia. In between attacks, the patients will have open angles with normal IOP. PSS responds well to steroids, with most cases only resulting in surgery if refractory glaucoma develops. FUS can be differentiated from PSS through history, physical examination, and a trial of steroid medication. [34]"}
+{"id": "article-101507_22", "title": "Fuchs Uveitis Syndrome -- Differential Diagnosis", "content": "Herpes keratouveitis (HKU) may be considered in the differential diagnosis. Patients with HKU have the clinical features of iridocyclitis, like those of FUS; however, these patients will have stromal edema along with pigmented keratic precipitates and endotheliitis. Other eye findings of posterior synechiae, sphincter damage, and sectoral iris atrophy can also be seen. HKU can be differentiated from FUS by the typical herpetic lesions and diagnostic tests. Viral culture and a viral antigen test can detect the presence of HSV-1 or HSV-2 in ocular fluids. [35]", "contents": "Fuchs Uveitis Syndrome -- Differential Diagnosis. Herpes keratouveitis (HKU) may be considered in the differential diagnosis. Patients with HKU have the clinical features of iridocyclitis, like those of FUS; however, these patients will have stromal edema along with pigmented keratic precipitates and endotheliitis. Other eye findings of posterior synechiae, sphincter damage, and sectoral iris atrophy can also be seen. HKU can be differentiated from FUS by the typical herpetic lesions and diagnostic tests. Viral culture and a viral antigen test can detect the presence of HSV-1 or HSV-2 in ocular fluids. [35]"}
+{"id": "article-101507_23", "title": "Fuchs Uveitis Syndrome -- Differential Diagnosis", "content": "Alternative differential diagnoses that are common etiologies of chronic uveitis, such as a varicella-zoster virus (VZV) and cytomegalovirus (CMV), should also be considered. These infectious etiologies usually have reduced corneal sensitivity and skin manifestations that help differentiate them from FUS. [36]", "contents": "Fuchs Uveitis Syndrome -- Differential Diagnosis. Alternative differential diagnoses that are common etiologies of chronic uveitis, such as a varicella-zoster virus (VZV) and cytomegalovirus (CMV), should also be considered. These infectious etiologies usually have reduced corneal sensitivity and skin manifestations that help differentiate them from FUS. [36]"}
+{"id": "article-101507_24", "title": "Fuchs Uveitis Syndrome -- Differential Diagnosis", "content": "FUS may be distinguished from the various causes of increased IOP. A common cause of increased IOP would be acute angle-closure glaucoma, which would have the unique characteristics of a fixed and dilated pupil paired with severe pain, nausea, and vomiting, all of which would be absent in a patient with FUS.", "contents": "Fuchs Uveitis Syndrome -- Differential Diagnosis. FUS may be distinguished from the various causes of increased IOP. A common cause of increased IOP would be acute angle-closure glaucoma, which would have the unique characteristics of a fixed and dilated pupil paired with severe pain, nausea, and vomiting, all of which would be absent in a patient with FUS."}
+{"id": "article-101507_25", "title": "Fuchs Uveitis Syndrome -- Prognosis", "content": "The prognosis for patients who undergo cataract surgery is favorable, with an overall 85% success rate defined as 20/40 or better visual acuity. [2] These rates are better than other uveitis cases. A study done in Italy showed that 33.3% of patients who had cataract surgery subsequently developed posterior capsule opacification, leading to treatment with YAG laser capsulotomy. [19] The prevalence of posterior capsule opacification in FUS after cataract removal is similar to that of the same complication after senile cataract removal, ranging between 20% and 40%. [19] [37] [38] It is theorized that this percentage can be decreased through aggressive treatment of removing all the cortex. [37]", "contents": "Fuchs Uveitis Syndrome -- Prognosis. The prognosis for patients who undergo cataract surgery is favorable, with an overall 85% success rate defined as 20/40 or better visual acuity. [2] These rates are better than other uveitis cases. A study done in Italy showed that 33.3% of patients who had cataract surgery subsequently developed posterior capsule opacification, leading to treatment with YAG laser capsulotomy. [19] The prevalence of posterior capsule opacification in FUS after cataract removal is similar to that of the same complication after senile cataract removal, ranging between 20% and 40%. [19] [37] [38] It is theorized that this percentage can be decreased through aggressive treatment of removing all the cortex. [37]"}
+{"id": "article-101507_26", "title": "Fuchs Uveitis Syndrome -- Prognosis", "content": "In a report by La Hey et al, as many as 73% of patients failed maximal medical therapy for glaucoma. [39] Other studies have shown better outcomes with medical management, with Jones reporting a failure in only 37% of patients. [14] [40] Surgery is required in about 47% to 66% of patients with glaucoma, with most patients gaining back their baseline visual acuity. [1] [14] [21] [24]", "contents": "Fuchs Uveitis Syndrome -- Prognosis. In a report by La Hey et al, as many as 73% of patients failed maximal medical therapy for glaucoma. [39] Other studies have shown better outcomes with medical management, with Jones reporting a failure in only 37% of patients. [14] [40] Surgery is required in about 47% to 66% of patients with glaucoma, with most patients gaining back their baseline visual acuity. [1] [14] [21] [24]"}
+{"id": "article-101507_27", "title": "Fuchs Uveitis Syndrome -- Prognosis", "content": "In a retrospective study by Al-Mansour et al, patients diagnosed with FUS showed worsening visual acuity in only 10% of the eyes in the follow-up period after being diagnosed with FUS, with most eyes having improved or unchanged visual acuity. [4]", "contents": "Fuchs Uveitis Syndrome -- Prognosis. In a retrospective study by Al-Mansour et al, patients diagnosed with FUS showed worsening visual acuity in only 10% of the eyes in the follow-up period after being diagnosed with FUS, with most eyes having improved or unchanged visual acuity. [4]"}
+{"id": "article-101507_28", "title": "Fuchs Uveitis Syndrome -- Complications", "content": "One of the most serious complications of\u00a0FUS is secondary glaucoma, which may cause permanent visual loss in patients. Secondary glaucoma has a prevalence of 15% to 59%. [39] [41] Medical therapy is rarely adequate in controlling the elevated IOP for those who have FUS and who subsequently develop secondary glaucoma. When medical management is unsuccessful, surgical intervention is needed, primarily trabeculectomy. [3] [4]", "contents": "Fuchs Uveitis Syndrome -- Complications. One of the most serious complications of\u00a0FUS is secondary glaucoma, which may cause permanent visual loss in patients. Secondary glaucoma has a prevalence of 15% to 59%. [39] [41] Medical therapy is rarely adequate in controlling the elevated IOP for those who have FUS and who subsequently develop secondary glaucoma. When medical management is unsuccessful, surgical intervention is needed, primarily trabeculectomy. [3] [4]"}
+{"id": "article-101507_29", "title": "Fuchs Uveitis Syndrome -- Complications", "content": "Trabeculectomy is the standard surgical procedure displaying the highest success rate. Adjunctive treatment with mitomycin C has proven successful in lowering the average IOP in patients after trabeculectomy; however, bevacizumab was not as successful as an adjunctive treatment in a study by Elgin et al. [39] [42] [43]", "contents": "Fuchs Uveitis Syndrome -- Complications. Trabeculectomy is the standard surgical procedure displaying the highest success rate. Adjunctive treatment with mitomycin C has proven successful in lowering the average IOP in patients after trabeculectomy; however, bevacizumab was not as successful as an adjunctive treatment in a study by Elgin et al. [39] [42] [43]"}
+{"id": "article-101507_30", "title": "Fuchs Uveitis Syndrome -- Complications", "content": "The major cause of poor vision in FUS patients is cataract formation, with a prevalence of 23% to 90.7%. [4] The clinical and visual outcomes of patients are good with various types of cataract extraction strategies consisting of phacoemulsification and small-incision cataract surgery. Both surgical techniques provide lower postoperative and intraoperative complication rates than extracapsular cataract extraction. [4] [14] [44] [45]", "contents": "Fuchs Uveitis Syndrome -- Complications. The major cause of poor vision in FUS patients is cataract formation, with a prevalence of 23% to 90.7%. [4] The clinical and visual outcomes of patients are good with various types of cataract extraction strategies consisting of phacoemulsification and small-incision cataract surgery. Both surgical techniques provide lower postoperative and intraoperative complication rates than extracapsular cataract extraction. [4] [14] [44] [45]"}
+{"id": "article-101507_31", "title": "Fuchs Uveitis Syndrome -- Deterrence and Patient Education", "content": "Patients with\u00a0FUS should be informed about the alarming symptoms of sudden increased IOP. Both pain and a decrease in visual acuity should lead the patient to seek medical care immediately to prevent permanent vision loss. If the patient is diagnosed with FUS early in the disease process, they should become aware of the high probability of acquiring a cataract, the likely need for cataract removal, and prompt surgical treatment for refractory glaucoma.", "contents": "Fuchs Uveitis Syndrome -- Deterrence and Patient Education. Patients with\u00a0FUS should be informed about the alarming symptoms of sudden increased IOP. Both pain and a decrease in visual acuity should lead the patient to seek medical care immediately to prevent permanent vision loss. If the patient is diagnosed with FUS early in the disease process, they should become aware of the high probability of acquiring a cataract, the likely need for cataract removal, and prompt surgical treatment for refractory glaucoma."}
+{"id": "article-101507_32", "title": "Fuchs Uveitis Syndrome -- Pearls and Other Issues", "content": "FUS\u00a0is a unique pathology with many theorized pathophysiological mechanisms. It is a chronic anterior uveitis that is primarily unilateral but can be bilateral. FUS is associated with the presence of oligoclonal rubella antibodies in the aqueous humor.\u00a0Even though the etiology is unclear, the prognosis in patients diagnosed with the pathology is good when secondary complications of cataracts and glaucoma are treated.", "contents": "Fuchs Uveitis Syndrome -- Pearls and Other Issues. FUS\u00a0is a unique pathology with many theorized pathophysiological mechanisms. It is a chronic anterior uveitis that is primarily unilateral but can be bilateral. FUS is associated with the presence of oligoclonal rubella antibodies in the aqueous humor.\u00a0Even though the etiology is unclear, the prognosis in patients diagnosed with the pathology is good when secondary complications of cataracts and glaucoma are treated."}
+{"id": "article-101507_33", "title": "Fuchs Uveitis Syndrome -- Pearls and Other Issues", "content": "Management of FUS primarily consists of managing secondary complications of cataracts and glaucoma that occur during the disease.\u00a0Physicians should be able to diagnose patients with this pathology through history and physical examination. FUS may be misdiagnosed due to its similarity to other inflammatory conditions or uveitides.", "contents": "Fuchs Uveitis Syndrome -- Pearls and Other Issues. Management of FUS primarily consists of managing secondary complications of cataracts and glaucoma that occur during the disease.\u00a0Physicians should be able to diagnose patients with this pathology through history and physical examination. FUS may be misdiagnosed due to its similarity to other inflammatory conditions or uveitides."}
+{"id": "article-101507_34", "title": "Fuchs Uveitis Syndrome -- Enhancing Healthcare Team Outcomes", "content": "Management of\u00a0FUS could be improved with early recognition of signs and symptoms. The\u00a0eye care specialist, nurse, and technician should always ask the patient if visual acuity has decreased or floaters are noted. A thorough history and physical examination should be taken. The eye care team should take note of any significant difference in iris color between the eyes and perform a complete eye examination.", "contents": "Fuchs Uveitis Syndrome -- Enhancing Healthcare Team Outcomes. Management of\u00a0FUS could be improved with early recognition of signs and symptoms. The\u00a0eye care specialist, nurse, and technician should always ask the patient if visual acuity has decreased or floaters are noted. A thorough history and physical examination should be taken. The eye care team should take note of any significant difference in iris color between the eyes and perform a complete eye examination."}
+{"id": "article-101507_35", "title": "Fuchs Uveitis Syndrome -- Enhancing Healthcare Team Outcomes", "content": "The prognosis for most patients will be good with proper communication and patient education. [4] The ophthalmologist should weigh the risks and benefits of doing medical management over surgical management. All interprofessional team members involved in the case must be able to communicate with other team members regarding their observations and interventions, and documenting these interactions in the patient's medical record is also essential.", "contents": "Fuchs Uveitis Syndrome -- Enhancing Healthcare Team Outcomes. The prognosis for most patients will be good with proper communication and patient education. [4] The ophthalmologist should weigh the risks and benefits of doing medical management over surgical management. All interprofessional team members involved in the case must be able to communicate with other team members regarding their observations and interventions, and documenting these interactions in the patient's medical record is also essential."}
+{"id": "article-101507_36", "title": "Fuchs Uveitis Syndrome -- Review Questions", "content": "Access free multiple choice questions on this topic. Click here for a simplified version. Comment on this article.", "contents": "Fuchs Uveitis Syndrome -- Review Questions. Access free multiple choice questions on this topic. Click here for a simplified version. Comment on this article."}

statpearls/chunk/article-101758.jsonl

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+{"id": "article-101758_0", "title": "Chronic Iron Deficiency -- Continuing Education Activity", "content": "Chronic iron deficiency is the most common nutrient deficiency in the world and a significant common cause of anemia worldwide. It is mainly caused by inadequate dietary intake, hemorrhage, and malabsorption. This activity reviews the workup and treatment of chronic iron deficiency.", "contents": "Chronic Iron Deficiency -- Continuing Education Activity. Chronic iron deficiency is the most common nutrient deficiency in the world and a significant common cause of anemia worldwide. It is mainly caused by inadequate dietary intake, hemorrhage, and malabsorption. This activity reviews the workup and treatment of chronic iron deficiency."}
+{"id": "article-101758_1", "title": "Chronic Iron Deficiency -- Continuing Education Activity", "content": "Objectives: Review the etiology of chronic iron deficiency. Describe the common physical examination findings associated with chronic iron deficiency. Summarize the treatment options available for chronic iron deficiency. Outline the importance of collaboration and communication amongst the interprofessional team to improve outcomes for patients with chronic iron deficiency. Access free multiple choice questions on this topic.", "contents": "Chronic Iron Deficiency -- Continuing Education Activity. Objectives: Review the etiology of chronic iron deficiency. Describe the common physical examination findings associated with chronic iron deficiency. Summarize the treatment options available for chronic iron deficiency. Outline the importance of collaboration and communication amongst the interprofessional team to improve outcomes for patients with chronic iron deficiency. Access free multiple choice questions on this topic."}
+{"id": "article-101758_2", "title": "Chronic Iron Deficiency -- Introduction", "content": "Iron is essential for multiple biological functions of the body. It is necessary for the synthesis of hemoglobin, myoglobin, cell regulation/proliferation, DNA synthesis, and electron transport in the mitochondria. [1]", "contents": "Chronic Iron Deficiency -- Introduction. Iron is essential for multiple biological functions of the body. It is necessary for the synthesis of hemoglobin, myoglobin, cell regulation/proliferation, DNA synthesis, and electron transport in the mitochondria. [1]"}
+{"id": "article-101758_3", "title": "Chronic Iron Deficiency -- Introduction", "content": "Nearly two-thirds of the body iron is found in the circulating RBCs as part of hemoglobin, with remaining iron present in the storage form(bone marrow, liver, etc.) myoglobin and many enzymes involved in various physiological functions. [2]", "contents": "Chronic Iron Deficiency -- Introduction. Nearly two-thirds of the body iron is found in the circulating RBCs as part of hemoglobin, with remaining iron present in the storage form(bone marrow, liver, etc.) myoglobin and many enzymes involved in various physiological functions. [2]"}
+{"id": "article-101758_4", "title": "Chronic Iron Deficiency -- Introduction", "content": "Iron deficiency or sideropenia is a state where total body iron stores are inadequate to support normal metabolic functions. Iron is the most common nutritional worldwide deficiency and is the most common cause of anemia among an estimated 2 billion people worldwide. [3] Iron deficiency can be absolute or functional. Women of reproductive age and children between ages 0 to 5 are particularly at risk.", "contents": "Chronic Iron Deficiency -- Introduction. Iron deficiency or sideropenia is a state where total body iron stores are inadequate to support normal metabolic functions. Iron is the most common nutritional worldwide deficiency and is the most common cause of anemia among an estimated 2 billion people worldwide. [3] Iron deficiency can be absolute or functional. Women of reproductive age and children between ages 0 to 5 are particularly at risk."}
+{"id": "article-101758_5", "title": "Chronic Iron Deficiency -- Introduction", "content": "As there are no well established diagnostic criteria for iron deficiency without anemia and symptoms are vague, it can easily be missed. Clinicians should suspect a chronic iron deficiency in patients with normal\u00a0complete blood counts\u00a0who present with symptoms similar to anemia symptoms and have low ferritin. These patients need to be investigated for evidence of iron deficiency and inquired about blood loss in medical history.", "contents": "Chronic Iron Deficiency -- Introduction. As there are no well established diagnostic criteria for iron deficiency without anemia and symptoms are vague, it can easily be missed. Clinicians should suspect a chronic iron deficiency in patients with normal\u00a0complete blood counts\u00a0who present with symptoms similar to anemia symptoms and have low ferritin. These patients need to be investigated for evidence of iron deficiency and inquired about blood loss in medical history."}
+{"id": "article-101758_6", "title": "Chronic Iron Deficiency -- Etiology", "content": "As the majority of the body's iron is present in RBCs, bleeding from any site can cause iron deficiency. It is the most common cause of iron deficiency in developed countries. Overt causes of bleeding like hematemesis, menorrhagia, multiple pregnancies, and childbirth, etc. can easily be recognized based on history alone. Other causes like occult\u00a0gastrointestinal (GI) bleeding, parasitic infections like hookworm, and frequent blood donations can be easily overlooked.\u00a0Frequent blood donation is an important cause of iron deficiency, especially in women. [4]", "contents": "Chronic Iron Deficiency -- Etiology. As the majority of the body's iron is present in RBCs, bleeding from any site can cause iron deficiency. It is the most common cause of iron deficiency in developed countries. Overt causes of bleeding like hematemesis, menorrhagia, multiple pregnancies, and childbirth, etc. can easily be recognized based on history alone. Other causes like occult\u00a0gastrointestinal (GI) bleeding, parasitic infections like hookworm, and frequent blood donations can be easily overlooked.\u00a0Frequent blood donation is an important cause of iron deficiency, especially in women. [4]"}
+{"id": "article-101758_7", "title": "Chronic Iron Deficiency -- Etiology", "content": "Inadequate dietary intake is rare in developed nations. There are two forms of dietary iron; heme iron, which is present in animal sources, is more readily absorbed by the body than non-heme iron from plant-based foods. People from poor socio-economic backgrounds, vegetarians/vegans, and elderly who do\u00a0not eat a balanced diet are prone to developing iron deficiency.\u00a0In toddlers, excessive milk or juice intake, prolonged bottle-feeding, and snacking contributes to iron deficiency. [5]", "contents": "Chronic Iron Deficiency -- Etiology. Inadequate dietary intake is rare in developed nations. There are two forms of dietary iron; heme iron, which is present in animal sources, is more readily absorbed by the body than non-heme iron from plant-based foods. People from poor socio-economic backgrounds, vegetarians/vegans, and elderly who do\u00a0not eat a balanced diet are prone to developing iron deficiency.\u00a0In toddlers, excessive milk or juice intake, prolonged bottle-feeding, and snacking contributes to iron deficiency. [5]"}
+{"id": "article-101758_8", "title": "Chronic Iron Deficiency -- Etiology", "content": "Malabsorption of iron occurs in\u00a0celiac disease, atrophic gastritis, Helicobacter pylori infection, and bariatric surgery. Reduced absorption of iron can also present in association with some dietary elements like\u00a0tannates, phosphates, phytates, oxalates, and calcium. Certain medications can interfere with iron absorption. Examples include gastric acid-suppressing drugs, antibiotics, levodopa, levothyroxine, ibandronate. [6] Iron deficiency also occurs in chronic disease conditions like chronic kidney disease (CKD), chronic heart failure, inflammatory bowel disease, certain malignancies, and rheumatoid arthritis, etc. SLC11A2 mutation and IRIDA (iron refractory iron deficiency anemia) due to\u00a0TMPRSS6 mutation are rare inherited conditions associated with iron deficiency.", "contents": "Chronic Iron Deficiency -- Etiology. Malabsorption of iron occurs in\u00a0celiac disease, atrophic gastritis, Helicobacter pylori infection, and bariatric surgery. Reduced absorption of iron can also present in association with some dietary elements like\u00a0tannates, phosphates, phytates, oxalates, and calcium. Certain medications can interfere with iron absorption. Examples include gastric acid-suppressing drugs, antibiotics, levodopa, levothyroxine, ibandronate. [6] Iron deficiency also occurs in chronic disease conditions like chronic kidney disease (CKD), chronic heart failure, inflammatory bowel disease, certain malignancies, and rheumatoid arthritis, etc. SLC11A2 mutation and IRIDA (iron refractory iron deficiency anemia) due to\u00a0TMPRSS6 mutation are rare inherited conditions associated with iron deficiency."}
+{"id": "article-101758_9", "title": "Chronic Iron Deficiency -- Epidemiology", "content": "According to WHO\u2019s Global Burden of Disease Project 2000 (GBD 2000), iron deficiency is responsible for 841,000 deaths worldwide with the major burden of mortality seen in Africa and parts of Asia. [7]", "contents": "Chronic Iron Deficiency -- Epidemiology. According to WHO\u2019s Global Burden of Disease Project 2000 (GBD 2000), iron deficiency is responsible for 841,000 deaths worldwide with the major burden of mortality seen in Africa and parts of Asia. [7]"}
+{"id": "article-101758_10", "title": "Chronic Iron Deficiency -- Epidemiology", "content": "In the US, iron deficiency is seen in 9% of toddlers between ages 1 and 2 years. Compared to white toddlers, Hispanic toddlers are twice as likely to have an iron deficiency.\u00a0The prevalence in adolescent girls and women in the reproductive age group is between 9% to 11%. It is most common in multiparous women from low-income minority populations. In males, it is seen in around 1% of the population with a slightly higher prevalence of 2% to 4% in middle-aged and older men. [8] [5] There is a positive correlation between obesity and the risk of developing iron deficiency. [9]", "contents": "Chronic Iron Deficiency -- Epidemiology. In the US, iron deficiency is seen in 9% of toddlers between ages 1 and 2 years. Compared to white toddlers, Hispanic toddlers are twice as likely to have an iron deficiency.\u00a0The prevalence in adolescent girls and women in the reproductive age group is between 9% to 11%. It is most common in multiparous women from low-income minority populations. In males, it is seen in around 1% of the population with a slightly higher prevalence of 2% to 4% in middle-aged and older men. [8] [5] There is a positive correlation between obesity and the risk of developing iron deficiency. [9]"}
+{"id": "article-101758_11", "title": "Chronic Iron Deficiency -- Pathophysiology", "content": "The maintenance of iron homeostasis occurs via a balance of absorption and iron losses. Absorption in the small intestine is the primary regulating factor of iron content in the body. Iron is absorbed in divalent form by enterocytes via the divalent metal transporter (DMT1). Once absorbed, it is sequestered in ferritin if body stores are adequate. If iron levels are low, iron is bound to transferrin by ferroportin. Once loaded on to transferrin, iron is transported to cells for metabolism. Hepcidin is a peptide that inhibits ferroportin and decreases the absorption of iron into circulation. [10]", "contents": "Chronic Iron Deficiency -- Pathophysiology. The maintenance of iron homeostasis occurs via a balance of absorption and iron losses. Absorption in the small intestine is the primary regulating factor of iron content in the body. Iron is absorbed in divalent form by enterocytes via the divalent metal transporter (DMT1). Once absorbed, it is sequestered in ferritin if body stores are adequate. If iron levels are low, iron is bound to transferrin by ferroportin. Once loaded on to transferrin, iron is transported to cells for metabolism. Hepcidin is a peptide that inhibits ferroportin and decreases the absorption of iron into circulation. [10]"}
+{"id": "article-101758_12", "title": "Chronic Iron Deficiency -- Pathophysiology", "content": "Iron enters cells after transferrin binds to the transferrin receptor (TfR). Iron levels are further controlled by iron-regulatory proteins 1 and 2(IRP1 and IRP2), which optimize cellular iron availability by upregulating the expression of multiple genes. [11]", "contents": "Chronic Iron Deficiency -- Pathophysiology. Iron enters cells after transferrin binds to the transferrin receptor (TfR). Iron levels are further controlled by iron-regulatory proteins 1 and 2(IRP1 and IRP2), which optimize cellular iron availability by upregulating the expression of multiple genes. [11]"}
+{"id": "article-101758_13", "title": "Chronic Iron Deficiency -- Pathophysiology", "content": "Iron deficiency occurs in three stages. In the pre-latent stage, iron stores are low or absent, but serum iron concentration is normal. In the latent stage, transferrin saturation and serum iron become reduced in addition to low ferritin. The last stage is marked by a drop in hemoglobin along with depletion of iron stores and a reduction in serum iron and transferrin saturation. [12]", "contents": "Chronic Iron Deficiency -- Pathophysiology. Iron deficiency occurs in three stages. In the pre-latent stage, iron stores are low or absent, but serum iron concentration is normal. In the latent stage, transferrin saturation and serum iron become reduced in addition to low ferritin. The last stage is marked by a drop in hemoglobin along with depletion of iron stores and a reduction in serum iron and transferrin saturation. [12]"}
+{"id": "article-101758_14", "title": "Chronic Iron Deficiency -- History and Physical", "content": "The majority of symptoms are nonspecific, which can include but not limited to generalized weakness, fatigue, poor concentration, irritability, headaches, shortness of breath on exertion, and decreased exercise capacity.\u00a0These are attributable to low oxygen delivery to tissues and reduced activity of iron-containing enzymes.", "contents": "Chronic Iron Deficiency -- History and Physical. The majority of symptoms are nonspecific, which can include but not limited to generalized weakness, fatigue, poor concentration, irritability, headaches, shortness of breath on exertion, and decreased exercise capacity.\u00a0These are attributable to low oxygen delivery to tissues and reduced activity of iron-containing enzymes."}
+{"id": "article-101758_15", "title": "Chronic Iron Deficiency -- History and Physical", "content": "Pica occurs in approximately half of these patients, and pagophagia (craving for ice) is quite specific for iron deficiency. [13] Patients may have a history of dry mouth, hair loss, dysphagia, brittle fingernails, and restless leg syndrome.", "contents": "Chronic Iron Deficiency -- History and Physical. Pica occurs in approximately half of these patients, and pagophagia (craving for ice) is quite specific for iron deficiency. [13] Patients may have a history of dry mouth, hair loss, dysphagia, brittle fingernails, and restless leg syndrome."}
+{"id": "article-101758_16", "title": "Chronic Iron Deficiency -- History and Physical", "content": "Beeturia is a finding which is not specific for iron deficiency but is\u00a0more common in these individuals.\u00a0It is the result of a change in\u00a0gastrointestinal function due to severe iron deficiency. The urine turns red following the ingestion of beets. [14]", "contents": "Chronic Iron Deficiency -- History and Physical. Beeturia is a finding which is not specific for iron deficiency but is\u00a0more common in these individuals.\u00a0It is the result of a change in\u00a0gastrointestinal function due to severe iron deficiency. The urine turns red following the ingestion of beets. [14]"}
+{"id": "article-101758_17", "title": "Chronic Iron Deficiency -- History and Physical", "content": "The physical examination can be normal or may reveal dry skin, hair loss, atrophic glossitis, cheilosis, pallor, brittle nails, and koilonychia (spoon-shaped nails). Cardiac auscultation may reveal a systolic murmur. [15]", "contents": "Chronic Iron Deficiency -- History and Physical. The physical examination can be normal or may reveal dry skin, hair loss, atrophic glossitis, cheilosis, pallor, brittle nails, and koilonychia (spoon-shaped nails). Cardiac auscultation may reveal a systolic murmur. [15]"}
+{"id": "article-101758_18", "title": "Chronic Iron Deficiency -- Evaluation", "content": "The diagnosis of iron deficiency is based mainly on history, examination, and laboratory tests. In uncomplicated cases, serum iron, transferrin, ferritin, TIBC, and TSAT should be used for evaluation. Serum iron varies during the day and is influenced by diet. A fasting sample should be obtained in the morning. [12] Absolute iron deficiency is diagnosed when serum ferritin is less than 30 ng/mL. [16]", "contents": "Chronic Iron Deficiency -- Evaluation. The diagnosis of iron deficiency is based mainly on history, examination, and laboratory tests. In uncomplicated cases, serum iron, transferrin, ferritin, TIBC, and TSAT should be used for evaluation. Serum iron varies during the day and is influenced by diet. A fasting sample should be obtained in the morning. [12] Absolute iron deficiency is diagnosed when serum ferritin is less than 30 ng/mL. [16]"}
+{"id": "article-101758_19", "title": "Chronic Iron Deficiency -- Evaluation", "content": "TSAT is calculated as the ratio of serum iron to TIBC.\u00a0It is one of the earliest biomarkers of iron deficiency and is useful when serum ferritin is unequivocal. A decrease (less than 20%) indicates an iron deficiency, either absolute or functional. [15] [3] Hemoglobin does not become low until a significant percentage of body iron becomes depleted. Hence, normal hemoglobin does not exclude iron deficiency. Other iron studies available for the evaluation of iron deficiency are:", "contents": "Chronic Iron Deficiency -- Evaluation. TSAT is calculated as the ratio of serum iron to TIBC.\u00a0It is one of the earliest biomarkers of iron deficiency and is useful when serum ferritin is unequivocal. A decrease (less than 20%) indicates an iron deficiency, either absolute or functional. [15] [3] Hemoglobin does not become low until a significant percentage of body iron becomes depleted. Hence, normal hemoglobin does not exclude iron deficiency. Other iron studies available for the evaluation of iron deficiency are:"}
+{"id": "article-101758_20", "title": "Chronic Iron Deficiency -- Evaluation", "content": "Soluble transferrin receptor (sTfR) and sTfR-ferritin index - sTfR\u00a0is elevated in iron deficiency because of the upregulation of transferrin receptors. It can help differentiate between absolute (increased sTfR) and functional ID (normal sTfR). [3] [17] [3] Zinc protoporphyrin/heme ratio - Decreased iron supply for the formation of hemoglobin leads to increased utilization of zinc and an increase in the ZPP/H ratio; this is preferable to the invasive bone marrow aspiration. [17] Reticulocyte hemoglobin content - Provides an estimate of iron availability for RBC production over a few days before the test. Thus, it is a useful indicator of early iron deficiency, and sequential measurements can also help to guide response to parenteral iron therapy. Inflammation does not influence this parameter and is useful in determining iron status in patients with CKD. [17] [18]", "contents": "Chronic Iron Deficiency -- Evaluation. Soluble transferrin receptor (sTfR) and sTfR-ferritin index - sTfR\u00a0is elevated in iron deficiency because of the upregulation of transferrin receptors. It can help differentiate between absolute (increased sTfR) and functional ID (normal sTfR). [3] [17] [3] Zinc protoporphyrin/heme ratio - Decreased iron supply for the formation of hemoglobin leads to increased utilization of zinc and an increase in the ZPP/H ratio; this is preferable to the invasive bone marrow aspiration. [17] Reticulocyte hemoglobin content - Provides an estimate of iron availability for RBC production over a few days before the test. Thus, it is a useful indicator of early iron deficiency, and sequential measurements can also help to guide response to parenteral iron therapy. Inflammation does not influence this parameter and is useful in determining iron status in patients with CKD. [17] [18]"}
+{"id": "article-101758_21", "title": "Chronic Iron Deficiency -- Treatment / Management", "content": "Patients with uncomplicated iron deficiency without comorbidities should receive treatment with oral iron therapy. Oral iron is readily available, inexpensive, effective, safe, and convenient.\u00a0Some of the available formulations include ferrous sulfate, ferrous fumarate, and ferrous gluconate. High molecular weight dextran has been withdrawn due to a high frequency of serious anaphylactic reactions. [10]", "contents": "Chronic Iron Deficiency -- Treatment / Management. Patients with uncomplicated iron deficiency without comorbidities should receive treatment with oral iron therapy. Oral iron is readily available, inexpensive, effective, safe, and convenient.\u00a0Some of the available formulations include ferrous sulfate, ferrous fumarate, and ferrous gluconate. High molecular weight dextran has been withdrawn due to a high frequency of serious anaphylactic reactions. [10]"}
+{"id": "article-101758_22", "title": "Chronic Iron Deficiency -- Treatment / Management", "content": "Gastrointestinal (GI) side effects occur in up to 70% of the patients taking oral iron, leading to noncompliance with treatment.\u00a0GI symptoms can be minimized by the use of chelated forms of iron. Enteric-coated tablets lead to poor absorption and are not viable options. [16] [17] [19]", "contents": "Chronic Iron Deficiency -- Treatment / Management. Gastrointestinal (GI) side effects occur in up to 70% of the patients taking oral iron, leading to noncompliance with treatment.\u00a0GI symptoms can be minimized by the use of chelated forms of iron. Enteric-coated tablets lead to poor absorption and are not viable options. [16] [17] [19]"}
+{"id": "article-101758_23", "title": "Chronic Iron Deficiency -- Treatment / Management", "content": "Intravenous iron is available in many forms, such as ferric carboxymaltose, ferric gluconate, ferric/iron sucrose, ferumoxytol, and low-molecular-weight iron dextran. Response to\u00a0intravenous iron merits observation to establish the need for further supplementation six to eight weeks after initial iron replacement. [3]", "contents": "Chronic Iron Deficiency -- Treatment / Management. Intravenous iron is available in many forms, such as ferric carboxymaltose, ferric gluconate, ferric/iron sucrose, ferumoxytol, and low-molecular-weight iron dextran. Response to\u00a0intravenous iron merits observation to establish the need for further supplementation six to eight weeks after initial iron replacement. [3]"}
+{"id": "article-101758_24", "title": "Chronic Iron Deficiency -- Treatment / Management", "content": "There is a low risk of allergic reactions with all IV iron formulations. Premedication with antihistamines does not prevent infusion reactions and should not be given. Patients with a history of asthma or drug allergies should receive steroids before infusion.", "contents": "Chronic Iron Deficiency -- Treatment / Management. There is a low risk of allergic reactions with all IV iron formulations. Premedication with antihistamines does not prevent infusion reactions and should not be given. Patients with a history of asthma or drug allergies should receive steroids before infusion."}
+{"id": "article-101758_25", "title": "Chronic Iron Deficiency -- Treatment / Management", "content": "In pregnancy, oral iron is given as a supplement during the first trimester as the safety of IV iron in the first trimester remains unestablished. Generally, oral iron is given to pregnant women if they can tolerate it. Exceptions include women with severe anemia, women with Inflammatory Bowel Disease, and those who have undergone bariatric surgery. In these patients, IV iron is preferable. All IV forms have equal efficacy and safety except for some formulations of ferric gluconate, which utilize benzyl alcohol as a preservative and should be avoided because of the possibility of harm to the fetus.", "contents": "Chronic Iron Deficiency -- Treatment / Management. In pregnancy, oral iron is given as a supplement during the first trimester as the safety of IV iron in the first trimester remains unestablished. Generally, oral iron is given to pregnant women if they can tolerate it. Exceptions include women with severe anemia, women with Inflammatory Bowel Disease, and those who have undergone bariatric surgery. In these patients, IV iron is preferable. All IV forms have equal efficacy and safety except for some formulations of ferric gluconate, which utilize benzyl alcohol as a preservative and should be avoided because of the possibility of harm to the fetus."}
+{"id": "article-101758_26", "title": "Chronic Iron Deficiency -- Differential Diagnosis", "content": "The differential diagnoses for iron deficiency without anemia are broad as the majority of the symptoms are non-specific and seen in many other conditions. These can include causes of fatigue e.g., fibromyalgia, chronic fatigue syndrome, depression/mood disorders, chronic medical conditions, and hypothyroidism, etc. Differential diagnoses also include other causes of pica e.g., eating disorders, psychiatric conditions, malnutrition, and causes of restless legs syndrome-like neurological conditions and pregnancy.", "contents": "Chronic Iron Deficiency -- Differential Diagnosis. The differential diagnoses for iron deficiency without anemia are broad as the majority of the symptoms are non-specific and seen in many other conditions. These can include causes of fatigue e.g., fibromyalgia, chronic fatigue syndrome, depression/mood disorders, chronic medical conditions, and hypothyroidism, etc. Differential diagnoses also include other causes of pica e.g., eating disorders, psychiatric conditions, malnutrition, and causes of restless legs syndrome-like neurological conditions and pregnancy."}
+{"id": "article-101758_27", "title": "Chronic Iron Deficiency -- Prognosis", "content": "Iron deficiency is an easily treatable condition with excellent prognosis in uncomplicated cases with no comorbidities. If untreated, it is associated with significant morbidity and mortality, especially in older adults and those with underlying chronic medical conditions, e.g., heart failure, CKD. [1]", "contents": "Chronic Iron Deficiency -- Prognosis. Iron deficiency is an easily treatable condition with excellent prognosis in uncomplicated cases with no comorbidities. If untreated, it is associated with significant morbidity and mortality, especially in older adults and those with underlying chronic medical conditions, e.g., heart failure, CKD. [1]"}
+{"id": "article-101758_28", "title": "Chronic Iron Deficiency -- Complications", "content": "If untreated, iron deficiency is associated with significant cognitive impairment and poor quality of life.", "contents": "Chronic Iron Deficiency -- Complications. If untreated, iron deficiency is associated with significant cognitive impairment and poor quality of life."}
+{"id": "article-101758_29", "title": "Chronic Iron Deficiency -- Complications", "content": "During pregnancy, untreated iron deficiency can affect fetal brain maturation, cause low birth weight, and predispose the baby to develop iron deficiency. Maternal adverse outcomes include depression, increased risk of sepsis, and maternal mortality. [2] [20] In patients undergoing cardiac or abdominal surgery, preoperative iron deficiency correlates with poor outcomes. [16] In patients with heart failure, chronic iron deficiency shows an association with an increase in mortality.", "contents": "Chronic Iron Deficiency -- Complications. During pregnancy, untreated iron deficiency can affect fetal brain maturation, cause low birth weight, and predispose the baby to develop iron deficiency. Maternal adverse outcomes include depression, increased risk of sepsis, and maternal mortality. [2] [20] In patients undergoing cardiac or abdominal surgery, preoperative iron deficiency correlates with poor outcomes. [16] In patients with heart failure, chronic iron deficiency shows an association with an increase in mortality."}
+{"id": "article-101758_30", "title": "Chronic Iron Deficiency -- Deterrence and Patient Education", "content": "Patients should receive counsel regarding consuming iron-rich foods, fruits, and vegetables high in vitamin C. In babies born to iron deficient mothers, delayed umbilical cord clamping can be helpful in preventing iron deficiency in neonates. [20]", "contents": "Chronic Iron Deficiency -- Deterrence and Patient Education. Patients should receive counsel regarding consuming iron-rich foods, fruits, and vegetables high in vitamin C. In babies born to iron deficient mothers, delayed umbilical cord clamping can be helpful in preventing iron deficiency in neonates. [20]"}
+{"id": "article-101758_31", "title": "Chronic Iron Deficiency -- Deterrence and Patient Education", "content": "In infants, iron should be supplemented by iron-fortified cereal and formula after\u00a0six months of breastfeeding. Anti helminthic drugs should be given to children with parasitic infections. In areas where the prevalence of iron deficiency is high, women of the reproductive age group should take daily iron supplements. [10] [2]", "contents": "Chronic Iron Deficiency -- Deterrence and Patient Education. In infants, iron should be supplemented by iron-fortified cereal and formula after\u00a0six months of breastfeeding. Anti helminthic drugs should be given to children with parasitic infections. In areas where the prevalence of iron deficiency is high, women of the reproductive age group should take daily iron supplements. [10] [2]"}
+{"id": "article-101758_32", "title": "Chronic Iron Deficiency -- Pearls and Other Issues", "content": "Iron deficiency is a preventable condition. Screening can identify iron deficiency at an early stage and improve outcomes. It is reasonable to perform annual screening with CBC and iron studies in populations at high risk e.g., women with menorrhagia, low iron intake, or a history of iron deficiency. In general, women in the reproductive age group can be screened every five years with hemoglobin or hematocrit. It may be reasonable to screen men and postmenopausal women once or more frequently if any risk factors are present.", "contents": "Chronic Iron Deficiency -- Pearls and Other Issues. Iron deficiency is a preventable condition. Screening can identify iron deficiency at an early stage and improve outcomes. It is reasonable to perform annual screening with CBC and iron studies in populations at high risk e.g., women with menorrhagia, low iron intake, or a history of iron deficiency. In general, women in the reproductive age group can be screened every five years with hemoglobin or hematocrit. It may be reasonable to screen men and postmenopausal women once or more frequently if any risk factors are present."}
+{"id": "article-101758_33", "title": "Chronic Iron Deficiency -- Enhancing Healthcare Team Outcomes", "content": "Chronic iron deficiency is a global health problem. It is easy to overlook it as the presentation is often vague and nonspecific. In developing countries, inadequate dietary intake is the leading cause of chronic iron deficiency, whereas hemorrhage is the leading cause of chronic iron deficiency in developed nations. The causes of iron deficiency could be due to a variety of gynecological, obstetrical, metabolic, and gastrointestinal etiologies. The physical exam is often normal, and the cause cannot be determined without lab investigations.", "contents": "Chronic Iron Deficiency -- Enhancing Healthcare Team Outcomes. Chronic iron deficiency is a global health problem. It is easy to overlook it as the presentation is often vague and nonspecific. In developing countries, inadequate dietary intake is the leading cause of chronic iron deficiency, whereas hemorrhage is the leading cause of chronic iron deficiency in developed nations. The causes of iron deficiency could be due to a variety of gynecological, obstetrical, metabolic, and gastrointestinal etiologies. The physical exam is often normal, and the cause cannot be determined without lab investigations."}
+{"id": "article-101758_34", "title": "Chronic Iron Deficiency -- Enhancing Healthcare Team Outcomes", "content": "A primary care provider should always be involved in the care of the patient. It is important to consult a hematologist, OB/GYN, or a gastroenterologist as necessary. A dietician can play an essential role in the primary prevention of iron deficiency through diet adjustment.\u00a0Laboratory technologists have a vital role to play in diagnosing chronic iron deficiency. Pharmacists can help decide the appropriate oral or\u00a0intravenous iron formulations that best fit the patient's requirements. Nurses not only educate the patients but assist in administering treatment.\u00a0Effective collaboration and communication between healthcare professionals can ensure optimal outcomes in all patients. [Level\u00a05]", "contents": "Chronic Iron Deficiency -- Enhancing Healthcare Team Outcomes. A primary care provider should always be involved in the care of the patient. It is important to consult a hematologist, OB/GYN, or a gastroenterologist as necessary. A dietician can play an essential role in the primary prevention of iron deficiency through diet adjustment.\u00a0Laboratory technologists have a vital role to play in diagnosing chronic iron deficiency. Pharmacists can help decide the appropriate oral or\u00a0intravenous iron formulations that best fit the patient's requirements. Nurses not only educate the patients but assist in administering treatment.\u00a0Effective collaboration and communication between healthcare professionals can ensure optimal outcomes in all patients. [Level\u00a05]"}
+{"id": "article-101758_35", "title": "Chronic Iron Deficiency -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Chronic Iron Deficiency -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

statpearls/chunk/article-101816.jsonl

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+{"id": "article-101816_0", "title": "Histology, Osteoprogenitor Cells -- Introduction", "content": "Osteoprogenitor cells, also known as osteogenic cells, are stem cells in the bone that play a prodigal role in bone repair and growth (see Image. Cells in the Bone). [1] These cells are the precursors to the more specialized bone cells (osteocytes and osteoblasts) and reside in the bone marrow. Osteoprogenitor cells originate from infant mesenchymal cells and turn into spindle cells at the surface of matured bones. In developing bones, they appear more frequently and activate multifunctional stages to remodel the bones. The body loses the ability to synthesize or utilize more osteoprogenitor cells with age. Dysfunction of osteoprogenitor cells may delay ossification and lead to a spectrum of diseases such as dwarfism\u00a0and Kashin-Beck disease. [2]", "contents": "Histology, Osteoprogenitor Cells -- Introduction. Osteoprogenitor cells, also known as osteogenic cells, are stem cells in the bone that play a prodigal role in bone repair and growth (see Image. Cells in the Bone). [1] These cells are the precursors to the more specialized bone cells (osteocytes and osteoblasts) and reside in the bone marrow. Osteoprogenitor cells originate from infant mesenchymal cells and turn into spindle cells at the surface of matured bones. In developing bones, they appear more frequently and activate multifunctional stages to remodel the bones. The body loses the ability to synthesize or utilize more osteoprogenitor cells with age. Dysfunction of osteoprogenitor cells may delay ossification and lead to a spectrum of diseases such as dwarfism\u00a0and Kashin-Beck disease. [2]"}
+{"id": "article-101816_1", "title": "Histology, Osteoprogenitor Cells -- Structure", "content": "Osteoprogenitor cells are often referred to as preosteoblasts.\u00a0They can be present within the endosteum, the cellular layer of the periosteum, and the lining of the osteogenic cells. Osteoprogenitor cells exist as flattened spindle-shaped structures in matured bones that no longer display active bone remodeling or formation. They attach to the bone surface and\u00a0are called inactive osteoblasts during this period. In maturing bones, however, these cells appear in their largest form. During fetal development or high turnover periods\u00a0in adult osteogenesis, numerous osteoprogenitor cells function to give rise to osteoblasts. These structures display plump oval nuclei and emboldened abundant spindle-shaped cytoplasm at this stage, later converting to characteristic cuboidal active osteoblasts. [3] [4]", "contents": "Histology, Osteoprogenitor Cells -- Structure. Osteoprogenitor cells are often referred to as preosteoblasts.\u00a0They can be present within the endosteum, the cellular layer of the periosteum, and the lining of the osteogenic cells. Osteoprogenitor cells exist as flattened spindle-shaped structures in matured bones that no longer display active bone remodeling or formation. They attach to the bone surface and\u00a0are called inactive osteoblasts during this period. In maturing bones, however, these cells appear in their largest form. During fetal development or high turnover periods\u00a0in adult osteogenesis, numerous osteoprogenitor cells function to give rise to osteoblasts. These structures display plump oval nuclei and emboldened abundant spindle-shaped cytoplasm at this stage, later converting to characteristic cuboidal active osteoblasts. [3] [4]"}
+{"id": "article-101816_2", "title": "Histology, Osteoprogenitor Cells -- Function", "content": "Osteoprogenitors can self-proliferate and self-renew. They participate in osteogenic differentiation and play a role in regulating angiogenesis. [5] Osteoprogenitor cells can differentiate into osteoblasts through mitotic division or by dividing into\u00a02 stem cells via a highly regulated mechanism,\u00a0which remains static during the proliferation process. After DNA synthesis and cell expansion, the cell retains its original genetic information. The endocrine system and local factors (growth factors and cytokines) mainly regulate osteogenesis.", "contents": "Histology, Osteoprogenitor Cells -- Function. Osteoprogenitors can self-proliferate and self-renew. They participate in osteogenic differentiation and play a role in regulating angiogenesis. [5] Osteoprogenitor cells can differentiate into osteoblasts through mitotic division or by dividing into\u00a02 stem cells via a highly regulated mechanism,\u00a0which remains static during the proliferation process. After DNA synthesis and cell expansion, the cell retains its original genetic information. The endocrine system and local factors (growth factors and cytokines) mainly regulate osteogenesis."}
+{"id": "article-101816_3", "title": "Histology, Osteoprogenitor Cells -- Function", "content": "Neuropeptide Y is a potent regulator of osteogenesis, and recent studies have confirmed that osteoprogenitor cells originating from hypothalamic Y2-/- mice have enhanced osteogenic activities. [6] Proline-rich tyrosine kinase 2 supposedly regulates the differentiation of early osteoprogenitors, and proline-rich tyrosine kinase 2 inhibitors promote osteogenesis and could act as a treatment for osteoporosis. [7] Osteoprogenitor cells also reside in the perichondrium. These osteoprogenitors hyper-regulate bone morphogenetic proteins during differentiation into mature osteoblasts and are responsible for the production of bone matrix. [8]", "contents": "Histology, Osteoprogenitor Cells -- Function. Neuropeptide Y is a potent regulator of osteogenesis, and recent studies have confirmed that osteoprogenitor cells originating from hypothalamic Y2-/- mice have enhanced osteogenic activities. [6] Proline-rich tyrosine kinase 2 supposedly regulates the differentiation of early osteoprogenitors, and proline-rich tyrosine kinase 2 inhibitors promote osteogenesis and could act as a treatment for osteoporosis. [7] Osteoprogenitor cells also reside in the perichondrium. These osteoprogenitors hyper-regulate bone morphogenetic proteins during differentiation into mature osteoblasts and are responsible for the production of bone matrix. [8]"}
+{"id": "article-101816_4", "title": "Histology, Osteoprogenitor Cells -- Tissue Preparation", "content": "Bone marrow stromal cells (BMSCs) yield testable osteoprogenitors. The cell samples are diluted with phosphate-buffered saline (PBS) at a ratio of 1:3, and then nucleated cells are isolated with a density gradient solution. Preparatory phase complete medium (CM) consists of\u00a0 0.1 mmol/L nonessential amino acids, alpha-MEM with 10% fetal bovine serum, 4.5 mg/mL d-glucose, 1 mmol/L sodium pyruvate, 100 U/mL penicillin, 100 mmol/L HEPES buffer, 100 \u03bcg/mL streptomycin, and 0.29 mg/mL l-glutamine. [9]", "contents": "Histology, Osteoprogenitor Cells -- Tissue Preparation. Bone marrow stromal cells (BMSCs) yield testable osteoprogenitors. The cell samples are diluted with phosphate-buffered saline (PBS) at a ratio of 1:3, and then nucleated cells are isolated with a density gradient solution. Preparatory phase complete medium (CM) consists of\u00a0 0.1 mmol/L nonessential amino acids, alpha-MEM with 10% fetal bovine serum, 4.5 mg/mL d-glucose, 1 mmol/L sodium pyruvate, 100 U/mL penicillin, 100 mmol/L HEPES buffer, 100 \u03bcg/mL streptomycin, and 0.29 mg/mL l-glutamine. [9]"}
+{"id": "article-101816_5", "title": "Histology, Osteoprogenitor Cells -- Tissue Preparation", "content": "The collected nucleated cells are plated at 100,000 cells/cm^2 density in supplemented CM. The CM supplement requires an additional 5 ng/mL fibroblast growth factor-2 (GF2) and 10 nmol/L dexamethasones; both elements proliferate osteogenic commitment of bone marrow stromal cells. The supplemental process undergoes humidification at 37 degrees C in a 5% CO2 incubator. [10]", "contents": "Histology, Osteoprogenitor Cells -- Tissue Preparation. The collected nucleated cells are plated at 100,000 cells/cm^2 density in supplemented CM. The CM supplement requires an additional 5 ng/mL fibroblast growth factor-2 (GF2) and 10 nmol/L dexamethasones; both elements proliferate osteogenic commitment of bone marrow stromal cells. The supplemental process undergoes humidification at 37 degrees C in a 5% CO2 incubator. [10]"}
+{"id": "article-101816_6", "title": "Histology, Osteoprogenitor Cells -- Histochemistry and Cytochemistry", "content": "Several research groups have studied the development of osteoprogenitor cells. A study suggests that the perichondrial Thy-1\u2013positive cells demonstrate potential osteogenic activity and participate in osteoblast formation during endochondral ossification. Another study shows intense alkaline phosphatase activity\u00a02 weeks after osteogenic induction and the presence of mineralized nodules. The expression of bone sialoprotein, dentin matrix protein-1, and osteocalcin increases due to ALP proliferation. As confirmed by flow cytometry, 55 to 65% of cells display the cell-surface markers Sca1+ and Thy1+ in vitro expansion for an alpha-SMA-GFP positive population. The alpha-SMA\u2013GFP-positive population also exhibits higher proliferative and osteogenic probabilities compared to an alpha-SMA\u2013GFP-negative population. [8] [11]", "contents": "Histology, Osteoprogenitor Cells -- Histochemistry and Cytochemistry. Several research groups have studied the development of osteoprogenitor cells. A study suggests that the perichondrial Thy-1\u2013positive cells demonstrate potential osteogenic activity and participate in osteoblast formation during endochondral ossification. Another study shows intense alkaline phosphatase activity\u00a02 weeks after osteogenic induction and the presence of mineralized nodules. The expression of bone sialoprotein, dentin matrix protein-1, and osteocalcin increases due to ALP proliferation. As confirmed by flow cytometry, 55 to 65% of cells display the cell-surface markers Sca1+ and Thy1+ in vitro expansion for an alpha-SMA-GFP positive population. The alpha-SMA\u2013GFP-positive population also exhibits higher proliferative and osteogenic probabilities compared to an alpha-SMA\u2013GFP-negative population. [8] [11]"}
+{"id": "article-101816_7", "title": "Histology, Osteoprogenitor Cells -- Microscopy, Light", "content": "Final visualization of osteoprogenitor cells under the microscope involves a delicate preparation phase: the explants are fixed in 4% buffered formalin for\u00a01 whole day, and samples are decalcified with 0.5 mol/L ethylenediaminetetraacetic acid (pH 8) for 7 to 10 days. The samples are deposited in paraffin, and the cross-sections of the samples are prepared with 5 um thickness at\u00a03 different strata. [12]", "contents": "Histology, Osteoprogenitor Cells -- Microscopy, Light. Final visualization of osteoprogenitor cells under the microscope involves a delicate preparation phase: the explants are fixed in 4% buffered formalin for\u00a01 whole day, and samples are decalcified with 0.5 mol/L ethylenediaminetetraacetic acid (pH 8) for 7 to 10 days. The samples are deposited in paraffin, and the cross-sections of the samples are prepared with 5 um thickness at\u00a03 different strata. [12]"}
+{"id": "article-101816_8", "title": "Histology, Osteoprogenitor Cells -- Microscopy, Light", "content": "The samples are stained with hematoxylin/eosin and Masson/Trichrome, and both a qualitative exam for the presence of bone tissue and a quantitative exam by computerized bone histomorphometry is conducted. For each hematoxylin/eosin-stained cross-section, 3 or 4 images (adequate to fill the construct cross-sections) are required to calculate the bone tissue area and available area for tissue ingrowth (net implant area - undegraded scaffold area) by digital imaging analysis. Under the scanning electron microscopy (SEM) visuals, the red color in the slides indicates that the Masson/Trichrome stains indicate lamellar and remodeled bone, while the blue color shows freshly deposited and immature bone. [9]", "contents": "Histology, Osteoprogenitor Cells -- Microscopy, Light. The samples are stained with hematoxylin/eosin and Masson/Trichrome, and both a qualitative exam for the presence of bone tissue and a quantitative exam by computerized bone histomorphometry is conducted. For each hematoxylin/eosin-stained cross-section, 3 or 4 images (adequate to fill the construct cross-sections) are required to calculate the bone tissue area and available area for tissue ingrowth (net implant area - undegraded scaffold area) by digital imaging analysis. Under the scanning electron microscopy (SEM) visuals, the red color in the slides indicates that the Masson/Trichrome stains indicate lamellar and remodeled bone, while the blue color shows freshly deposited and immature bone. [9]"}
+{"id": "article-101816_9", "title": "Histology, Osteoprogenitor Cells -- Pathophysiology", "content": "Bone tumors are formed within osteoprogenitor or stromal cell lineage during Paget disease (PD), which likely derive from genetic alterations related to familial Paget\u2019s disease. During Paget\u2019s disease, the endosteal surface undergoes active remodeling, and abnormal osteoclasts bearing nuclear inclusions occur. The fibrotic tissues in bone biopsies from PD patients are considered to be made of surplus elongated, sophisticatedly branched stromal cells that display high alkaline phosphatase levels; these cells are similar to the pre-osteogenic stromal cells located within the normal bone marrow. [13]", "contents": "Histology, Osteoprogenitor Cells -- Pathophysiology. Bone tumors are formed within osteoprogenitor or stromal cell lineage during Paget disease (PD), which likely derive from genetic alterations related to familial Paget\u2019s disease. During Paget\u2019s disease, the endosteal surface undergoes active remodeling, and abnormal osteoclasts bearing nuclear inclusions occur. The fibrotic tissues in bone biopsies from PD patients are considered to be made of surplus elongated, sophisticatedly branched stromal cells that display high alkaline phosphatase levels; these cells are similar to the pre-osteogenic stromal cells located within the normal bone marrow. [13]"}
+{"id": "article-101816_10", "title": "Histology, Osteoprogenitor Cells -- Pathophysiology", "content": "Early and full-blown pagetic lesions show dynamic transformations in the arrangement, number, and function of stromal cells within endosteal/medullary tissue. An excessive amount of bone marrow osteoprogenitor cells in pagetic lesion areas verify earlier data on static and dynamic histomorphometry in patients with Paget\u2019s disease. Previous data revealed that the rate of osteogenesis increases during Paget disease, but research has confirmed that there is also a surge in the birthrate of osteoblasts. [14]", "contents": "Histology, Osteoprogenitor Cells -- Pathophysiology. Early and full-blown pagetic lesions show dynamic transformations in the arrangement, number, and function of stromal cells within endosteal/medullary tissue. An excessive amount of bone marrow osteoprogenitor cells in pagetic lesion areas verify earlier data on static and dynamic histomorphometry in patients with Paget\u2019s disease. Previous data revealed that the rate of osteogenesis increases during Paget disease, but research has confirmed that there is also a surge in the birthrate of osteoblasts. [14]"}
+{"id": "article-101816_11", "title": "Histology, Osteoprogenitor Cells -- Pathophysiology", "content": "The quality of the new bones depends on nature and hypermineralization. Most stromal/osteoblastic abnormalities result from bone mass increment, characterized by denser and thicker trabecular structures. Another characteristic is compromised mechanical integrity caused by poor architectural organization and transformations within the mineralized matrix material. [15]", "contents": "Histology, Osteoprogenitor Cells -- Pathophysiology. The quality of the new bones depends on nature and hypermineralization. Most stromal/osteoblastic abnormalities result from bone mass increment, characterized by denser and thicker trabecular structures. Another characteristic is compromised mechanical integrity caused by poor architectural organization and transformations within the mineralized matrix material. [15]"}
+{"id": "article-101816_12", "title": "Histology, Osteoprogenitor Cells -- Clinical Significance", "content": "Mesenchymal stem cells (MSCs) collected from adipose and bone marrow tissue hold therapeutic value for various bone disease treatments. Current studies demonstrate the benefit of bone grafts based on combinations of MSC, biomimetic scaffolds, and growth factor delivery, which showed an increased osteogenic regeneration rate with minimal side effects. The specific mechanisms of cellular signaling in bone remodeling are essential in understanding the incorporation of newer effective treatment methods for numerous bone diseases. [16]", "contents": "Histology, Osteoprogenitor Cells -- Clinical Significance. Mesenchymal stem cells (MSCs) collected from adipose and bone marrow tissue hold therapeutic value for various bone disease treatments. Current studies demonstrate the benefit of bone grafts based on combinations of MSC, biomimetic scaffolds, and growth factor delivery, which showed an increased osteogenic regeneration rate with minimal side effects. The specific mechanisms of cellular signaling in bone remodeling are essential in understanding the incorporation of newer effective treatment methods for numerous bone diseases. [16]"}
+{"id": "article-101816_13", "title": "Histology, Osteoprogenitor Cells -- Clinical Significance", "content": "Various transplant therapies involving osteogenic autologous bone grafts are less frequently used; patient-specific cell therapies involving autologous BM-MNCs (bone marrow mononuclear cells) composed of stem cells, monocytes, lymphocytes, and dendritic cells are rising in popularity for bone pathology treatments. All patients suffering from long-bone pseudoarthrosis attained full bone consolidation when treated with autologous BM-MNCs and allogeneic cancellous bone grafts. Bone marrow aspirate utilized during osteonecrosis treatment via minimally invasive decompression of the femoral head decreased disease progress and yielded overall pain and symptom relief. Bone marrow concentrated injections lead to better osteogenic unions, resulting in complete recovery in post-operative achondroplastic dwarf patients within 2\u00a0to 10 months after femoral lightning surgeries. Intravenous BMC injections, mixed with iloprost, proliferate fracture healing in patients with avascular necrosis. Patients receiving Intra-articular BMNc displayed better chewing and maximum interincisal opening with integral pain relief. [17] [16]", "contents": "Histology, Osteoprogenitor Cells -- Clinical Significance. Various transplant therapies involving osteogenic autologous bone grafts are less frequently used; patient-specific cell therapies involving autologous BM-MNCs (bone marrow mononuclear cells) composed of stem cells, monocytes, lymphocytes, and dendritic cells are rising in popularity for bone pathology treatments. All patients suffering from long-bone pseudoarthrosis attained full bone consolidation when treated with autologous BM-MNCs and allogeneic cancellous bone grafts. Bone marrow aspirate utilized during osteonecrosis treatment via minimally invasive decompression of the femoral head decreased disease progress and yielded overall pain and symptom relief. Bone marrow concentrated injections lead to better osteogenic unions, resulting in complete recovery in post-operative achondroplastic dwarf patients within 2\u00a0to 10 months after femoral lightning surgeries. Intravenous BMC injections, mixed with iloprost, proliferate fracture healing in patients with avascular necrosis. Patients receiving Intra-articular BMNc displayed better chewing and maximum interincisal opening with integral pain relief. [17] [16]"}
+{"id": "article-101816_14", "title": "Histology, Osteoprogenitor Cells -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Histology, Osteoprogenitor Cells -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

statpearls/chunk/article-101818.jsonl

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+{"id": "article-101818_0", "title": "Histology, Osteocytes -- Introduction", "content": "Osteocytes are one of the four kinds of bone cells. Due to derivation from osteoblasts, these cells are highly specialized in nature and are responsible for the maintenance of the bony matrix. Specially built with innate proteins that help them to survive in hypoxic conditions, osteocytes maintain biomineralization. Not only do osteocytes contribute to bone mass via controlling osteoblast and osteoclast activity, but these cells act as main players in phosphate metabolism. Osteocytic necrosis is caused due to pathologic conditions such as osteoarthritis and osteoporosis, leading to developing skeletal fragility and dysfunctional signal repair and/or microdamage. Immobilization-induced hypoxia and glucocorticoid treatment may also lead to osteocytic necrosis or apoptosis. Osteocytes react to implant biomaterials in dynamic ways and are currently under active stem-cell research for trauma care and bone remodeling purposes. [1]", "contents": "Histology, Osteocytes -- Introduction. Osteocytes are one of the four kinds of bone cells. Due to derivation from osteoblasts, these cells are highly specialized in nature and are responsible for the maintenance of the bony matrix. Specially built with innate proteins that help them to survive in hypoxic conditions, osteocytes maintain biomineralization. Not only do osteocytes contribute to bone mass via controlling osteoblast and osteoclast activity, but these cells act as main players in phosphate metabolism. Osteocytic necrosis is caused due to pathologic conditions such as osteoarthritis and osteoporosis, leading to developing skeletal fragility and dysfunctional signal repair and/or microdamage. Immobilization-induced hypoxia and glucocorticoid treatment may also lead to osteocytic necrosis or apoptosis. Osteocytes react to implant biomaterials in dynamic ways and are currently under active stem-cell research for trauma care and bone remodeling purposes. [1]"}
+{"id": "article-101818_1", "title": "Histology, Osteocytes -- Structure", "content": "Osteocyte resides within the lacunae located between the lamellae of the matrix. Each lacuna consists of one osteocyte. Osteocytes are flat, almond-shaped in the structure; they have a depth of about 7 micrometers and length of about 15 micrometers. The cell body diameter ranges from 5 to 20 micrometers and may obtain 40\u00a0to 60 processes per cell within a cellular distance of 20 to 30 micrometers. A mature osteocyte holds a single nucleus, which has a membrane and one or two nucleoli. The nucleus usually exists toward the vascular side of the surface. These cells exhibit a predominantly reduced Golgi complex and rough endoplasmic reticulum. These specialized structures also exhibit a more condensed nuclear chromatin. Osteocytes compose an extensive connecting syncytial network with small dendritic, or cytoplasmic, processes taking place in canaliculi. Osteocytes have expanded longevity and are long-living by nature. [2] [3]", "contents": "Histology, Osteocytes -- Structure. Osteocyte resides within the lacunae located between the lamellae of the matrix. Each lacuna consists of one osteocyte. Osteocytes are flat, almond-shaped in the structure; they have a depth of about 7 micrometers and length of about 15 micrometers. The cell body diameter ranges from 5 to 20 micrometers and may obtain 40\u00a0to 60 processes per cell within a cellular distance of 20 to 30 micrometers. A mature osteocyte holds a single nucleus, which has a membrane and one or two nucleoli. The nucleus usually exists toward the vascular side of the surface. These cells exhibit a predominantly reduced Golgi complex and rough endoplasmic reticulum. These specialized structures also exhibit a more condensed nuclear chromatin. Osteocytes compose an extensive connecting syncytial network with small dendritic, or cytoplasmic, processes taking place in canaliculi. Osteocytes have expanded longevity and are long-living by nature. [2] [3]"}
+{"id": "article-101818_2", "title": "Histology, Osteocytes -- Function", "content": "Nutrient exchange involving osteocytes may nourish a chain of approximately 15 cells. Processes involving adjacent cells allow contact with gap junctions; molecules pass intracellularly via these structures. The small amount of extracellular substance between the bone matrix and osteocytes may instigate a few molecular exchanges between blood vessels and osteocytes. Osteocytes are actively involved in the perseverance of the bony matrix; osteocytic necrosis leads to resorption of the bony matrix. Despite their inert qualities, osteocytes perform molecular modification and synthesis along with signal transmission over long distances. After a bone fracture, for instance, osteocytic glutamate transporters compose nerve growth factors, proving their ability to sense and transfer information. Matured osteocytes are the most common cells in bone tissues, and the majority of receptor activities involved with bone function are available in these cells. Osteocytic necrosis also leads to trabecular bone decay, decreased bone formation, and malfunctioning loading.", "contents": "Histology, Osteocytes -- Function. Nutrient exchange involving osteocytes may nourish a chain of approximately 15 cells. Processes involving adjacent cells allow contact with gap junctions; molecules pass intracellularly via these structures. The small amount of extracellular substance between the bone matrix and osteocytes may instigate a few molecular exchanges between blood vessels and osteocytes. Osteocytes are actively involved in the perseverance of the bony matrix; osteocytic necrosis leads to resorption of the bony matrix. Despite their inert qualities, osteocytes perform molecular modification and synthesis along with signal transmission over long distances. After a bone fracture, for instance, osteocytic glutamate transporters compose nerve growth factors, proving their ability to sense and transfer information. Matured osteocytes are the most common cells in bone tissues, and the majority of receptor activities involved with bone function are available in these cells. Osteocytic necrosis also leads to trabecular bone decay, decreased bone formation, and malfunctioning loading."}
+{"id": "article-101818_3", "title": "Histology, Osteocytes -- Function", "content": "Osteocytes also control osteoblastic and osteoclastic activities within a basic multicellular unit (BMU), a transient anatomic structure for insulating bone remodeling. Osteocytic proteins like sclerostin contribute to mineral metabolism aside from other molecules such as\u00a0 MEPE, FGF-23, PHEX, and DMP-1, which help to regulate phosphate and biomineralization. Osteocytes also regulate bone mass and act as an essential endocrine regulator of phosphate metabolism. [4] [5] [6]", "contents": "Histology, Osteocytes -- Function. Osteocytes also control osteoblastic and osteoclastic activities within a basic multicellular unit (BMU), a transient anatomic structure for insulating bone remodeling. Osteocytic proteins like sclerostin contribute to mineral metabolism aside from other molecules such as\u00a0 MEPE, FGF-23, PHEX, and DMP-1, which help to regulate phosphate and biomineralization. Osteocytes also regulate bone mass and act as an essential endocrine regulator of phosphate metabolism. [4] [5] [6]"}
+{"id": "article-101818_4", "title": "Histology, Osteocytes -- Tissue Preparation", "content": "Medical scientists typically use trabecular bone samples from the anterior iliac crest, as this sample can be collected from healthy patients as surgical waste material from procedures like the sinus floor elevation surgery. Creating human osteocyte culture is a tedious process: firstly, researchers collect the sample in sterile phosphate-based saline (PBS) with antimicrobial agents. They wash the biopsy materials three times using phosphate-buffered saline and then allocate the biopsy samples to a petri dish. They use a 23 scalpel to fragment the trabecular bone from the original sample in a PBS-treated petri dish.", "contents": "Histology, Osteocytes -- Tissue Preparation. Medical scientists typically use trabecular bone samples from the anterior iliac crest, as this sample can be collected from healthy patients as surgical waste material from procedures like the sinus floor elevation surgery. Creating human osteocyte culture is a tedious process: firstly, researchers collect the sample in sterile phosphate-based saline (PBS) with antimicrobial agents. They wash the biopsy materials three times using phosphate-buffered saline and then allocate the biopsy samples to a petri dish. They use a 23 scalpel to fragment the trabecular bone from the original sample in a PBS-treated petri dish."}
+{"id": "article-101818_5", "title": "Histology, Osteocytes -- Tissue Preparation", "content": "Afterward, they use a 10 blade to divide the trabecular bone pieces into 1\u00a0to 2 mm square samples. In serum-free DMEM, they make 2 mg ml^\u22121 collagenase II solution and filter the solution with a 0.2 um filter unit. They place the bone fragments inside a 50 ml centrifuge tube, which is premixed with collagenase II and mix properly. They incubate those fragments using collagenase II for two hours at 37 degrees C inside a rocking water bath to clean any existing adhering cells on top of the bone surfaces. They then wash those samples with DMEM consisting of 10% serum made off fetal Clone I.", "contents": "Histology, Osteocytes -- Tissue Preparation. Afterward, they use a 10 blade to divide the trabecular bone pieces into 1\u00a0to 2 mm square samples. In serum-free DMEM, they make 2 mg ml^\u22121 collagenase II solution and filter the solution with a 0.2 um filter unit. They place the bone fragments inside a 50 ml centrifuge tube, which is premixed with collagenase II and mix properly. They incubate those fragments using collagenase II for two hours at 37 degrees C inside a rocking water bath to clean any existing adhering cells on top of the bone surfaces. They then wash those samples with DMEM consisting of 10% serum made off fetal Clone I."}
+{"id": "article-101818_6", "title": "Histology, Osteocytes -- Tissue Preparation", "content": "A subdivision phase follows: they submerge the bone samples into another petri dish; they then divide them into equal sections weighing about 100 mg. They transfer those portions into wells of a culture plate (12 wells suggested); the samples are treated with cCM. After incubating the samples at 37 degrees C with 5% CO2 overnight, they wash the samples with PBS 4\u00a0or 5 times the next day, followed by a repetition of the overnight treatments. The medium is replenished twice a week, and the process continues for seven days. At the preparation period, the scientists continue to add cytokines, hormones, chemicals, etc. into the osteocytic culture; osteocytic signaling factors are also measured in this modified culture medium. The additional analysis derives from the collection of total RNA from the samples using triazole. [7]", "contents": "Histology, Osteocytes -- Tissue Preparation. A subdivision phase follows: they submerge the bone samples into another petri dish; they then divide them into equal sections weighing about 100 mg. They transfer those portions into wells of a culture plate (12 wells suggested); the samples are treated with cCM. After incubating the samples at 37 degrees C with 5% CO2 overnight, they wash the samples with PBS 4\u00a0or 5 times the next day, followed by a repetition of the overnight treatments. The medium is replenished twice a week, and the process continues for seven days. At the preparation period, the scientists continue to add cytokines, hormones, chemicals, etc. into the osteocytic culture; osteocytic signaling factors are also measured in this modified culture medium. The additional analysis derives from the collection of total RNA from the samples using triazole. [7]"}
+{"id": "article-101818_7", "title": "Histology, Osteocytes -- Histochemistry and Cytochemistry", "content": "Internal osteocytic histochemical design is still under active research; scientists generated a few hypotheses. The first theory suggests that osteocytic enzymatic reactions occur due to the artifactual diffusion of TRAP\u2019s (Type 5 tartrate-resistant acid phosphatase) histochemical reaction yields from the actual reaction site (bone-resorbing surface). A second theory suggests that the enzyme reactions are not histochemical diffusion artifacts but true reactions that display TRAP proteins in osteocytes; by this hypothesis, the scientists proposed that the proteins diffuse from the bone-resorbing surface via the bone canaliculi under physiological treatments in vivo.", "contents": "Histology, Osteocytes -- Histochemistry and Cytochemistry. Internal osteocytic histochemical design is still under active research; scientists generated a few hypotheses. The first theory suggests that osteocytic enzymatic reactions occur due to the artifactual diffusion of TRAP\u2019s (Type 5 tartrate-resistant acid phosphatase) histochemical reaction yields from the actual reaction site (bone-resorbing surface). A second theory suggests that the enzyme reactions are not histochemical diffusion artifacts but true reactions that display TRAP proteins in osteocytes; by this hypothesis, the scientists proposed that the proteins diffuse from the bone-resorbing surface via the bone canaliculi under physiological treatments in vivo."}
+{"id": "article-101818_8", "title": "Histology, Osteocytes -- Histochemistry and Cytochemistry", "content": "A final hypothesis indicates that osteocytic enzymatic reactions directly show the TRAP enzyme proteins produced by the respective osteocytes. While all of the proposed hypotheses are under study, one investigation strongly suggests that osteocytes in proximal areas to bone resorption surface create TRAP proteins and display histochemical TRAP reactions taking place within cytoplasmic granular structures. The probable TRAP protein diffusion deriving from osteoclasts via bone canaliculi to the TRAP-positive osteocytes is significant. [8] [9]", "contents": "Histology, Osteocytes -- Histochemistry and Cytochemistry. A final hypothesis indicates that osteocytic enzymatic reactions directly show the TRAP enzyme proteins produced by the respective osteocytes. While all of the proposed hypotheses are under study, one investigation strongly suggests that osteocytes in proximal areas to bone resorption surface create TRAP proteins and display histochemical TRAP reactions taking place within cytoplasmic granular structures. The probable TRAP protein diffusion deriving from osteoclasts via bone canaliculi to the TRAP-positive osteocytes is significant. [8] [9]"}
+{"id": "article-101818_9", "title": "Histology, Osteocytes -- Microscopy, Light", "content": "The visualization of sclerostin confirms the presence of osteocytes in the bone pieces. On day 7, researchers fix bone samples in cold 4% phosphate-buffered formaldehyde. They dehydrate the samples in graded ethanol by repeating the incubation process in 100% ethanol at least twice; methylmethacrylate mixture emission follows the incubation procedure. They cut the samples with Leica/Reichert-Jung Polycut S (SM2500) microtome into 5 um pieces. The researchers rehydrate the sections and douse the endogenous peroxidase with about 3% H2O2 in 40% methanol in PBS. They proceed to incubate the samples with 1% trypsin for 15 min at 37 \u00b0C to retrieve antigen. They incubate the bones with a 3-amino-9-ethylcarbazole reagent to develop a color visualization and counterstain the samples with hematoxylin. They visualize the sclerostin staining under preferred light microscopes, such as a Zeiss Apotome 2 microscope. [7]", "contents": "Histology, Osteocytes -- Microscopy, Light. The visualization of sclerostin confirms the presence of osteocytes in the bone pieces. On day 7, researchers fix bone samples in cold 4% phosphate-buffered formaldehyde. They dehydrate the samples in graded ethanol by repeating the incubation process in 100% ethanol at least twice; methylmethacrylate mixture emission follows the incubation procedure. They cut the samples with Leica/Reichert-Jung Polycut S (SM2500) microtome into 5 um pieces. The researchers rehydrate the sections and douse the endogenous peroxidase with about 3% H2O2 in 40% methanol in PBS. They proceed to incubate the samples with 1% trypsin for 15 min at 37 \u00b0C to retrieve antigen. They incubate the bones with a 3-amino-9-ethylcarbazole reagent to develop a color visualization and counterstain the samples with hematoxylin. They visualize the sclerostin staining under preferred light microscopes, such as a Zeiss Apotome 2 microscope. [7]"}
+{"id": "article-101818_10", "title": "Histology, Osteocytes -- Pathophysiology", "content": "Degraded or malfunctioning osteocytes may lead to various pathological conditions, such as hypophosphatemic rickets, sclerosteosis, and necrotic bone. Autosomal recessive hypophosphatemic rickets (ARHR) type 1 happens because of a lack of function mutations in dentin matrix protein 1, a type of noncollagenous bone matrix protein found in osteocytes and pre-osteocytic osteoblasts. This protein contributes to osteocyte proliferation and FGF23 downregulation. ARHR 2 happens because of a lack of function mutations in ectonucleotide pyrophosphatase/phosphodiesterase 1 (ENPP1); ENPP1 produces inorganic pyrophosphate (PPi), a crucial calcification inhibitor, and is related to ectopic calcification disorders in some cases.", "contents": "Histology, Osteocytes -- Pathophysiology. Degraded or malfunctioning osteocytes may lead to various pathological conditions, such as hypophosphatemic rickets, sclerosteosis, and necrotic bone. Autosomal recessive hypophosphatemic rickets (ARHR) type 1 happens because of a lack of function mutations in dentin matrix protein 1, a type of noncollagenous bone matrix protein found in osteocytes and pre-osteocytic osteoblasts. This protein contributes to osteocyte proliferation and FGF23 downregulation. ARHR 2 happens because of a lack of function mutations in ectonucleotide pyrophosphatase/phosphodiesterase 1 (ENPP1); ENPP1 produces inorganic pyrophosphate (PPi), a crucial calcification inhibitor, and is related to ectopic calcification disorders in some cases."}
+{"id": "article-101818_11", "title": "Histology, Osteocytes -- Pathophysiology", "content": "SOST codes for a specific protein known as the 190-residue glycoprotein sclerostin, which is mainly released by osteocytes. Sclerostin is an osteogenesis inhibitor that suppresses the canonical Wnt signaling pathway within osteoblast lineage cells. Sclerostin articulates to Wnt-signaling coreceptors LRP5 and LRP6, blockading Wnt particle articulation to those receptors. Sclerosteosis, caused by a decreased sclerostin expression, results in less restrained osteogenesis, leading to progressive hyperostosis. Sclerostin, therefore, relies on its coreceptor, LRP4.", "contents": "Histology, Osteocytes -- Pathophysiology. SOST codes for a specific protein known as the 190-residue glycoprotein sclerostin, which is mainly released by osteocytes. Sclerostin is an osteogenesis inhibitor that suppresses the canonical Wnt signaling pathway within osteoblast lineage cells. Sclerostin articulates to Wnt-signaling coreceptors LRP5 and LRP6, blockading Wnt particle articulation to those receptors. Sclerosteosis, caused by a decreased sclerostin expression, results in less restrained osteogenesis, leading to progressive hyperostosis. Sclerostin, therefore, relies on its coreceptor, LRP4."}
+{"id": "article-101818_12", "title": "Histology, Osteocytes -- Pathophysiology", "content": "Osteonecrosis refers to the classic pattern of cell death and complex osteogenesis and bone resorption processes. Osteocyte necrosis (ON) initiates with hematopoietic and adipocytic cellular necrosis along with interstitial marrow edema. ON happens after about 2 to 3 hours of anoxia; histological signs of osteocytic necrosis do not display until about 24 to 72 hours after hypoxia. ON is first characterized by pyknosis of nuclei, followed by hollow osteocyte lacunae. Capillary revascularization and reactive hyperemia slightly take place at the periphery of the necrosis site, followed by a repair process combining both bone resorption and production that incompletely changes dead with living bone. Nouveau bone overlays onto dead trabeculae along with fragmentary resorption of dead bone. Bone resorption outperforms formation resulting in a net removal of bone, deformed structural integrity of the subchondral trabeculae, joint incongruity, and subchondral fracture. [10] [11] [12] [13]", "contents": "Histology, Osteocytes -- Pathophysiology. Osteonecrosis refers to the classic pattern of cell death and complex osteogenesis and bone resorption processes. Osteocyte necrosis (ON) initiates with hematopoietic and adipocytic cellular necrosis along with interstitial marrow edema. ON happens after about 2 to 3 hours of anoxia; histological signs of osteocytic necrosis do not display until about 24 to 72 hours after hypoxia. ON is first characterized by pyknosis of nuclei, followed by hollow osteocyte lacunae. Capillary revascularization and reactive hyperemia slightly take place at the periphery of the necrosis site, followed by a repair process combining both bone resorption and production that incompletely changes dead with living bone. Nouveau bone overlays onto dead trabeculae along with fragmentary resorption of dead bone. Bone resorption outperforms formation resulting in a net removal of bone, deformed structural integrity of the subchondral trabeculae, joint incongruity, and subchondral fracture. [10] [11] [12] [13]"}
+{"id": "article-101818_13", "title": "Histology, Osteocytes -- Clinical Significance", "content": "Contemporary data suggests that osteocytic functions have led to various therapeutic measures to alter their physiology. Osteocytes, the prevalent and advanced-most bone cells, and osteocyte-derived proteins (i.e., sclerostin) lead to the development of newer strategies to treat various orthopedic conditions.", "contents": "Histology, Osteocytes -- Clinical Significance. Contemporary data suggests that osteocytic functions have led to various therapeutic measures to alter their physiology. Osteocytes, the prevalent and advanced-most bone cells, and osteocyte-derived proteins (i.e., sclerostin) lead to the development of newer strategies to treat various orthopedic conditions."}
+{"id": "article-101818_14", "title": "Histology, Osteocytes -- Clinical Significance", "content": "Researchers recognize that sclerostin as a vital molecule governing bone health. Osteocytes, source of sclerostin, are the main integrators of mechanical and chemical signals that lead to significant changes within the human body. The deep reach of the sophisticated vascular system passing via the canalicular fluid and osteocytic network composes a model delivery system for various small molecules.", "contents": "Histology, Osteocytes -- Clinical Significance. Researchers recognize that sclerostin as a vital molecule governing bone health. Osteocytes, source of sclerostin, are the main integrators of mechanical and chemical signals that lead to significant changes within the human body. The deep reach of the sophisticated vascular system passing via the canalicular fluid and osteocytic network composes a model delivery system for various small molecules."}
+{"id": "article-101818_15", "title": "Histology, Osteocytes -- Clinical Significance", "content": "Further applications of sclerostin action are under active research, as seen in chondrocyte expression of sclerostin in osteoarthritis. Maintaining sclerostin levels is crucial to protecting the intricate balance among the osteoblast, the osteocytes, and the osteoclast. [14] [15]", "contents": "Histology, Osteocytes -- Clinical Significance. Further applications of sclerostin action are under active research, as seen in chondrocyte expression of sclerostin in osteoarthritis. Maintaining sclerostin levels is crucial to protecting the intricate balance among the osteoblast, the osteocytes, and the osteoclast. [14] [15]"}
+{"id": "article-101818_16", "title": "Histology, Osteocytes -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Histology, Osteocytes -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

statpearls/chunk/article-101958.jsonl

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+{"id": "article-101958_0", "title": "Dyspareunia -- Continuing Education Activity", "content": "Dyspareunia is defined by genital pain that can be experienced before, during, or after intercourse. It is debatable whether this condition can be classified as a sexual disorder or pain disorder as identifying a specific etiology can prove challenging. Dyspareumia can have a significant effect on physical and mental health, as well as quality of life. This activity illustrates the evaluation and management of dyspareunia, and highlights the role of interprofessional team in managing patients with this condition.", "contents": "Dyspareunia -- Continuing Education Activity. Dyspareunia is defined by genital pain that can be experienced before, during, or after intercourse. It is debatable whether this condition can be classified as a sexual disorder or pain disorder as identifying a specific etiology can prove challenging. Dyspareumia can have a significant effect on physical and mental health, as well as quality of life. This activity illustrates the evaluation and management of dyspareunia, and highlights the role of interprofessional team in managing patients with this condition."}
+{"id": "article-101958_1", "title": "Dyspareunia -- Continuing Education Activity", "content": "Objectives: Outline the patient history associated with dyspareunia. Review the psychosocial considerations for patients with dyspareunia. Summarize the treatment considerations for patients with dyspareunia. Describe how to counsel a patient with dyspareunia. Access free multiple choice questions on this topic.", "contents": "Dyspareunia -- Continuing Education Activity. Objectives: Outline the patient history associated with dyspareunia. Review the psychosocial considerations for patients with dyspareunia. Summarize the treatment considerations for patients with dyspareunia. Describe how to counsel a patient with dyspareunia. Access free multiple choice questions on this topic."}
+{"id": "article-101958_2", "title": "Dyspareunia -- Introduction", "content": "Painful sexual intercourse is a common female health problem. [1] In medical terminology, it is called dyspareunia. It is a complex disorder that often goes neglected. The prevalence of dyspareunia varies from 3 to 18% worldwide, and it can affect 10 to 28% of the population in a lifetime. [2] [3] dyspareunia can be further categorized into superficial or deep, and primary or secondary. Superficial dyspareunia is limited to the vulva or vaginal entrance, while deep dyspareunia means the extension of pain into the deeper parts of the vagina or lower pelvis. Deep dyspareunia is frequently associated with deep penetration. [4] Primary dyspareunia pain initiates at the start of sexual intercourse, while in secondary dyspareunia, pain begins after some time of pain-free sexual activity.", "contents": "Dyspareunia -- Introduction. Painful sexual intercourse is a common female health problem. [1] In medical terminology, it is called dyspareunia. It is a complex disorder that often goes neglected. The prevalence of dyspareunia varies from 3 to 18% worldwide, and it can affect 10 to 28% of the population in a lifetime. [2] [3] dyspareunia can be further categorized into superficial or deep, and primary or secondary. Superficial dyspareunia is limited to the vulva or vaginal entrance, while deep dyspareunia means the extension of pain into the deeper parts of the vagina or lower pelvis. Deep dyspareunia is frequently associated with deep penetration. [4] Primary dyspareunia pain initiates at the start of sexual intercourse, while in secondary dyspareunia, pain begins after some time of pain-free sexual activity."}
+{"id": "article-101958_3", "title": "Dyspareunia -- Introduction", "content": "Dyspareunia is sometimes intermixed with vulvodynia, a genital pain that lasts more than three months with or without the association of sexual intercourse. [5] Dyspareunia can also lead to sexual difficulties, such as lack of sexual desire and arousal, and can cause trouble in sexual relationships. [6] It can have a significant impact on physical as well as mental health. It can lead to depression, anxiety, hypervigilance to pain, negative body image, and low self-esteem. So prompt management is crucial to address this disorder. [7] [8] [9] In this review, we will focus on the etiology, epidemiology, evaluation, management, and prognosis of dyspareunia.", "contents": "Dyspareunia -- Introduction. Dyspareunia is sometimes intermixed with vulvodynia, a genital pain that lasts more than three months with or without the association of sexual intercourse. [5] Dyspareunia can also lead to sexual difficulties, such as lack of sexual desire and arousal, and can cause trouble in sexual relationships. [6] It can have a significant impact on physical as well as mental health. It can lead to depression, anxiety, hypervigilance to pain, negative body image, and low self-esteem. So prompt management is crucial to address this disorder. [7] [8] [9] In this review, we will focus on the etiology, epidemiology, evaluation, management, and prognosis of dyspareunia."}
+{"id": "article-101958_4", "title": "Dyspareunia -- Etiology", "content": "The etiology of dyspareunia encompasses structural, inflammatory, infectious, neoplastic, traumatic, hormonal, and psychosocial conditions. Anatomic causes include pelvis floor muscle dysfunction, uterine retroversion, hymenal remnants, and pelvic organ prolapse. Lack of lubrication is most common in reproductive years and is attributable to hormonal as well as sexual arousal disorders. For reproductive-aged females, contraceptives can cause inadequate lubrication. Whereas, the decreased estrogen levels noted in post-menopausal females can\u00a0cause vaginal atrophy by\u00a0thinning the vaginal mucosa that is responsible for promoting vaginal secretions. Endometriosis\u00a0is a condition in which endometrial glands and stroma are present outside the uterus.", "contents": "Dyspareunia -- Etiology. The etiology of dyspareunia encompasses structural, inflammatory, infectious, neoplastic, traumatic, hormonal, and psychosocial conditions. Anatomic causes include pelvis floor muscle dysfunction, uterine retroversion, hymenal remnants, and pelvic organ prolapse. Lack of lubrication is most common in reproductive years and is attributable to hormonal as well as sexual arousal disorders. For reproductive-aged females, contraceptives can cause inadequate lubrication. Whereas, the decreased estrogen levels noted in post-menopausal females can\u00a0cause vaginal atrophy by\u00a0thinning the vaginal mucosa that is responsible for promoting vaginal secretions. Endometriosis\u00a0is a condition in which endometrial glands and stroma are present outside the uterus."}
+{"id": "article-101958_5", "title": "Dyspareunia -- Etiology", "content": "The etiology of endometriosis-associated deep dyspareunia could also be due to endometriosis-specific factors or indirect contributors like bladder/pelvic floor dysfunction.\u00a0In women\u00a0regardless of the staging of endometriosis, the severity of deep dyspareunia was strongly associated with bladder/pelvic floor tenderness and painful bladder syndrome, independent of endometriosis-specific factors, which suggests the role of myofascial or sensitization pain mechanisms in some women with deep dyspareunia. [10]", "contents": "Dyspareunia -- Etiology. The etiology of endometriosis-associated deep dyspareunia could also be due to endometriosis-specific factors or indirect contributors like bladder/pelvic floor dysfunction.\u00a0In women\u00a0regardless of the staging of endometriosis, the severity of deep dyspareunia was strongly associated with bladder/pelvic floor tenderness and painful bladder syndrome, independent of endometriosis-specific factors, which suggests the role of myofascial or sensitization pain mechanisms in some women with deep dyspareunia. [10]"}
+{"id": "article-101958_6", "title": "Dyspareunia -- Etiology", "content": "Dermatologic diseases such as lichen planus, lichen sclerosis, and psoriasis can cause significant inflammation to the vaginal mucosa as well. Perivaginal and\u00a0pelvic infections such as urethritis, vaginitis, and pelvic inflammatory disease can result from gonorrhea, chlamydia, candida, trichomoniasis,\u00a0bacterial vaginosis, and virals pathogens such as herpes. Postpartum dyspareunia more commonly presents after perineal trauma from delivery than those with an uncomplicated vaginal delivery with intact perineum or unsutured tear. [11]", "contents": "Dyspareunia -- Etiology. Dermatologic diseases such as lichen planus, lichen sclerosis, and psoriasis can cause significant inflammation to the vaginal mucosa as well. Perivaginal and\u00a0pelvic infections such as urethritis, vaginitis, and pelvic inflammatory disease can result from gonorrhea, chlamydia, candida, trichomoniasis,\u00a0bacterial vaginosis, and virals pathogens such as herpes. Postpartum dyspareunia more commonly presents after perineal trauma from delivery than those with an uncomplicated vaginal delivery with intact perineum or unsutured tear. [11]"}
+{"id": "article-101958_7", "title": "Dyspareunia -- Etiology", "content": "Vaginismus is a more common condition in younger women and defined as an involuntary contraction of the\u00a0pelvic floor muscles on attempted vaginal penetration\u00a0and can be the result of a pelvic floor dysfunction or psychosocial issues such as a history of sexual abuse. [12]", "contents": "Dyspareunia -- Etiology. Vaginismus is a more common condition in younger women and defined as an involuntary contraction of the\u00a0pelvic floor muscles on attempted vaginal penetration\u00a0and can be the result of a pelvic floor dysfunction or psychosocial issues such as a history of sexual abuse. [12]"}
+{"id": "article-101958_8", "title": "Dyspareunia -- Epidemiology", "content": "The incidence of dyspareunia mainly depends on the definition used\u00a0and, therefore, the\u00a0population sampled. In the United States, the prevalence can be between 7% to 46%. Dyspareunia affects both males and females. However, it is far more common in the female population. Women with symptoms severe enough to require medical attention comprise a small subset as most patients do not seek medical attention making the true incidence rather challenging to determine. [12]", "contents": "Dyspareunia -- Epidemiology. The incidence of dyspareunia mainly depends on the definition used\u00a0and, therefore, the\u00a0population sampled. In the United States, the prevalence can be between 7% to 46%. Dyspareunia affects both males and females. However, it is far more common in the female population. Women with symptoms severe enough to require medical attention comprise a small subset as most patients do not seek medical attention making the true incidence rather challenging to determine. [12]"}
+{"id": "article-101958_9", "title": "Dyspareunia -- History and Physical", "content": "Obtaining a history in a nonjudgmental way is crucial and should include pain descriptors: duration, intensity, location, exacerbating and\u00a0alleviating factors, and any associated psychologic components. The location and onset can help to differentiate entry versus deep pain. Whereas a burning pain more commonly links to vaginitis, vulvodynia, atrophy, or inadequate lubrication, a deep aching pain may be noted in pelvic congestion syndrome, pelvic inflammatory disease, endometriosis, retroverted uterus, uterine fibroids, and adnexal pathology. A situational versus a more generalized description (occurs only with certain partners or with all encounters) may more strongly link with psychologic considerations. [13] The IMPACT( Initial Measurement of Patient-Reported Pelvic Floor Complaints Tool) form consists of different questions relevant to pelvic floor abnormalities. It also helps in dealing with dyspareunia patients. [14]", "contents": "Dyspareunia -- History and Physical. Obtaining a history in a nonjudgmental way is crucial and should include pain descriptors: duration, intensity, location, exacerbating and\u00a0alleviating factors, and any associated psychologic components. The location and onset can help to differentiate entry versus deep pain. Whereas a burning pain more commonly links to vaginitis, vulvodynia, atrophy, or inadequate lubrication, a deep aching pain may be noted in pelvic congestion syndrome, pelvic inflammatory disease, endometriosis, retroverted uterus, uterine fibroids, and adnexal pathology. A situational versus a more generalized description (occurs only with certain partners or with all encounters) may more strongly link with psychologic considerations. [13] The IMPACT( Initial Measurement of Patient-Reported Pelvic Floor Complaints Tool) form consists of different questions relevant to pelvic floor abnormalities. It also helps in dealing with dyspareunia patients. [14]"}
+{"id": "article-101958_10", "title": "Dyspareunia -- History and Physical", "content": "In the first step of physical examination, it is always advisable to educate the patient about the examination and her anatomy in detail. [15] Then it should begin with a visual inspection of the labia majora and\u00a0labia minora, vestibular area, anus, and urethral orifice to evaluate for any lesions, labial hypertrophy, leukoplakia, or erythema. The speculum exam should take place after selecting an appropriately sized speculum (consider a pediatric speculum for patient comfort) that is warmed and lubricated. Examine the cervix for any associated lesions, erythema, and discharge at which time appropriate cultures are obtainable. The bimanual examination should then evaluate for any adnexal masses/cysts, uterine masses, and additional anatomic variants. [16] [17] [18]", "contents": "Dyspareunia -- History and Physical. In the first step of physical examination, it is always advisable to educate the patient about the examination and her anatomy in detail. [15] Then it should begin with a visual inspection of the labia majora and\u00a0labia minora, vestibular area, anus, and urethral orifice to evaluate for any lesions, labial hypertrophy, leukoplakia, or erythema. The speculum exam should take place after selecting an appropriately sized speculum (consider a pediatric speculum for patient comfort) that is warmed and lubricated. Examine the cervix for any associated lesions, erythema, and discharge at which time appropriate cultures are obtainable. The bimanual examination should then evaluate for any adnexal masses/cysts, uterine masses, and additional anatomic variants. [16] [17] [18]"}
+{"id": "article-101958_11", "title": "Dyspareunia -- Evaluation", "content": "Laboratory evaluation rarely helps in guiding the diagnosis or treatment of dyspareunia. However, It is better to rule out other abnormalities to reach the exact diagnosis. Since the pain in the vulvodynia is similar to dyspareunia, it is better to rule this out by performing a cotton swab test during the vulvar examination. [15]", "contents": "Dyspareunia -- Evaluation. Laboratory evaluation rarely helps in guiding the diagnosis or treatment of dyspareunia. However, It is better to rule out other abnormalities to reach the exact diagnosis. Since the pain in the vulvodynia is similar to dyspareunia, it is better to rule this out by performing a cotton swab test during the vulvar examination. [15]"}
+{"id": "article-101958_12", "title": "Dyspareunia -- Evaluation", "content": "Further tests can include pelvic cultures for gonorrhea, chlamydia, trichomoniasis, Candida, and Gardnerella are indicated when women present with vaginal or cervical discharge. Genital ulcers can be testing performed for herpes simplex, syphilis, or appropriate culture. Women with associated dysuria, urgency, frequency or suprapubic discomfort should receive a urinalysis. Visible lesions noted on physical exam should undergo tissue biopsy. [19] Transvaginal ultrasound can help evaluate pelvic masses, endometrial hyperplasia, ovarian cysts, or congenital anomalies.", "contents": "Dyspareunia -- Evaluation. Further tests can include pelvic cultures for gonorrhea, chlamydia, trichomoniasis, Candida, and Gardnerella are indicated when women present with vaginal or cervical discharge. Genital ulcers can be testing performed for herpes simplex, syphilis, or appropriate culture. Women with associated dysuria, urgency, frequency or suprapubic discomfort should receive a urinalysis. Visible lesions noted on physical exam should undergo tissue biopsy. [19] Transvaginal ultrasound can help evaluate pelvic masses, endometrial hyperplasia, ovarian cysts, or congenital anomalies."}
+{"id": "article-101958_13", "title": "Dyspareunia -- Treatment / Management", "content": "For the treatment of dyspareunia, a multimodal treatment approach is advantageous to address all the aspects of pain (physical, emotional, and behavioral). It should involve a team consisting of the gynecologist, pain management expert, physical therapist, sexual therapist, and mental health professionals with a specialization in chronic pain. [20] In the first step, a physician should acknowledge that patient has pain. The patient should receive counsel that pain management may take time, and its quite possible that it may not completely resolve even after the completion of treatment. Patients should be informed of all the treatment options in detail and help them to choose the best possible treatment option. The conservative nonsurgical approach should be the first step.", "contents": "Dyspareunia -- Treatment / Management. For the treatment of dyspareunia, a multimodal treatment approach is advantageous to address all the aspects of pain (physical, emotional, and behavioral). It should involve a team consisting of the gynecologist, pain management expert, physical therapist, sexual therapist, and mental health professionals with a specialization in chronic pain. [20] In the first step, a physician should acknowledge that patient has pain. The patient should receive counsel that pain management may take time, and its quite possible that it may not completely resolve even after the completion of treatment. Patients should be informed of all the treatment options in detail and help them to choose the best possible treatment option. The conservative nonsurgical approach should be the first step."}
+{"id": "article-101958_14", "title": "Dyspareunia -- Treatment / Management", "content": "Medical treatment options available for dyspareunia include oral tricyclic antidepressants, oral or topical hormonal replacement, oral NSAIDs, botox injections, cognitive behavioral therapy, and other brain-based therapies. Treatment of dyspareunia depends on the etiology of the patient's complaint. Dyspareunia due to post-menopausal vaginal atrophy can have treatment with systemic and topical hormone replacement therapy, selective estrogen receptor modulator therapy, and the use of vaginal dehydroepiandrosterone. [21] Clinicians treat infectious causes with the appropriate antibiotic, antifungal, or antiviral therapy based upon culture results. Post-partum dyspareunia can respond to vaginal lubricants, scar tissue massage, or surgery for persistent cases. Botulinum toxin injection has proved to be effective in the treatment of dyspareunia caused by pelvic floor myalgia and contracture. [22] [23]", "contents": "Dyspareunia -- Treatment / Management. Medical treatment options available for dyspareunia include oral tricyclic antidepressants, oral or topical hormonal replacement, oral NSAIDs, botox injections, cognitive behavioral therapy, and other brain-based therapies. Treatment of dyspareunia depends on the etiology of the patient's complaint. Dyspareunia due to post-menopausal vaginal atrophy can have treatment with systemic and topical hormone replacement therapy, selective estrogen receptor modulator therapy, and the use of vaginal dehydroepiandrosterone. [21] Clinicians treat infectious causes with the appropriate antibiotic, antifungal, or antiviral therapy based upon culture results. Post-partum dyspareunia can respond to vaginal lubricants, scar tissue massage, or surgery for persistent cases. Botulinum toxin injection has proved to be effective in the treatment of dyspareunia caused by pelvic floor myalgia and contracture. [22] [23]"}
+{"id": "article-101958_15", "title": "Dyspareunia -- Treatment / Management", "content": "Pelvic floor physical therapy can serve as an adjuvant treatment option in most cases of dyspareunia. It relaxes the pelvic floor muscles and re-educates the pain receptors. [24] Cognitive-behavioral therapy has shown promising results in reducing anxiety and fear related to dyspareunia. It is the most commonly used behavioral intervention and is a strong recommendation. [25] Surgical treatment is adopted as a last resort when all conservative medical and behavioral treatment options have failed. It is usually useful in identifying and/or treat pelvic adhesions, endometriosis, and pelvic organ prolapse. [26]", "contents": "Dyspareunia -- Treatment / Management. Pelvic floor physical therapy can serve as an adjuvant treatment option in most cases of dyspareunia. It relaxes the pelvic floor muscles and re-educates the pain receptors. [24] Cognitive-behavioral therapy has shown promising results in reducing anxiety and fear related to dyspareunia. It is the most commonly used behavioral intervention and is a strong recommendation. [25] Surgical treatment is adopted as a last resort when all conservative medical and behavioral treatment options have failed. It is usually useful in identifying and/or treat pelvic adhesions, endometriosis, and pelvic organ prolapse. [26]"}
+{"id": "article-101958_16", "title": "Dyspareunia -- Differential Diagnosis", "content": "To reach the exact diagnosis of dyspareunia is a tricky one as it can be confused with other disorders of similar complaints. Several disorders must be ruled out based upon the history and physical examination before making the diagnosis of dyspareunia. Some of these are listed below: Vulvodynia Vaginismus Atrophic vaginitis Vulvar vestibulitis Endometriosis and pelvic adhesions Uterine fibroids Pelvic congestion Pelvic inflammatory disease, endometritis Other urogenital tract infections [27]", "contents": "Dyspareunia -- Differential Diagnosis. To reach the exact diagnosis of dyspareunia is a tricky one as it can be confused with other disorders of similar complaints. Several disorders must be ruled out based upon the history and physical examination before making the diagnosis of dyspareunia. Some of these are listed below: Vulvodynia Vaginismus Atrophic vaginitis Vulvar vestibulitis Endometriosis and pelvic adhesions Uterine fibroids Pelvic congestion Pelvic inflammatory disease, endometritis Other urogenital tract infections [27]"}
+{"id": "article-101958_17", "title": "Dyspareunia -- Prognosis", "content": "The prognosis of dyspareunia depends on the causative factor of this pain. If the underlying cause is known and curable, then it has a better prognosis. Its prognosis is poor in idiopathic dyspareunia. Following treatment, patients with dyspareunia should receive counsel about the prognosis of the disorder. Treatment can last for several months, and complete resolution is also not guaranteed. Studies suggest that results start appearing after at least three months. After that, the patient's distress starts decreasing with improved quality of life. A 24-month follow-up is recommended for the best results. [28]", "contents": "Dyspareunia -- Prognosis. The prognosis of dyspareunia depends on the causative factor of this pain. If the underlying cause is known and curable, then it has a better prognosis. Its prognosis is poor in idiopathic dyspareunia. Following treatment, patients with dyspareunia should receive counsel about the prognosis of the disorder. Treatment can last for several months, and complete resolution is also not guaranteed. Studies suggest that results start appearing after at least three months. After that, the patient's distress starts decreasing with improved quality of life. A 24-month follow-up is recommended for the best results. [28]"}
+{"id": "article-101958_18", "title": "Dyspareunia -- Complications", "content": "Dyspareunia is usually a treatable disease and doesn't result in major complications. Regardless of the non-malignant nature of the disease, timely management and intervention are crucial to obviate distressing sequelae. If the patients do not seek prompt, appropriate medical care, it can result in loss of sexual interest and problems with relationships. It also results in significant distress and conflicts among the partners.", "contents": "Dyspareunia -- Complications. Dyspareunia is usually a treatable disease and doesn't result in major complications. Regardless of the non-malignant nature of the disease, timely management and intervention are crucial to obviate distressing sequelae. If the patients do not seek prompt, appropriate medical care, it can result in loss of sexual interest and problems with relationships. It also results in significant distress and conflicts among the partners."}
+{"id": "article-101958_19", "title": "Dyspareunia -- Complications", "content": "Psychiatric issues may arise if dyspareunia remains untreated. Psychiatric issues like major depression due to dyspareunia are more prevalent in younger women. In very few cases, fear of pain during sexual activity can result in female infertility. [29]", "contents": "Dyspareunia -- Complications. Psychiatric issues may arise if dyspareunia remains untreated. Psychiatric issues like major depression due to dyspareunia are more prevalent in younger women. In very few cases, fear of pain during sexual activity can result in female infertility. [29]"}
+{"id": "article-101958_20", "title": "Dyspareunia -- Deterrence and Patient Education", "content": "In general, patients are hesitant to discuss their sexual dysfunctions and can go unnoticed for a long time. [30] Patients should be encouraged to discuss their sexual health with a physician. Dyspareunia is a challenging topic for discussion for both the patient and the physician. It can also lead to suboptimal management.", "contents": "Dyspareunia -- Deterrence and Patient Education. In general, patients are hesitant to discuss their sexual dysfunctions and can go unnoticed for a long time. [30] Patients should be encouraged to discuss their sexual health with a physician. Dyspareunia is a challenging topic for discussion for both the patient and the physician. It can also lead to suboptimal management."}
+{"id": "article-101958_21", "title": "Dyspareunia -- Deterrence and Patient Education", "content": "Clinicians need sufficient education and training to evaluate and treat the patient's dyspareunia properly. [30] It is important to allay patient fears and provide reassurance for them to discuss this condition with their primary care physician, who can then refer to specialists to guide treatment depending on the etiology.", "contents": "Dyspareunia -- Deterrence and Patient Education. Clinicians need sufficient education and training to evaluate and treat the patient's dyspareunia properly. [30] It is important to allay patient fears and provide reassurance for them to discuss this condition with their primary care physician, who can then refer to specialists to guide treatment depending on the etiology."}
+{"id": "article-101958_22", "title": "Dyspareunia -- Enhancing Healthcare Team Outcomes", "content": "Management of Dyspareunia is a typical example for healthcare providers to ensure patient-centered care. The symptoms, physical findings, and concerns related to dyspareunia are managed by collaborative efforts of a team consisting of gynecologists, urologists, psychiatrists, pain specialists, and paramedical staff.\u00a0To standardize treatment, a Pelvic Floor Disorder Consortium (PFDC) came into existence, which also provides guidance to treat several other conditions. It reviews multiple symptoms, function, and quality of life questionnaires. The PFDC is comprised of urogynecologists, urologists, gynecologists, physiotherapists, and other advanced care physicians that deal with complex concerns of sexual dysfunctions. [31]", "contents": "Dyspareunia -- Enhancing Healthcare Team Outcomes. Management of Dyspareunia is a typical example for healthcare providers to ensure patient-centered care. The symptoms, physical findings, and concerns related to dyspareunia are managed by collaborative efforts of a team consisting of gynecologists, urologists, psychiatrists, pain specialists, and paramedical staff.\u00a0To standardize treatment, a Pelvic Floor Disorder Consortium (PFDC) came into existence, which also provides guidance to treat several other conditions. It reviews multiple symptoms, function, and quality of life questionnaires. The PFDC is comprised of urogynecologists, urologists, gynecologists, physiotherapists, and other advanced care physicians that deal with complex concerns of sexual dysfunctions. [31]"}
+{"id": "article-101958_23", "title": "Dyspareunia -- Enhancing Healthcare Team Outcomes", "content": "A multidisciplinary treatment approach has shown to be beneficial in dyspareunia.\u00a0The general care physician usually initiates the connection with the patient and develop a rapport. Adequate education regarding the course of the disease should be provided to the patients. A psychiatrist should be involved to relieve the patient's distress. Sexual pain specialists should also offer consultation when needed. Pelvic floor rehabilitation has shown promising results in dyspareunia treatment. [32] Hence by a team effort, health care outcomes can be improved significantly.", "contents": "Dyspareunia -- Enhancing Healthcare Team Outcomes. A multidisciplinary treatment approach has shown to be beneficial in dyspareunia.\u00a0The general care physician usually initiates the connection with the patient and develop a rapport. Adequate education regarding the course of the disease should be provided to the patients. A psychiatrist should be involved to relieve the patient's distress. Sexual pain specialists should also offer consultation when needed. Pelvic floor rehabilitation has shown promising results in dyspareunia treatment. [32] Hence by a team effort, health care outcomes can be improved significantly."}
+{"id": "article-101958_24", "title": "Dyspareunia -- Review Questions", "content": "Access free multiple choice questions on this topic. Click here for a simplified version. Comment on this article.", "contents": "Dyspareunia -- Review Questions. Access free multiple choice questions on this topic. Click here for a simplified version. Comment on this article."}

statpearls/chunk/article-102.jsonl

@@ -0,0 +1,41 @@
+{"id": "article-102_0", "title": "Carvedilol -- Continuing Education Activity", "content": "Carvedilol is a nonselective adrenergic blocker indicated for the chronic therapy of heart failure with reduced ejection fraction, hypertension, and left ventricular dysfunction following myocardial infarction in clinically stable patients. Carvedilol is utilized off-label for stable angina, atrial fibrillation, prophylaxis against cirrhotic esophageal variceal bleeding, and the management of ventricular arrhythmias. This activity reviews the mechanism of action, adverse event profile, toxicity, dosing, pharmacodynamics, and monitoring of carvedilol. This activity also\u00a0provides essential insights for clinicians and other members of the interprofessional healthcare team, facilitating the appropriate utilization of carvedilol for its indicated conditions.", "contents": "Carvedilol -- Continuing Education Activity. Carvedilol is a nonselective adrenergic blocker indicated for the chronic therapy of heart failure with reduced ejection fraction, hypertension, and left ventricular dysfunction following myocardial infarction in clinically stable patients. Carvedilol is utilized off-label for stable angina, atrial fibrillation, prophylaxis against cirrhotic esophageal variceal bleeding, and the management of ventricular arrhythmias. This activity reviews the mechanism of action, adverse event profile, toxicity, dosing, pharmacodynamics, and monitoring of carvedilol. This activity also\u00a0provides essential insights for clinicians and other members of the interprofessional healthcare team, facilitating the appropriate utilization of carvedilol for its indicated conditions."}
+{"id": "article-102_1", "title": "Carvedilol -- Continuing Education Activity", "content": "Objectives: Identify the diverse indications for carvedilol, including its off-label uses in stable angina, atrial fibrillation, and prophylaxis against cirrhotic esophageal variceal bleeding. Screen patients for potential contraindications, such as severe hypotension, second or third-degree AV block, and other conditions that may necessitate caution or alternative therapies. Apply knowledge of carvedilol's mechanism of action to optimize therapeutic outcomes in cardiovascular conditions, balancing its beta-blocking properties and peripheral vasodilating effects. Collaborate with other healthcare professionals to ensure a holistic approach to patient care, incorporating carvedilol into a comprehensive treatment plan that addresses cardiovascular conditions. Access free multiple choice questions on this topic.", "contents": "Carvedilol -- Continuing Education Activity. Objectives: Identify the diverse indications for carvedilol, including its off-label uses in stable angina, atrial fibrillation, and prophylaxis against cirrhotic esophageal variceal bleeding. Screen patients for potential contraindications, such as severe hypotension, second or third-degree AV block, and other conditions that may necessitate caution or alternative therapies. Apply knowledge of carvedilol's mechanism of action to optimize therapeutic outcomes in cardiovascular conditions, balancing its beta-blocking properties and peripheral vasodilating effects. Collaborate with other healthcare professionals to ensure a holistic approach to patient care, incorporating carvedilol into a comprehensive treatment plan that addresses cardiovascular conditions. Access free multiple choice questions on this topic."}
+{"id": "article-102_2", "title": "Carvedilol -- Indications", "content": "Carvedilol is a nonselective adrenergic blocker indicated for the chronic therapy of heart failure with reduced ejection fraction (HFrEF), hypertension, and left ventricular dysfunction following myocardial infarction in clinically stable patients.", "contents": "Carvedilol -- Indications. Carvedilol is a nonselective adrenergic blocker indicated for the chronic therapy of heart failure with reduced ejection fraction (HFrEF), hypertension, and left ventricular dysfunction following myocardial infarction in clinically stable patients."}
+{"id": "article-102_3", "title": "Carvedilol -- Indications", "content": "The 2017 guidelines from the American College of Cardiology/American Heart Association Task Force on Clinical Practice and the Heart Rhythm Society recommend carvedilol (immediate- or extended-release capsule) as a beta blocker for treating heart failure with reduced ejection fraction (HFrEF). [1] Several studies support this recommendation, with noteworthy endorsement from the 2002 COPERNICUS trial. This pivotal study demonstrated that carvedilol significantly reduces the risk of death and hospitalizations for heart failure by 31%, as compared to a placebo group, in patients with New York Heart Association classes III and IV heart failure with an ejection fraction of less than 25%. [2]", "contents": "Carvedilol -- Indications. The 2017 guidelines from the American College of Cardiology/American Heart Association Task Force on Clinical Practice and the Heart Rhythm Society recommend carvedilol (immediate- or extended-release capsule) as a beta blocker for treating heart failure with reduced ejection fraction (HFrEF). [1] Several studies support this recommendation, with noteworthy endorsement from the 2002 COPERNICUS trial. This pivotal study demonstrated that carvedilol significantly reduces the risk of death and hospitalizations for heart failure by 31%, as compared to a placebo group, in patients with New York Heart Association classes III and IV heart failure with an ejection fraction of less than 25%. [2]"}
+{"id": "article-102_4", "title": "Carvedilol -- Indications", "content": "In addition, the 2022 American Heart Association/American College of Cardiology/Heart Failure Society of America (AHA/ACC/HFSA) guidelines advocate for the use of 3 beta blockers\u2014carvedilol, bisoprolol, and sustained-release metoprolol succinate\u2014in patients with HFrEF. This recommendation aims to reduce both mortality and hospitalizations effectively. In addition, prescribing carvedilol upon discharge is associated with a decrease in 60- to 90-day mortality and rehospitalization rates. [3]", "contents": "Carvedilol -- Indications. In addition, the 2022 American Heart Association/American College of Cardiology/Heart Failure Society of America (AHA/ACC/HFSA) guidelines advocate for the use of 3 beta blockers\u2014carvedilol, bisoprolol, and sustained-release metoprolol succinate\u2014in patients with HFrEF. This recommendation aims to reduce both mortality and hospitalizations effectively. In addition, prescribing carvedilol upon discharge is associated with a decrease in 60- to 90-day mortality and rehospitalization rates. [3]"}
+{"id": "article-102_5", "title": "Carvedilol -- Indications", "content": "Another important study worth noting is the 2003 COMET trial, which compared carvedilol to metoprolol tartrate. The findings revealed that carvedilol, in contrast to metoprolol tartrate, reduced all-cause mortality in patients with HFrEF and an ejection fraction equal to 35%. [4] Criticism is directed at these findings. Notably, a comparison between carvedilol and metoprolol was made in the COMET trial. However, it should be acknowledged that patients randomized to receive metoprolol were administered metoprolol tartrate at 50 mg twice daily. This represented an alternative and underdosed form of metoprolol, differing from the metoprolol succinate at 200 mg daily used in the MERIT-HF trial, which demonstrated a reduction in all-cause mortality. [4] [5] This result highlights a common topic in the treatment of heart failure with these 2 beta blockers. Subsequent investigations have revealed no difference in all-cause mortality or hospitalizations between carvedilol and metoprolol succinate, with some studies favoring metoprolol succinate. However, these findings stem from meta-analyses and observational studies rather than randomized trials. [6] [7] [8]", "contents": "Carvedilol -- Indications. Another important study worth noting is the 2003 COMET trial, which compared carvedilol to metoprolol tartrate. The findings revealed that carvedilol, in contrast to metoprolol tartrate, reduced all-cause mortality in patients with HFrEF and an ejection fraction equal to 35%. [4] Criticism is directed at these findings. Notably, a comparison between carvedilol and metoprolol was made in the COMET trial. However, it should be acknowledged that patients randomized to receive metoprolol were administered metoprolol tartrate at 50 mg twice daily. This represented an alternative and underdosed form of metoprolol, differing from the metoprolol succinate at 200 mg daily used in the MERIT-HF trial, which demonstrated a reduction in all-cause mortality. [4] [5] This result highlights a common topic in the treatment of heart failure with these 2 beta blockers. Subsequent investigations have revealed no difference in all-cause mortality or hospitalizations between carvedilol and metoprolol succinate, with some studies favoring metoprolol succinate. However, these findings stem from meta-analyses and observational studies rather than randomized trials. [6] [7] [8]"}
+{"id": "article-102_6", "title": "Carvedilol -- Indications", "content": "The CAPRICORN trial, published in 2001, provided substantial evidence endorsing the use of carvedilol in cases of left ventricular dysfunction following a myocardial infarction. The study reported a significant reduction in all-cause mortality among patients with left ventricular dysfunction following an acute myocardial infarction. [9]", "contents": "Carvedilol -- Indications. The CAPRICORN trial, published in 2001, provided substantial evidence endorsing the use of carvedilol in cases of left ventricular dysfunction following a myocardial infarction. The study reported a significant reduction in all-cause mortality among patients with left ventricular dysfunction following an acute myocardial infarction. [9]"}
+{"id": "article-102_7", "title": "Carvedilol -- Indications -- Off-Label Uses", "content": "Off-label indications for carvedilol include stable angina, atrial fibrillation, cirrhotic esophageal variceal bleeding prophylaxis, and ventricular arrhythmias. These off-label uses can generally be extrapolated to most beta blockers rather than being specific to carvedilol alone. For example, stable angina is commonly addressed with beta blockers, and anti-anginal therapy aims for a target heart rate of 55 to 60, irrespective of the specific beta blocker used by clinicians. Similarly, effective rate control therapy for atrial fibrillation can be accomplished with nearly any beta blocker.", "contents": "Carvedilol -- Indications -- Off-Label Uses. Off-label indications for carvedilol include stable angina, atrial fibrillation, cirrhotic esophageal variceal bleeding prophylaxis, and ventricular arrhythmias. These off-label uses can generally be extrapolated to most beta blockers rather than being specific to carvedilol alone. For example, stable angina is commonly addressed with beta blockers, and anti-anginal therapy aims for a target heart rate of 55 to 60, irrespective of the specific beta blocker used by clinicians. Similarly, effective rate control therapy for atrial fibrillation can be accomplished with nearly any beta blocker."}
+{"id": "article-102_8", "title": "Carvedilol -- Indications -- Off-Label Uses", "content": "Specific beta blockers, other than carvedilol, are recommended to prevent esophageal variceal bleeding. However, certain studies have indicated that carvedilol might exhibit greater efficacy in reducing hepatic venous pressure or preventing variceal bleeding than other beta blockers. [10] [11] [12] The American Association for the Study of Liver Diseases recommends the use of nonselective beta blockers (NSBBs), including propranolol, carvedilol, or nadolol, for pharmacotherapy in the primary prophylaxis of first variceal hemorrhage in cases of medium or large varices. [13]", "contents": "Carvedilol -- Indications -- Off-Label Uses. Specific beta blockers, other than carvedilol, are recommended to prevent esophageal variceal bleeding. However, certain studies have indicated that carvedilol might exhibit greater efficacy in reducing hepatic venous pressure or preventing variceal bleeding than other beta blockers. [10] [11] [12] The American Association for the Study of Liver Diseases recommends the use of nonselective beta blockers (NSBBs), including propranolol, carvedilol, or nadolol, for pharmacotherapy in the primary prophylaxis of first variceal hemorrhage in cases of medium or large varices. [13]"}
+{"id": "article-102_9", "title": "Carvedilol -- Mechanism of Action", "content": "Carvedilol is a nonselective adrenergic blocker, specifically categorized as an NSBB with alpha-1\u2013adrenergic receptor antagonist properties. [14] [15] This medication is a nonselective cardiac beta blocker with\u00a0peripheral vasodilating effects, which improve blood flow throughout the body. [16] Due to its distinctive mechanism, carvedilol maintains cardiac output by decreasing afterload with a cardiac beta blockade. Carvedilol\u00a0exerts a lesser effect on heart rate than pure selective beta blockers.", "contents": "Carvedilol -- Mechanism of Action. Carvedilol is a nonselective adrenergic blocker, specifically categorized as an NSBB with alpha-1\u2013adrenergic receptor antagonist properties. [14] [15] This medication is a nonselective cardiac beta blocker with\u00a0peripheral vasodilating effects, which improve blood flow throughout the body. [16] Due to its distinctive mechanism, carvedilol maintains cardiac output by decreasing afterload with a cardiac beta blockade. Carvedilol\u00a0exerts a lesser effect on heart rate than pure selective beta blockers."}
+{"id": "article-102_10", "title": "Carvedilol -- Mechanism of Action", "content": "Additional benefits of carvedilol include antioxidant effects, reduced neutrophil infiltration, apoptosis inhibition, diminished vascular smooth muscle migration, and\u00a0enhanced myocardial remodeling following an acute myocardial infarction. [14] Carvedilol can potentially treat atherosclerotic disease by preventing the formation of oxidized low-density lipoproteins and inhibiting vascular smooth muscle cell proliferation and migration, thus impeding its progression. [17]", "contents": "Carvedilol -- Mechanism of Action. Additional benefits of carvedilol include antioxidant effects, reduced neutrophil infiltration, apoptosis inhibition, diminished vascular smooth muscle migration, and\u00a0enhanced myocardial remodeling following an acute myocardial infarction. [14] Carvedilol can potentially treat atherosclerotic disease by preventing the formation of oxidized low-density lipoproteins and inhibiting vascular smooth muscle cell proliferation and migration, thus impeding its progression. [17]"}
+{"id": "article-102_11", "title": "Carvedilol -- Mechanism of Action", "content": "Carvedilol primarily lowers blood pressure by diminishing arterial vascular resistance through its alpha-1\u2013blocking properties, resulting in a decrease in afterload. The efficacy of the drug is notable in the management of hypertension, particularly in patients with renal impairment, where caution is advised against the use of diuretics and angiotensin-converting enzyme inhibitors (ACEI). [16] Compared to other classes of antihypertensive medications, carvedilol shows similar efficacy to other beta blockers, calcium channel blockers, ACEI, and diuretics. [15]", "contents": "Carvedilol -- Mechanism of Action. Carvedilol primarily lowers blood pressure by diminishing arterial vascular resistance through its alpha-1\u2013blocking properties, resulting in a decrease in afterload. The efficacy of the drug is notable in the management of hypertension, particularly in patients with renal impairment, where caution is advised against the use of diuretics and angiotensin-converting enzyme inhibitors (ACEI). [16] Compared to other classes of antihypertensive medications, carvedilol shows similar efficacy to other beta blockers, calcium channel blockers, ACEI, and diuretics. [15]"}
+{"id": "article-102_12", "title": "Carvedilol -- Mechanism of Action -- Pharmacokinetics", "content": "Absorption: Carvedilol exhibits rapid absorption, reaching peak plasma concentration (Cmax) within 1 to 2 hours after administration. Administration with food slows the absorption rate, although the bioavailability remains unaffected. Although carvedilol is well absorbed in the body, it experiences significant first-pass metabolism, resulting in poor systemic bioavailability of 25%. [18] Distribution: Carvedilol is a highly lipophilic drug that undergoes extensive distribution into tissues, leading to a substantial volume of distribution (Vd) of 1.5 L/kg.", "contents": "Carvedilol -- Mechanism of Action -- Pharmacokinetics. Absorption: Carvedilol exhibits rapid absorption, reaching peak plasma concentration (Cmax) within 1 to 2 hours after administration. Administration with food slows the absorption rate, although the bioavailability remains unaffected. Although carvedilol is well absorbed in the body, it experiences significant first-pass metabolism, resulting in poor systemic bioavailability of 25%. [18] Distribution: Carvedilol is a highly lipophilic drug that undergoes extensive distribution into tissues, leading to a substantial volume of distribution (Vd) of 1.5 L/kg."}
+{"id": "article-102_13", "title": "Carvedilol -- Mechanism of Action -- Pharmacokinetics", "content": "Metabolism: Carvedilol undergoes hepatic metabolism, initially through oxidation, followed by glucuronidation and conjugation. The primary mediators of its metabolism are cytochromes P450, specifically CYP2D6 and CYP2C9. In addition, carvedilol acts as an inhibitor of P-glycoprotein. [19]", "contents": "Carvedilol -- Mechanism of Action -- Pharmacokinetics. Metabolism: Carvedilol undergoes hepatic metabolism, initially through oxidation, followed by glucuronidation and conjugation. The primary mediators of its metabolism are cytochromes P450, specifically CYP2D6 and CYP2C9. In addition, carvedilol acts as an inhibitor of P-glycoprotein. [19]"}
+{"id": "article-102_14", "title": "Carvedilol -- Mechanism of Action -- Pharmacokinetics", "content": "Elimination: Carvedilol is primarily excreted into the bile and eliminated via feces, with only 16% accounted for by urinary excretion. The elimination half-life of carvedilol typically ranges between 6\u00a0and 7 hours. [20]", "contents": "Carvedilol -- Mechanism of Action -- Pharmacokinetics. Elimination: Carvedilol is primarily excreted into the bile and eliminated via feces, with only 16% accounted for by urinary excretion. The elimination half-life of carvedilol typically ranges between 6\u00a0and 7 hours. [20]"}
+{"id": "article-102_15", "title": "Carvedilol -- Administration -- Available Dosage Forms and Strengths", "content": "Carvedilol is an oral medication administered either twice daily in an immediate-release formulation or once daily in a controlled-release formulation. The dosage is tailored to each individual, considering their blood pressure and heart rate response. However, for heart failure, it is recommended to follow guideline-directed medical therapy (GDMT). The carvedilol dosage ranges from 3.125 mg twice daily to 25 mg twice daily. [21]", "contents": "Carvedilol -- Administration -- Available Dosage Forms and Strengths. Carvedilol is an oral medication administered either twice daily in an immediate-release formulation or once daily in a controlled-release formulation. The dosage is tailored to each individual, considering their blood pressure and heart rate response. However, for heart failure, it is recommended to follow guideline-directed medical therapy (GDMT). The carvedilol dosage ranges from 3.125 mg twice daily to 25 mg twice daily. [21]"}
+{"id": "article-102_16", "title": "Carvedilol -- Administration -- Adult Dosage", "content": "According to the FDA product insert, the recommended dosing based on the indication is as follows:", "contents": "Carvedilol -- Administration -- Adult Dosage. According to the FDA product insert, the recommended dosing based on the indication is as follows:"}
+{"id": "article-102_17", "title": "Carvedilol -- Administration -- Adult Dosage", "content": "Heart failure: In managing heart failure, the initial dosage is initiated at 3.125 mg twice daily, with subsequent increments to 6.25 mg, 12.5 mg, and then 25 mg twice daily over at least 2 weeks intervals. Clinicians are advised to maintain\u00a0lower doses if higher doses are not well-tolerated by the patient.", "contents": "Carvedilol -- Administration -- Adult Dosage. Heart failure: In managing heart failure, the initial dosage is initiated at 3.125 mg twice daily, with subsequent increments to 6.25 mg, 12.5 mg, and then 25 mg twice daily over at least 2 weeks intervals. Clinicians are advised to maintain\u00a0lower doses if higher doses are not well-tolerated by the patient."}
+{"id": "article-102_18", "title": "Carvedilol -- Administration -- Adult Dosage", "content": "Left ventricular dysfunction following myocardial infarction: Initiation of dosing for this condition begins at 6.25 mg twice daily, with subsequent increments to 12.5 mg and then 25 mg twice daily, following intervals of 3 to 10 days. A lower starting dose or slower titration is considered an alternative option.", "contents": "Carvedilol -- Administration -- Adult Dosage. Left ventricular dysfunction following myocardial infarction: Initiation of dosing for this condition begins at 6.25 mg twice daily, with subsequent increments to 12.5 mg and then 25 mg twice daily, following intervals of 3 to 10 days. A lower starting dose or slower titration is considered an alternative option."}
+{"id": "article-102_19", "title": "Carvedilol -- Administration -- Adult Dosage", "content": "Hypertension: The recommended approach for treating hypertension is to initiate dosing at 6.25 mg twice daily, with adjustments permissible based on the necessity for blood pressure control, escalating to 12.5 mg, and eventually 25 mg twice daily, following intervals of 1 to 2 weeks. (2.3)", "contents": "Carvedilol -- Administration -- Adult Dosage. Hypertension: The recommended approach for treating hypertension is to initiate dosing at 6.25 mg twice daily, with adjustments permissible based on the necessity for blood pressure control, escalating to 12.5 mg, and eventually 25 mg twice daily, following intervals of 1 to 2 weeks. (2.3)"}
+{"id": "article-102_20", "title": "Carvedilol -- Administration -- Adult Dosage", "content": "A maximum permissible dose of up to 100 mg daily is applicable for patients with a body weight of over 85 kg.\u00a0GDMT for heart failure dictates the up-titration of carvedilol to 25 mg twice daily, as tolerated. [1] [4]", "contents": "Carvedilol -- Administration -- Adult Dosage. A maximum permissible dose of up to 100 mg daily is applicable for patients with a body weight of over 85 kg.\u00a0GDMT for heart failure dictates the up-titration of carvedilol to 25 mg twice daily, as tolerated. [1] [4]"}
+{"id": "article-102_21", "title": "Carvedilol -- Administration -- Specific Patient Populations", "content": "Hepatic impairment: In cases of hepatic impairment, NSBBs, such as carvedilol, may be used for primary prophylaxis in patients with ascites and are also recommended for secondary prophylaxis of variceal bleeding. However, close monitoring for hypotension, worsening renal function, and potential infection is essential, and cessation of NSBB may be warranted if such complications arise. Due to the increased\u00a0risk of hypotension, the use of carvedilol is contraindicated in patients with severe or refractory ascites. [22] Dosage adjustments are not required for mild-to-moderate hepatic impairment. However, due to carvedilol's extensive hepatic metabolism,\u00a0it is\u00a0contraindicated in patients with severe hepatic impairment. [23] Renal impairment: No dosage adjustments are necessary for patients with renal impairment.", "contents": "Carvedilol -- Administration -- Specific Patient Populations. Hepatic impairment: In cases of hepatic impairment, NSBBs, such as carvedilol, may be used for primary prophylaxis in patients with ascites and are also recommended for secondary prophylaxis of variceal bleeding. However, close monitoring for hypotension, worsening renal function, and potential infection is essential, and cessation of NSBB may be warranted if such complications arise. Due to the increased\u00a0risk of hypotension, the use of carvedilol is contraindicated in patients with severe or refractory ascites. [22] Dosage adjustments are not required for mild-to-moderate hepatic impairment. However, due to carvedilol's extensive hepatic metabolism,\u00a0it is\u00a0contraindicated in patients with severe hepatic impairment. [23] Renal impairment: No dosage adjustments are necessary for patients with renal impairment."}
+{"id": "article-102_22", "title": "Carvedilol -- Administration -- Specific Patient Populations", "content": "Pregnancy considerations: The Chronic Hypertension during Pregnancy (CHAP) study indicated that\u00a0targeting a blood pressure below 140/90 mm Hg reduces the incidence of adverse pregnancy outcomes without compromising fetal growth. [24] The\u00a0American College of Obstetricians and Gynecologists (ACOG)\u00a0recommends initiating or titrating pharmacological therapy for chronic hypertension in pregnancy when blood pressure reaches or exceeds 140/90. However, guidelines recommend labetalol as the preferred antihypertensive agent during pregnancy. [25]", "contents": "Carvedilol -- Administration -- Specific Patient Populations. Pregnancy considerations: The Chronic Hypertension during Pregnancy (CHAP) study indicated that\u00a0targeting a blood pressure below 140/90 mm Hg reduces the incidence of adverse pregnancy outcomes without compromising fetal growth. [24] The\u00a0American College of Obstetricians and Gynecologists (ACOG)\u00a0recommends initiating or titrating pharmacological therapy for chronic hypertension in pregnancy when blood pressure reaches or exceeds 140/90. However, guidelines recommend labetalol as the preferred antihypertensive agent during pregnancy. [25]"}
+{"id": "article-102_23", "title": "Carvedilol -- Administration -- Specific Patient Populations", "content": "Breastfeeding considerations: Carvedilol, with approximately 95% plasma protein binding and a relatively long half-life, exhibits minimal renal excretion at only 1%. There is no significant evidence of exposure or accumulation in breastfed infants. However, due to insufficient clinical data on carvedilol during breastfeeding, alternative drugs may be preferred, particularly in the case of preterm infants. [26] Pediatric patients: Carvedilol does not have FDA approval for use in pediatric patients. However, it has been used off-label in pediatric patients with heart failure. [27] Older patients: As older patients\u00a0may be more susceptible to adverse effects, caution is advised when transitioning from the immediate-release to the controlled-release formulation.", "contents": "Carvedilol -- Administration -- Specific Patient Populations. Breastfeeding considerations: Carvedilol, with approximately 95% plasma protein binding and a relatively long half-life, exhibits minimal renal excretion at only 1%. There is no significant evidence of exposure or accumulation in breastfed infants. However, due to insufficient clinical data on carvedilol during breastfeeding, alternative drugs may be preferred, particularly in the case of preterm infants. [26] Pediatric patients: Carvedilol does not have FDA approval for use in pediatric patients. However, it has been used off-label in pediatric patients with heart failure. [27] Older patients: As older patients\u00a0may be more susceptible to adverse effects, caution is advised when transitioning from the immediate-release to the controlled-release formulation."}
+{"id": "article-102_24", "title": "Carvedilol -- Adverse Effects", "content": "Carvedilol is a generally well-tolerated medication, exhibiting fewer frequent adverse events than other beta blockers, and adverse events are typically dose-related. [15] A post-marketing surveillance study reported that only 7% of patients taking carvedilol had to discontinue treatment due to adverse events. [16] The\u00a0most prevalent adverse effect of carvedilol is undesired, excessive hypotension resulting from its vasodilating properties, leading to symptoms such as dizziness, lightheadedness, fatigue, and headaches. Additional adverse effects associated with the drug's beta-blocking properties include dyspnea, bronchospasm, bradycardia, malaise, and asthenia. [15]", "contents": "Carvedilol -- Adverse Effects. Carvedilol is a generally well-tolerated medication, exhibiting fewer frequent adverse events than other beta blockers, and adverse events are typically dose-related. [15] A post-marketing surveillance study reported that only 7% of patients taking carvedilol had to discontinue treatment due to adverse events. [16] The\u00a0most prevalent adverse effect of carvedilol is undesired, excessive hypotension resulting from its vasodilating properties, leading to symptoms such as dizziness, lightheadedness, fatigue, and headaches. Additional adverse effects associated with the drug's beta-blocking properties include dyspnea, bronchospasm, bradycardia, malaise, and asthenia. [15]"}
+{"id": "article-102_25", "title": "Carvedilol -- Adverse Effects", "content": "Adverse reactions to carvedilol include weight gain, depression, impotence, and memory loss. Moreover, it is crucial to acknowledge that abruptly discontinuing carvedilol can result in rebound hypertension. Although hepatotoxicity from carvedilol is rare, mild-to-moderate elevations in aminotransferase levels have been observed in less than 2% of patients on carvedilol therapy. These elevations are generally asymptomatic and resolve even with the continuation of treatment. Consequently, clinically apparent liver injury from carvedilol is rare and may be associated with an idiosyncratic reaction to carvedilol or its metabolites. [28]", "contents": "Carvedilol -- Adverse Effects. Adverse reactions to carvedilol include weight gain, depression, impotence, and memory loss. Moreover, it is crucial to acknowledge that abruptly discontinuing carvedilol can result in rebound hypertension. Although hepatotoxicity from carvedilol is rare, mild-to-moderate elevations in aminotransferase levels have been observed in less than 2% of patients on carvedilol therapy. These elevations are generally asymptomatic and resolve even with the continuation of treatment. Consequently, clinically apparent liver injury from carvedilol is rare and may be associated with an idiosyncratic reaction to carvedilol or its metabolites. [28]"}
+{"id": "article-102_26", "title": "Carvedilol -- Adverse Effects -- Drug-Drug Interactions", "content": "Antidepressants: Antidepressants, including fluoxetine, duloxetine, paroxetine, and bupropion, serve as potent inhibitors of CYP2D6. Their use can increase the concentrations of beta blockers, including carvedilol, potentially\u00a0increasing the risk of\u00a0severe adverse events such as hypotension, bradycardia, and falls. [29] Digoxin: Carvedilol and digoxin both slow atrioventricular conduction and decrease the heart rate. Concomitant use\u00a0of carvedilol and digoxin\u00a0can increase the risk of bradycardia. [30]", "contents": "Carvedilol -- Adverse Effects -- Drug-Drug Interactions. Antidepressants: Antidepressants, including fluoxetine, duloxetine, paroxetine, and bupropion, serve as potent inhibitors of CYP2D6. Their use can increase the concentrations of beta blockers, including carvedilol, potentially\u00a0increasing the risk of\u00a0severe adverse events such as hypotension, bradycardia, and falls. [29] Digoxin: Carvedilol and digoxin both slow atrioventricular conduction and decrease the heart rate. Concomitant use\u00a0of carvedilol and digoxin\u00a0can increase the risk of bradycardia. [30]"}
+{"id": "article-102_27", "title": "Carvedilol -- Adverse Effects -- Drug-Drug Interactions", "content": "Clonidine: Patients taking a beta blocker with drugs that deplete catecholamines, such as reserpine and clonidine, should undergo close monitoring for indications of low blood pressure and severe bradycardia. In cases where discontinuation is necessary, carvedilol should be halted before clonidine, and the discontinuation of clonidine should be executed gradually. [31]", "contents": "Carvedilol -- Adverse Effects -- Drug-Drug Interactions. Clonidine: Patients taking a beta blocker with drugs that deplete catecholamines, such as reserpine and clonidine, should undergo close monitoring for indications of low blood pressure and severe bradycardia. In cases where discontinuation is necessary, carvedilol should be halted before clonidine, and the discontinuation of clonidine should be executed gradually. [31]"}
+{"id": "article-102_28", "title": "Carvedilol -- Adverse Effects -- Drug-Drug Interactions", "content": "Cyclosporine: Carvedilol increases blood concentrations of cyclosporine by inhibiting P-glycoprotein\u2013mediated transport in the intestine. Close monitoring of cyclosporine levels is recommended when initiating carvedilol. [32]", "contents": "Carvedilol -- Adverse Effects -- Drug-Drug Interactions. Cyclosporine: Carvedilol increases blood concentrations of cyclosporine by inhibiting P-glycoprotein\u2013mediated transport in the intestine. Close monitoring of cyclosporine levels is recommended when initiating carvedilol. [32]"}
+{"id": "article-102_29", "title": "Carvedilol -- Adverse Effects -- Drug-Drug Interactions", "content": "Amiodarone: Amiodarone and its metabolite inhibit CYP2C9 and P-glycoprotein, significantly increasing the concentration of carvedilol's S (-) enantiomer. This heightened concentration may enhance beta-blocking activity and potentially reduce heart rate or slow cardiac conduction. Furthermore, it is imperative to closely monitor for bradycardia or heart block, especially when coadministering amiodarone with carvedilol.", "contents": "Carvedilol -- Adverse Effects -- Drug-Drug Interactions. Amiodarone: Amiodarone and its metabolite inhibit CYP2C9 and P-glycoprotein, significantly increasing the concentration of carvedilol's S (-) enantiomer. This heightened concentration may enhance beta-blocking activity and potentially reduce heart rate or slow cardiac conduction. Furthermore, it is imperative to closely monitor for bradycardia or heart block, especially when coadministering amiodarone with carvedilol."}
+{"id": "article-102_30", "title": "Carvedilol -- Adverse Effects -- Drug-Drug Interactions", "content": "Nondihydropyridine\u00a0calcium channel blockers: Coadministration of carvedilol with diltiazem or verapamil has been associated with bradycardia accompanied by hemodynamic compromise. Electrocardiogram and blood pressure monitoring are advised when using carvedilol in conjunction with calcium channel blockers, such as verapamil or diltiazem. [33]", "contents": "Carvedilol -- Adverse Effects -- Drug-Drug Interactions. Nondihydropyridine\u00a0calcium channel blockers: Coadministration of carvedilol with diltiazem or verapamil has been associated with bradycardia accompanied by hemodynamic compromise. Electrocardiogram and blood pressure monitoring are advised when using carvedilol in conjunction with calcium channel blockers, such as verapamil or diltiazem. [33]"}
+{"id": "article-102_31", "title": "Carvedilol -- Contraindications", "content": "Absolute contraindications for using carvedilol include severe hypotension, second or third-degree AV block, sick sinus syndrome, severe bradycardia in the absence of a functional pacemaker, severe decompensated heart failure requiring inotropic support, and a history of a severe hypersensitivity reaction. Clinicians should exercise caution in patients with a history of asthma or reactive airway disease, with the recommendation to refrain from using carvedilol in individuals with active wheezing due to its beta-blocking properties. [34] Additionally, as discussed earlier, carvedilol is contraindicated in cases of severe hepatic impairment. [23]", "contents": "Carvedilol -- Contraindications. Absolute contraindications for using carvedilol include severe hypotension, second or third-degree AV block, sick sinus syndrome, severe bradycardia in the absence of a functional pacemaker, severe decompensated heart failure requiring inotropic support, and a history of a severe hypersensitivity reaction. Clinicians should exercise caution in patients with a history of asthma or reactive airway disease, with the recommendation to refrain from using carvedilol in individuals with active wheezing due to its beta-blocking properties. [34] Additionally, as discussed earlier, carvedilol is contraindicated in cases of severe hepatic impairment. [23]"}
+{"id": "article-102_32", "title": "Carvedilol -- Contraindications -- Warning and Precautions", "content": "Abrupt cessation of carvedilol: Patients\u00a0with coronary artery disease undergoing carvedilol therapy should steer clear of abruptly discontinuing treatment to prevent the risk of severe angina exacerbation, myocardial infarction, and ventricular arrhythmias. A recommended approach is the gradual discontinuation over 1 to 2 weeks. This caution extends to patients treated for hypertension or heart failure alone. Hypotension: Hypotension and syncope were observed in heart failure trials, especially during initial dosing. Caution and gradual up-titration are advised, particularly in\u00a0older patients.", "contents": "Carvedilol -- Contraindications -- Warning and Precautions. Abrupt cessation of carvedilol: Patients\u00a0with coronary artery disease undergoing carvedilol therapy should steer clear of abruptly discontinuing treatment to prevent the risk of severe angina exacerbation, myocardial infarction, and ventricular arrhythmias. A recommended approach is the gradual discontinuation over 1 to 2 weeks. This caution extends to patients treated for hypertension or heart failure alone. Hypotension: Hypotension and syncope were observed in heart failure trials, especially during initial dosing. Caution and gradual up-titration are advised, particularly in\u00a0older patients."}
+{"id": "article-102_33", "title": "Carvedilol -- Contraindications -- Warning and Precautions", "content": "Nonallergic bronchospasm: Beta blockers are generally avoided in bronchospastic diseases such as chronic obstructive pulmonary disease. Thus, caution should be exercised when using carvedilol in such cases. Thyrotoxicosis: Beta blockers have the potential to mask symptoms of hyperthyroidism, and abrupt withdrawal may exacerbate hyperthyroidism. [35] Floppy iris syndrome: Carvedilol's alpha-1\u2013blocking property in cataract surgery may increase the risk of intraoperative floppy iris syndrome. [36]", "contents": "Carvedilol -- Contraindications -- Warning and Precautions. Nonallergic bronchospasm: Beta blockers are generally avoided in bronchospastic diseases such as chronic obstructive pulmonary disease. Thus, caution should be exercised when using carvedilol in such cases. Thyrotoxicosis: Beta blockers have the potential to mask symptoms of hyperthyroidism, and abrupt withdrawal may exacerbate hyperthyroidism. [35] Floppy iris syndrome: Carvedilol's alpha-1\u2013blocking property in cataract surgery may increase the risk of intraoperative floppy iris syndrome. [36]"}
+{"id": "article-102_34", "title": "Carvedilol -- Monitoring", "content": "Vital signs, such as blood pressure and heart rate, should be monitored before initiation and at each dose titration. Individuals undergoing heart failure treatment necessitate vigilant monitoring for any indications of decompensation. Assessing the patient's renal function is advisable, particularly in the presence of risk factors for renal impairment. A study also suggested an elevated risk of hypoglycemia in hospitalized patients receiving carvedilol. Furthermore, beta blockers, including carvedilol, have demonstrated the ability to prevent the autonomic response during hypoglycemia. Therefore, regular monitoring of blood glucose levels is imperative for patients undergoing carvedilol therapy. [37]", "contents": "Carvedilol -- Monitoring. Vital signs, such as blood pressure and heart rate, should be monitored before initiation and at each dose titration. Individuals undergoing heart failure treatment necessitate vigilant monitoring for any indications of decompensation. Assessing the patient's renal function is advisable, particularly in the presence of risk factors for renal impairment. A study also suggested an elevated risk of hypoglycemia in hospitalized patients receiving carvedilol. Furthermore, beta blockers, including carvedilol, have demonstrated the ability to prevent the autonomic response during hypoglycemia. Therefore, regular monitoring of blood glucose levels is imperative for patients undergoing carvedilol therapy. [37]"}
+{"id": "article-102_35", "title": "Carvedilol -- Monitoring", "content": "In addition, it is recommended to monitor serum digoxin levels in high-risk patients taking carvedilol, as it can increase exposure to digoxin. [38] The response to therapy can be monitored by assessing Kansas City Cardiomyopathy Questionnaire scores in heart failure patients. Moreover, it is noteworthy that predischarge NT-proBNP levels can serve as valuable indicators for monitoring the patient's clinical course and determining postdischarge prognosis. [3]", "contents": "Carvedilol -- Monitoring. In addition, it is recommended to monitor serum digoxin levels in high-risk patients taking carvedilol, as it can increase exposure to digoxin. [38] The response to therapy can be monitored by assessing Kansas City Cardiomyopathy Questionnaire scores in heart failure patients. Moreover, it is noteworthy that predischarge NT-proBNP levels can serve as valuable indicators for monitoring the patient's clinical course and determining postdischarge prognosis. [3]"}
+{"id": "article-102_36", "title": "Carvedilol -- Toxicity", "content": "Toxicity is primarily treated with supportive care and acute stabilization through specific therapies based on the clinical features. Treatment for symptomatic bradycardia or heart block involves isotonic fluid administration and intravenous (IV) atropine. In cases of bronchospasm, options include beta-sympathomimetic agents (administered as aerosol or IV) or IV aminophylline. Depending on the extent of hemodynamic instability, interventions may involve the insertion of a temporary pacemaker or using inotropic or vasopressor medications. IV glucagon is commonly utilized as a first-line therapy and adjunct to supportive treatment for reversing the effects of beta-blocker toxicity. [39]", "contents": "Carvedilol -- Toxicity. Toxicity is primarily treated with supportive care and acute stabilization through specific therapies based on the clinical features. Treatment for symptomatic bradycardia or heart block involves isotonic fluid administration and intravenous (IV) atropine. In cases of bronchospasm, options include beta-sympathomimetic agents (administered as aerosol or IV) or IV aminophylline. Depending on the extent of hemodynamic instability, interventions may involve the insertion of a temporary pacemaker or using inotropic or vasopressor medications. IV glucagon is commonly utilized as a first-line therapy and adjunct to supportive treatment for reversing the effects of beta-blocker toxicity. [39]"}
+{"id": "article-102_37", "title": "Carvedilol -- Toxicity", "content": "Severe cases of poisoning may require intubation due to respiratory failure. Cardiopulmonary resuscitation should be carried out according to the AHA advanced cardiac life support (ACLS) protocol. [40] The options for\u00a0bronchospasm include beta-sympathomimetic agents (administered as aerosol or IV) or IV aminophylline.\u00a0Notably,\u00a0as carvedilol is a lipid-soluble drug, it has the potential to induce neuropsychiatric manifestations, such as depression and seizures. For generalized tonic-clonic seizures, the American Epilepsy Society recommends IV lorazepam as the preferred choice. [41] IV lipid emulsion therapy has been used to treat carvedilol toxicity due to its lipophilic nature. [42] [43]", "contents": "Carvedilol -- Toxicity. Severe cases of poisoning may require intubation due to respiratory failure. Cardiopulmonary resuscitation should be carried out according to the AHA advanced cardiac life support (ACLS) protocol. [40] The options for\u00a0bronchospasm include beta-sympathomimetic agents (administered as aerosol or IV) or IV aminophylline.\u00a0Notably,\u00a0as carvedilol is a lipid-soluble drug, it has the potential to induce neuropsychiatric manifestations, such as depression and seizures. For generalized tonic-clonic seizures, the American Epilepsy Society recommends IV lorazepam as the preferred choice. [41] IV lipid emulsion therapy has been used to treat carvedilol toxicity due to its lipophilic nature. [42] [43]"}
+{"id": "article-102_38", "title": "Carvedilol -- Enhancing Healthcare Team Outcomes", "content": "Carvedilol, a nonselective adrenergic blocker, is indicated for HFrEF, hypertension, and left ventricular dysfunction following myocardial infarction in clinically stable patients. Effective management of these conditions with this agent necessitates the coordinated involvement of an interprofessional healthcare team. The ordering or prescribing of carvedilol is typically done by a clinician or specialist as deemed appropriate. Nevertheless, the active participation of a pharmacist is crucial to guarantee accurate dosing tailored to the specific condition and patient, as well as to verify potential drug interactions. Any concerns the pharmacist identifies should be promptly communicated to the prescriber, enabling them to consider alternative therapy if necessary.", "contents": "Carvedilol -- Enhancing Healthcare Team Outcomes. Carvedilol, a nonselective adrenergic blocker, is indicated for HFrEF, hypertension, and left ventricular dysfunction following myocardial infarction in clinically stable patients. Effective management of these conditions with this agent necessitates the coordinated involvement of an interprofessional healthcare team. The ordering or prescribing of carvedilol is typically done by a clinician or specialist as deemed appropriate. Nevertheless, the active participation of a pharmacist is crucial to guarantee accurate dosing tailored to the specific condition and patient, as well as to verify potential drug interactions. Any concerns the pharmacist identifies should be promptly communicated to the prescriber, enabling them to consider alternative therapy if necessary."}
+{"id": "article-102_39", "title": "Carvedilol -- Enhancing Healthcare Team Outcomes", "content": "Nurses are responsible for administering a particular drug a clinician prescribes in both inpatient and outpatient settings. They provide counseling to the patient on appropriate administration, educate them about potential adverse effects to monitor, and address any questions they may have. Furthermore, nurses\u00a0are critical in verifying patient adherence, observing potential adverse effects during follow-up visits, and reporting any concerns to the clinician. Therefore, interprofessional healthcare teams should collaborate to vigilantly watch signs and symptoms of toxicity, monitor treatment progress, and optimize outcomes. Furthermore, a study has shown that GDMT, including carvedilol, can significantly reduce mortality in patients with HFrEF. [44] An interprofessional team should implement this guideline-directed approach that utilizes coordinated care and open communication to drive improved patient outcomes.", "contents": "Carvedilol -- Enhancing Healthcare Team Outcomes. Nurses are responsible for administering a particular drug a clinician prescribes in both inpatient and outpatient settings. They provide counseling to the patient on appropriate administration, educate them about potential adverse effects to monitor, and address any questions they may have. Furthermore, nurses\u00a0are critical in verifying patient adherence, observing potential adverse effects during follow-up visits, and reporting any concerns to the clinician. Therefore, interprofessional healthcare teams should collaborate to vigilantly watch signs and symptoms of toxicity, monitor treatment progress, and optimize outcomes. Furthermore, a study has shown that GDMT, including carvedilol, can significantly reduce mortality in patients with HFrEF. [44] An interprofessional team should implement this guideline-directed approach that utilizes coordinated care and open communication to drive improved patient outcomes."}
+{"id": "article-102_40", "title": "Carvedilol -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Carvedilol -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

statpearls/chunk/article-102110.jsonl

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+{"id": "article-102110_0", "title": "Neck Rejuvenation -- Continuing Education Activity", "content": "Neck rejuvenation can address loose skin over the neck, platysmal bands, and effacement of the cervicomental angle. This activity reviews the evaluation of the aging neck and the roles the interprofessional team and a growing number of treatment modalities play in its management.", "contents": "Neck Rejuvenation -- Continuing Education Activity. Neck rejuvenation can address loose skin over the neck, platysmal bands, and effacement of the cervicomental angle. This activity reviews the evaluation of the aging neck and the roles the interprofessional team and a growing number of treatment modalities play in its management."}
+{"id": "article-102110_1", "title": "Neck Rejuvenation -- Continuing Education Activity", "content": "Objectives: Explain the appropriate selection of candidates for neck rejuvenation surgery. Identify the indications for neck rejuvenation surgery. Discuss the technical aspects of neck rejuvenation surgery. Review the complications associated with neck rejuvenation surgery. Access free multiple choice questions on this topic.", "contents": "Neck Rejuvenation -- Continuing Education Activity. Objectives: Explain the appropriate selection of candidates for neck rejuvenation surgery. Identify the indications for neck rejuvenation surgery. Discuss the technical aspects of neck rejuvenation surgery. Review the complications associated with neck rejuvenation surgery. Access free multiple choice questions on this topic."}
+{"id": "article-102110_2", "title": "Neck Rejuvenation -- Introduction", "content": "A common complaint of patients presenting for facial cosmetic evaluation is the appearance of aging in the neck. Specifically, vertical lines visible at the medial borders of the platysma muscles - known as platysmal bands - accumulation of fat in the submental area, and effacement of the cervicomental angle are frequently mentioned. Multiple options with varying degrees of invasiveness are available to address these concerns, such as neck lift with or without platysmaplasty, submental liposuction, deoxycholic acid injection, cryotherapy, botulinum toxin injection, and skin resurfacing, among others.", "contents": "Neck Rejuvenation -- Introduction. A common complaint of patients presenting for facial cosmetic evaluation is the appearance of aging in the neck. Specifically, vertical lines visible at the medial borders of the platysma muscles - known as platysmal bands - accumulation of fat in the submental area, and effacement of the cervicomental angle are frequently mentioned. Multiple options with varying degrees of invasiveness are available to address these concerns, such as neck lift with or without platysmaplasty, submental liposuction, deoxycholic acid injection, cryotherapy, botulinum toxin injection, and skin resurfacing, among others."}
+{"id": "article-102110_3", "title": "Neck Rejuvenation -- Introduction", "content": "Determining the appropriate treatment modality will depend on patient preference and goals, budget, general health, and underlying anatomy. Frequently, these procedures will be combined with other interventions, like face lifting and blepharoplasty, or dermal filler injections. Surgeons will often need to pair with allied healthcare personnel, such as injection nurses and aestheticians, in order to maximize patients' results and satisfaction. [1]", "contents": "Neck Rejuvenation -- Introduction. Determining the appropriate treatment modality will depend on patient preference and goals, budget, general health, and underlying anatomy. Frequently, these procedures will be combined with other interventions, like face lifting and blepharoplasty, or dermal filler injections. Surgeons will often need to pair with allied healthcare personnel, such as injection nurses and aestheticians, in order to maximize patients' results and satisfaction. [1]"}
+{"id": "article-102110_4", "title": "Neck Rejuvenation -- Anatomy and Physiology", "content": "Understanding the superficial anatomy of the neck is critical to not only selecting and planning the appropriate procedure but also documenting physical findings. The most commonly used system of categorizing aging neck changes is the Dedo classification, which follows: [2] Normal Skin laxity only Neck adiposity Platysmal banding Retrognathia Low lying hyoid", "contents": "Neck Rejuvenation -- Anatomy and Physiology. Understanding the superficial anatomy of the neck is critical to not only selecting and planning the appropriate procedure but also documenting physical findings. The most commonly used system of categorizing aging neck changes is the Dedo classification, which follows: [2] Normal Skin laxity only Neck adiposity Platysmal banding Retrognathia Low lying hyoid"}
+{"id": "article-102110_5", "title": "Neck Rejuvenation -- Anatomy and Physiology", "content": "Each successive category is more difficult to address than the last, with skin laxity easily reduced with a conservative neck lift. Underneath the skin, there is subdermal fat, which can be removed with liposuction, deoxycholic acid injection, and cryotherapy; liposuction is commonly combined with surgical neck lifting in the operating room. Beneath the subdermal fat lies the thin sheet of the platysma muscle. This muscle is contiguous with the mimetic muscles and superficial musculoaponeurotic system (SMAS) of the face; it produces the vertical bands seen in an aging neck when the medial borders dehisce away from each other and move laterally. Suturing the medial borders of the platysma back together during a platysmaplasty both helps to reduce the appearance of vertical bands and provides a strong sling that can be suspended laterally in order to restore a more youthful cervicomental angle during a neck lift. In the case of severe vertical banding, the platysma may be divided transversely at the level of the hyoid bone to further reduce the bands and redefine the cervicomental angle. [3]", "contents": "Neck Rejuvenation -- Anatomy and Physiology. Each successive category is more difficult to address than the last, with skin laxity easily reduced with a conservative neck lift. Underneath the skin, there is subdermal fat, which can be removed with liposuction, deoxycholic acid injection, and cryotherapy; liposuction is commonly combined with surgical neck lifting in the operating room. Beneath the subdermal fat lies the thin sheet of the platysma muscle. This muscle is contiguous with the mimetic muscles and superficial musculoaponeurotic system (SMAS) of the face; it produces the vertical bands seen in an aging neck when the medial borders dehisce away from each other and move laterally. Suturing the medial borders of the platysma back together during a platysmaplasty both helps to reduce the appearance of vertical bands and provides a strong sling that can be suspended laterally in order to restore a more youthful cervicomental angle during a neck lift. In the case of severe vertical banding, the platysma may be divided transversely at the level of the hyoid bone to further reduce the bands and redefine the cervicomental angle. [3]"}
+{"id": "article-102110_6", "title": "Neck Rejuvenation -- Anatomy and Physiology", "content": "Subplatysmal fat occupies the space between the platysma superficially and the deeper strap muscles that cover the larynx; this fat may be excised directly, if necessary, but should not be addressed blindly with liposuction due to the danger of injuring nearby vessels, nerves, and viscera. Retrognathia or microgenia and unfavorable hyoid position are important to recognize preoperatively because they will both contribute to a poor surgical outcome, but addressing them is not a typical part of neck rejuvenation procedures.", "contents": "Neck Rejuvenation -- Anatomy and Physiology. Subplatysmal fat occupies the space between the platysma superficially and the deeper strap muscles that cover the larynx; this fat may be excised directly, if necessary, but should not be addressed blindly with liposuction due to the danger of injuring nearby vessels, nerves, and viscera. Retrognathia or microgenia and unfavorable hyoid position are important to recognize preoperatively because they will both contribute to a poor surgical outcome, but addressing them is not a typical part of neck rejuvenation procedures."}
+{"id": "article-102110_7", "title": "Neck Rejuvenation -- Anatomy and Physiology", "content": "In addition to the structures referred to in the Dedo classification system, it is important to be aware of several other factors when considering cervical procedures. The submandibular glands may be prominent or ptotic, the appearance of which may be unpleasantly exacerbated by tightening the neck surgically or reducing submental adiposity; in some cases, reduction or removal of the glands may be considered. [4]", "contents": "Neck Rejuvenation -- Anatomy and Physiology. In addition to the structures referred to in the Dedo classification system, it is important to be aware of several other factors when considering cervical procedures. The submandibular glands may be prominent or ptotic, the appearance of which may be unpleasantly exacerbated by tightening the neck surgically or reducing submental adiposity; in some cases, reduction or removal of the glands may be considered. [4]"}
+{"id": "article-102110_8", "title": "Neck Rejuvenation -- Anatomy and Physiology", "content": "Evaluating the skin quality is important as well, given that the neck skin often shows similar signs of sun damage to those seen on the face, but the neck skin is thinner and has fewer dermal appendages, making it less resilient to resurfacing efforts. While most of the critical structures in the neck are located deeply, such as the carotid artery, larynx, internal jugular vein, and thyroid gland, there are some nerves and vessels at risk during cervical rhytidectomy. The marginal mandibular branch of the facial nerve is often\u00a0found 1\u00a0to 2 cm inferior to the inferior border of the mandible\u00a0posteriorly but crosses the mandible anteriorly on its course back up into the face to innervate the depressors of the lower lip. The cervical branch of the facial nerve innevates the platysma and is not as commonly injured as the marginal mandibular branch, but because the two nerves occasional split from a common trunk, the cervical branch may also contribute innervation to the lower lip depressors; therefore, injury to this branch may also result in weakness of the lower lip. [5] [6]", "contents": "Neck Rejuvenation -- Anatomy and Physiology. Evaluating the skin quality is important as well, given that the neck skin often shows similar signs of sun damage to those seen on the face, but the neck skin is thinner and has fewer dermal appendages, making it less resilient to resurfacing efforts. While most of the critical structures in the neck are located deeply, such as the carotid artery, larynx, internal jugular vein, and thyroid gland, there are some nerves and vessels at risk during cervical rhytidectomy. The marginal mandibular branch of the facial nerve is often\u00a0found 1\u00a0to 2 cm inferior to the inferior border of the mandible\u00a0posteriorly but crosses the mandible anteriorly on its course back up into the face to innervate the depressors of the lower lip. The cervical branch of the facial nerve innevates the platysma and is not as commonly injured as the marginal mandibular branch, but because the two nerves occasional split from a common trunk, the cervical branch may also contribute innervation to the lower lip depressors; therefore, injury to this branch may also result in weakness of the lower lip. [5] [6]"}
+{"id": "article-102110_9", "title": "Neck Rejuvenation -- Anatomy and Physiology", "content": "In the face proper, this nerve branch typically runs along with or even wraps around the distal aspect of the facial vein; damage to the nerve results in the inability to depress the lower lip and causes an asymmetric smile. More commonly injured, however, is the great auricular nerve, which lies deep and lateral to the platysma and courses over the sternocleidomastoid between Erb's point and the inferior aspect of the auricle. Roughly 1 cm anterior to this nerve lies the external jugular vein, which is also at risk for injury during rhytidectomy. [2]", "contents": "Neck Rejuvenation -- Anatomy and Physiology. In the face proper, this nerve branch typically runs along with or even wraps around the distal aspect of the facial vein; damage to the nerve results in the inability to depress the lower lip and causes an asymmetric smile. More commonly injured, however, is the great auricular nerve, which lies deep and lateral to the platysma and courses over the sternocleidomastoid between Erb's point and the inferior aspect of the auricle. Roughly 1 cm anterior to this nerve lies the external jugular vein, which is also at risk for injury during rhytidectomy. [2]"}
+{"id": "article-102110_10", "title": "Neck Rejuvenation -- Indications", "content": "Because there are numerous physical examination findings and specific chief complaints with respect to the aging neck, a discussion of indications for intervention should focus on the specific anatomical changes encountered in an individual patient. For example, skin laxity is easily addressed with a neck lift procedure, but if the skin appears wrinkled in the absence of significant redundancy, CO2 or Er:YAG laser resurfacing with conservative settings may be a more appropriate treatment modality.", "contents": "Neck Rejuvenation -- Indications. Because there are numerous physical examination findings and specific chief complaints with respect to the aging neck, a discussion of indications for intervention should focus on the specific anatomical changes encountered in an individual patient. For example, skin laxity is easily addressed with a neck lift procedure, but if the skin appears wrinkled in the absence of significant redundancy, CO2 or Er:YAG laser resurfacing with conservative settings may be a more appropriate treatment modality."}
+{"id": "article-102110_11", "title": "Neck Rejuvenation -- Indications", "content": "Similarly, if mild platysmal banding is the only complaint, injection of 10\u00a0to 30 units of onabotulinumtoxin, or its equivalent, per side may correct the issue; however, if vertical platysmal bands and skin redundancy are present together, a plastymaplasty can address the banding during the rhytidectomy for skin laxity. Submental liposuction can be performed for excess adiposity on its own or in conjunction with rhytidectomy; cryotherapy, radiofrequency ablation, and deoxycholic acid injections can also be used to reduce submental fat, typically as stand-alone procedures.", "contents": "Neck Rejuvenation -- Indications. Similarly, if mild platysmal banding is the only complaint, injection of 10\u00a0to 30 units of onabotulinumtoxin, or its equivalent, per side may correct the issue; however, if vertical platysmal bands and skin redundancy are present together, a plastymaplasty can address the banding during the rhytidectomy for skin laxity. Submental liposuction can be performed for excess adiposity on its own or in conjunction with rhytidectomy; cryotherapy, radiofrequency ablation, and deoxycholic acid injections can also be used to reduce submental fat, typically as stand-alone procedures."}
+{"id": "article-102110_12", "title": "Neck Rejuvenation -- Contraindications", "content": "Contraindications for cosmetic procedures of the neck include poor health that may increase the risk of cardiopulmonary complications under general anesthesia, unreasonable expectations for outcomes, and any conditions liable to result in postoperative complications.", "contents": "Neck Rejuvenation -- Contraindications. Contraindications for cosmetic procedures of the neck include poor health that may increase the risk of cardiopulmonary complications under general anesthesia, unreasonable expectations for outcomes, and any conditions liable to result in postoperative complications."}
+{"id": "article-102110_13", "title": "Neck Rejuvenation -- Contraindications", "content": "More specifically, patients with bleeding disorders or a requirement for ongoing anticoagulant therapy are more likely to develop a hematoma after rhytidectomy. Patients with poorly-controlled diabetes, vasculitides, recent smoking history, a history of scarring or poor wound healing, or immunomodulatory therapy may be at risk for delayed or suboptimal wound healing that may cause infection, scarring, or skin necrosis. [7]", "contents": "Neck Rejuvenation -- Contraindications. More specifically, patients with bleeding disorders or a requirement for ongoing anticoagulant therapy are more likely to develop a hematoma after rhytidectomy. Patients with poorly-controlled diabetes, vasculitides, recent smoking history, a history of scarring or poor wound healing, or immunomodulatory therapy may be at risk for delayed or suboptimal wound healing that may cause infection, scarring, or skin necrosis. [7]"}
+{"id": "article-102110_14", "title": "Neck Rejuvenation -- Equipment", "content": "Equipment required for a surgical neck lift typically includes a skin marker, local anesthetic or tumescent solution, #15 blade scalpel, retractor and light source, facelift scissors, needle drivers, electrocautery, suction, and sutures for both soft tissue suspension and skin closure. Heavy 2-0 or 3-0 polyester, polydioxanone, or polyglactin sutures work well for reapproximating the medial borders of the platysma. Smaller 4-0, 5-0, and 6-0 sutures are used for layered skin closure. A Barton-style dressing with ice packs is typically applied at the conclusion of the procedure.", "contents": "Neck Rejuvenation -- Equipment. Equipment required for a surgical neck lift typically includes a skin marker, local anesthetic or tumescent solution, #15 blade scalpel, retractor and light source, facelift scissors, needle drivers, electrocautery, suction, and sutures for both soft tissue suspension and skin closure. Heavy 2-0 or 3-0 polyester, polydioxanone, or polyglactin sutures work well for reapproximating the medial borders of the platysma. Smaller 4-0, 5-0, and 6-0 sutures are used for layered skin closure. A Barton-style dressing with ice packs is typically applied at the conclusion of the procedure."}
+{"id": "article-102110_15", "title": "Neck Rejuvenation -- Equipment", "content": "Skin resurfacing can be accomplished with numerous different systems, including carbon dioxide, diode, and erbium-doped yttrium-aluminum-garnet lasers, as well as broadband or intense pulsed light. If these systems are unavailable, a superficial chemical peel may also produce the desired effect. Other modalities, such as cryoablation and radiofrequency ablation, may also be used to reduce excess adiposity, and these procedures require specialized equipment to perform. Injection of botulinum toxin and deoxycholic acid requires minimal equipment: sterile saline, hypodermic needles, and a syringe.", "contents": "Neck Rejuvenation -- Equipment. Skin resurfacing can be accomplished with numerous different systems, including carbon dioxide, diode, and erbium-doped yttrium-aluminum-garnet lasers, as well as broadband or intense pulsed light. If these systems are unavailable, a superficial chemical peel may also produce the desired effect. Other modalities, such as cryoablation and radiofrequency ablation, may also be used to reduce excess adiposity, and these procedures require specialized equipment to perform. Injection of botulinum toxin and deoxycholic acid requires minimal equipment: sterile saline, hypodermic needles, and a syringe."}
+{"id": "article-102110_16", "title": "Neck Rejuvenation -- Personnel", "content": "Surgical interventions require an anesthesia provider, an operating room circulator nurse, a technologist, a surgeon, and potentially an additional surgical assistant, such as an RN first-assist or a physician assistant. Non-surgical treatments, like injections, can often be performed by a surgeon, a non-surgeon physician, such as a dermatologist, or a non-physician, such as a physician assistant or nurse.", "contents": "Neck Rejuvenation -- Personnel. Surgical interventions require an anesthesia provider, an operating room circulator nurse, a technologist, a surgeon, and potentially an additional surgical assistant, such as an RN first-assist or a physician assistant. Non-surgical treatments, like injections, can often be performed by a surgeon, a non-surgeon physician, such as a dermatologist, or a non-physician, such as a physician assistant or nurse."}
+{"id": "article-102110_17", "title": "Neck Rejuvenation -- Preparation", "content": "The most important aspect of preparation for any cosmetic procedure is patient counseling and expectation management. Treatment, surgical or otherwise, should not begin until the surgeon or other healthcare provider feels that the patient's goals and expectations are consistent with anticipated outcomes. Additionally, surgical patients should ideally temporarily discontinue anticoagulant therapy and quit smoking, if applicable.", "contents": "Neck Rejuvenation -- Preparation. The most important aspect of preparation for any cosmetic procedure is patient counseling and expectation management. Treatment, surgical or otherwise, should not begin until the surgeon or other healthcare provider feels that the patient's goals and expectations are consistent with anticipated outcomes. Additionally, surgical patients should ideally temporarily discontinue anticoagulant therapy and quit smoking, if applicable."}
+{"id": "article-102110_18", "title": "Neck Rejuvenation -- Preparation", "content": "Facial and great auricular nerve function should be evaluated and documented prior to rhytidectomy. Having preoperative photographs of the patient posted in the operating room for reference during the case is also helpful. The patient's jowls and platysmal bands should be marked while the patient is sitting upright, and the nurse performing the surgical scrub should avoid smearing or removing the marks.", "contents": "Neck Rejuvenation -- Preparation. Facial and great auricular nerve function should be evaluated and documented prior to rhytidectomy. Having preoperative photographs of the patient posted in the operating room for reference during the case is also helpful. The patient's jowls and platysmal bands should be marked while the patient is sitting upright, and the nurse performing the surgical scrub should avoid smearing or removing the marks."}
+{"id": "article-102110_19", "title": "Neck Rejuvenation -- Preparation", "content": "Regardless of whether the plan is for general anesthesia or not, injection of local anesthetic or tumescent solution will help to lower the analgesic requirement and aid hemostasis. Intravenous steroids will decrease edema and nausea in the immediate postoperative period, facilitating the patient's discharge home. [8]", "contents": "Neck Rejuvenation -- Preparation. Regardless of whether the plan is for general anesthesia or not, injection of local anesthetic or tumescent solution will help to lower the analgesic requirement and aid hemostasis. Intravenous steroids will decrease edema and nausea in the immediate postoperative period, facilitating the patient's discharge home. [8]"}
+{"id": "article-102110_20", "title": "Neck Rejuvenation -- Technique or Treatment", "content": "Submentoplasty [3] [9] [10]", "contents": "Neck Rejuvenation -- Technique or Treatment. Submentoplasty [3] [9] [10]"}
+{"id": "article-102110_21", "title": "Neck Rejuvenation -- Technique or Treatment", "content": "A skin incision is marked in a transverse submental crease, centered and roughly 3 cm in length. A #15 blade is then used to make a single stab incision in the center of the planned incision as well as two more, 1\u00a0to 2 mm inferior to the attachment of each ear lobule. A 2\u00a0to 3 mm liposuction cannula on a 10 cc syringe is then inserted through the stab incisions, the submental one first, and subsequently the lateral ones. Care should be taken to face the opening of the cannula away from the dermis so as not to cause postoperative texture irregularities or disrupt the blood supply to the skin.", "contents": "Neck Rejuvenation -- Technique or Treatment. A skin incision is marked in a transverse submental crease, centered and roughly 3 cm in length. A #15 blade is then used to make a single stab incision in the center of the planned incision as well as two more, 1\u00a0to 2 mm inferior to the attachment of each ear lobule. A 2\u00a0to 3 mm liposuction cannula on a 10 cc syringe is then inserted through the stab incisions, the submental one first, and subsequently the lateral ones. Care should be taken to face the opening of the cannula away from the dermis so as not to cause postoperative texture irregularities or disrupt the blood supply to the skin."}
+{"id": "article-102110_22", "title": "Neck Rejuvenation -- Technique or Treatment", "content": "Dry passes are made with the cannula under the skin to create tunnels prior to applying suction. The assistant should retract the skin away from the surgeon to create appropriate counter tension. The cannula's tip should be just visibly tenting the skin in order to ensure the liposuction remains sufficiently superficial to avoid damaging blood vessels or other important structures. The area of cannula dissection should remain superior to the hyoid and inferior to the border of the mandible, in order to avoid injury to the marginal mandibular nerve and larynx. Maintaining this plane will also facilitate later flap elevation.", "contents": "Neck Rejuvenation -- Technique or Treatment. Dry passes are made with the cannula under the skin to create tunnels prior to applying suction. The assistant should retract the skin away from the surgeon to create appropriate counter tension. The cannula's tip should be just visibly tenting the skin in order to ensure the liposuction remains sufficiently superficial to avoid damaging blood vessels or other important structures. The area of cannula dissection should remain superior to the hyoid and inferior to the border of the mandible, in order to avoid injury to the marginal mandibular nerve and larynx. Maintaining this plane will also facilitate later flap elevation."}
+{"id": "article-102110_23", "title": "Neck Rejuvenation -- Technique or Treatment", "content": "The submental incision is then made, allowing dissection to enter the subcutaneous plane. The skin flap is retracted with a double prong skin hook toward the surgeon while the assistant provides counter tension. Facelift scissors, such as Gorney-Freeman or Goldman-Fox scissors, are used to dissect in a subcutaneous plane from the submentum past the level of the hyoid. As the dissection proceeds inferiorly, a facelift retractor can be exchanged for the skin hook. Once the platysma borders are identified, additional lipectomy may be performed in between the muscle bellies, if necessary.", "contents": "Neck Rejuvenation -- Technique or Treatment. The submental incision is then made, allowing dissection to enter the subcutaneous plane. The skin flap is retracted with a double prong skin hook toward the surgeon while the assistant provides counter tension. Facelift scissors, such as Gorney-Freeman or Goldman-Fox scissors, are used to dissect in a subcutaneous plane from the submentum past the level of the hyoid. As the dissection proceeds inferiorly, a facelift retractor can be exchanged for the skin hook. Once the platysma borders are identified, additional lipectomy may be performed in between the muscle bellies, if necessary."}
+{"id": "article-102110_24", "title": "Neck Rejuvenation -- Technique or Treatment", "content": "A plane is developed along the undersurface of the platysma and carried 1\u00a0to 2 cm laterally. Fat on the deep surface may need to be removed; however, excessive fat removal in this area can lead to a cobra neck deformity. The fat that has been removed should be kept in saline in the event it needs to be replaced. If the cervicomental angle is extremely obtuse, the surgeon can dissect the platysma's medial border at the level of the hyoid and divide it transversely. The medial platysmal borders are then approximated with 3 or 4 buried, interrupted sutures between the hyoid and the mentum. Neck Lift [10] [11]", "contents": "Neck Rejuvenation -- Technique or Treatment. A plane is developed along the undersurface of the platysma and carried 1\u00a0to 2 cm laterally. Fat on the deep surface may need to be removed; however, excessive fat removal in this area can lead to a cobra neck deformity. The fat that has been removed should be kept in saline in the event it needs to be replaced. If the cervicomental angle is extremely obtuse, the surgeon can dissect the platysma's medial border at the level of the hyoid and divide it transversely. The medial platysmal borders are then approximated with 3 or 4 buried, interrupted sutures between the hyoid and the mentum. Neck Lift [10] [11]"}
+{"id": "article-102110_25", "title": "Neck Rejuvenation -- Technique or Treatment", "content": "Attention is now turned to the facial incisions. An abbreviated Blair incision is marked starting anterior to the lobule and proceeding onto the posterior surface of the auricle, and then posteriorly and inferiorly into the hairline. The incision is made with a #15 blade through the dermis and into a subcutaneous plane. Countertension should be applied on the neck, and the flap developed using facelift scissors. Casta\u00f1ares scissors are particularly helpful to divide the tough soft tissue attachments over the mastoid. Elevation then continues anteriorly to join the submental dissection. The flap is subdermal/supraplatysmal; therefore, the great auricular nerve and external jugular vein should not be at risk if the correct plane is maintained.", "contents": "Neck Rejuvenation -- Technique or Treatment. Attention is now turned to the facial incisions. An abbreviated Blair incision is marked starting anterior to the lobule and proceeding onto the posterior surface of the auricle, and then posteriorly and inferiorly into the hairline. The incision is made with a #15 blade through the dermis and into a subcutaneous plane. Countertension should be applied on the neck, and the flap developed using facelift scissors. Casta\u00f1ares scissors are particularly helpful to divide the tough soft tissue attachments over the mastoid. Elevation then continues anteriorly to join the submental dissection. The flap is subdermal/supraplatysmal; therefore, the great auricular nerve and external jugular vein should not be at risk if the correct plane is maintained."}
+{"id": "article-102110_26", "title": "Neck Rejuvenation -- Technique or Treatment", "content": "The surgeon places two\u00a0non-absorbable\u00a0sutures as buried half mattresses between the lateral border of the platysma and the mastoid periosteum. The vector of pull will be roughly parallel to the posterior border of the helix. The first suture is placed superiorly and the second more inferiorly. After hemostasis is obtained, the skin flaps are tailored to eliminate redundant skin, and the wounds are closed in layers over a drain, taking care to avoid excessive tension on the suture lines, particularly inferior to the lobules. Antibiotic ointment and a compressive head and neck dressing are applied.", "contents": "Neck Rejuvenation -- Technique or Treatment. The surgeon places two\u00a0non-absorbable\u00a0sutures as buried half mattresses between the lateral border of the platysma and the mastoid periosteum. The vector of pull will be roughly parallel to the posterior border of the helix. The first suture is placed superiorly and the second more inferiorly. After hemostasis is obtained, the skin flaps are tailored to eliminate redundant skin, and the wounds are closed in layers over a drain, taking care to avoid excessive tension on the suture lines, particularly inferior to the lobules. Antibiotic ointment and a compressive head and neck dressing are applied."}
+{"id": "article-102110_27", "title": "Neck Rejuvenation -- Technique or Treatment -- Laser Skin Resurfacing", "content": "Settings will vary by device, but it should be remembered that the combined thickness of the epidermis and dermis in the neck is just over 0.25 mm on average, whereas the skin of the cheek is over 1 mm in depth. This, combined with the lower concentration of dermal appendages, means that healing may be slower and less energy should be delivered than when performing facial resurfacing. Fractionated delivery of the laser may be preferable to fully ablative settings, if available, and resurfacing should stop when the papillary dermis is reached, indicated by the presence of pinpoint bleeding and a subtle change in skin color toward a more yellow hue. If performing laser resurfacing under the same anesthetic as a surgical neck lift, using even more conservative settings may be prudent.", "contents": "Neck Rejuvenation -- Technique or Treatment -- Laser Skin Resurfacing. Settings will vary by device, but it should be remembered that the combined thickness of the epidermis and dermis in the neck is just over 0.25 mm on average, whereas the skin of the cheek is over 1 mm in depth. This, combined with the lower concentration of dermal appendages, means that healing may be slower and less energy should be delivered than when performing facial resurfacing. Fractionated delivery of the laser may be preferable to fully ablative settings, if available, and resurfacing should stop when the papillary dermis is reached, indicated by the presence of pinpoint bleeding and a subtle change in skin color toward a more yellow hue. If performing laser resurfacing under the same anesthetic as a surgical neck lift, using even more conservative settings may be prudent."}
+{"id": "article-102110_28", "title": "Neck Rejuvenation -- Technique or Treatment -- Botulinum Toxin Injection", "content": "The platysmal bands are visualized with the patient in an upright position, and aliquots of 5 units of botulinum toxin are injected with a fine gauge hypodermic needle (30 or greater) in a vertical line along the medial border of the platysma. Typically, 3 to 6 injection sites are required on each side. The injections will take 1\u00a0to 2 weeks to reach their maximum effect and will last for 3\u00a0to 4 months. Repeat as necessary.", "contents": "Neck Rejuvenation -- Technique or Treatment -- Botulinum Toxin Injection. The platysmal bands are visualized with the patient in an upright position, and aliquots of 5 units of botulinum toxin are injected with a fine gauge hypodermic needle (30 or greater) in a vertical line along the medial border of the platysma. Typically, 3 to 6 injection sites are required on each side. The injections will take 1\u00a0to 2 weeks to reach their maximum effect and will last for 3\u00a0to 4 months. Repeat as necessary."}
+{"id": "article-102110_29", "title": "Neck Rejuvenation -- Technique or Treatment -- Other Modalities", "content": "The deoxycholic acid injection may be performed roughly every six weeks, but not usually more often than every 4, given the edema that typically follows injections. Cryoablation is also typically performed at roughly one-month intervals until the desired effect is reached; radiofrequency ablation is ideally performed as a single treatment only.", "contents": "Neck Rejuvenation -- Technique or Treatment -- Other Modalities. The deoxycholic acid injection may be performed roughly every six weeks, but not usually more often than every 4, given the edema that typically follows injections. Cryoablation is also typically performed at roughly one-month intervals until the desired effect is reached; radiofrequency ablation is ideally performed as a single treatment only."}
+{"id": "article-102110_30", "title": "Neck Rejuvenation -- Complications", "content": "While the most common adverse outcome associated with any cosmetic procedure is dissatisfaction, whether because the effect was insufficient or unexpected, there are several other potential complications that should be avoided if possible. With respect to surgery, hematomas and seromas are common in the early postoperative period, especially in hypertensive patients and patients on anticoagulants. Males are also at an increased risk of hematoma development because of the increased dermal blood flow associated with hair follicles. Over resection of fat in the submental area can result in a so-called \"cobra neck\" deformity, and excessive tension at closure can pull the ear lobe inferiorly into a \"pixie ear\" deformity, both of which can be avoided with a more conservative surgical technique.", "contents": "Neck Rejuvenation -- Complications. While the most common adverse outcome associated with any cosmetic procedure is dissatisfaction, whether because the effect was insufficient or unexpected, there are several other potential complications that should be avoided if possible. With respect to surgery, hematomas and seromas are common in the early postoperative period, especially in hypertensive patients and patients on anticoagulants. Males are also at an increased risk of hematoma development because of the increased dermal blood flow associated with hair follicles. Over resection of fat in the submental area can result in a so-called \"cobra neck\" deformity, and excessive tension at closure can pull the ear lobe inferiorly into a \"pixie ear\" deformity, both of which can be avoided with a more conservative surgical technique."}
+{"id": "article-102110_31", "title": "Neck Rejuvenation -- Complications", "content": "Permanent or temporary nerve injury can occur as well, particularly to the great auricular nerve, but also to the marginal mandibular branch of the facial nerve. Great auricular nerve injury leaves the inferior aspect of the pinna hyperesthetic, and marginal mandibular branch injury causes an asymmetric smile, because the lower lip depressors become weak. The uninjured side of the upper lip will depress normally, leaving the affected side higher up and causing an overall crooked appearance. Other standard risks apply as well, such as may occur with any other surgery: pain, bleeding, infection, scarring, alopecia, and need for further surgery.", "contents": "Neck Rejuvenation -- Complications. Permanent or temporary nerve injury can occur as well, particularly to the great auricular nerve, but also to the marginal mandibular branch of the facial nerve. Great auricular nerve injury leaves the inferior aspect of the pinna hyperesthetic, and marginal mandibular branch injury causes an asymmetric smile, because the lower lip depressors become weak. The uninjured side of the upper lip will depress normally, leaving the affected side higher up and causing an overall crooked appearance. Other standard risks apply as well, such as may occur with any other surgery: pain, bleeding, infection, scarring, alopecia, and need for further surgery."}
+{"id": "article-102110_32", "title": "Neck Rejuvenation -- Complications", "content": "The best way to avoid these complications is to be familiar with the relevant anatomy, operate meticulously, and counsel the patient thoroughly before surgery to ensure reasonable expectations. Additionally, the surgeon should have a low threshold for returning to the operating room within a year to perform a \"tuck up\" procedure to help remove any additional redundant skin that persisted or returned after surgery, or to address any remaining or platysmal bands, which also frequently recur after neck lifting. [12] [13] [14]", "contents": "Neck Rejuvenation -- Complications. The best way to avoid these complications is to be familiar with the relevant anatomy, operate meticulously, and counsel the patient thoroughly before surgery to ensure reasonable expectations. Additionally, the surgeon should have a low threshold for returning to the operating room within a year to perform a \"tuck up\" procedure to help remove any additional redundant skin that persisted or returned after surgery, or to address any remaining or platysmal bands, which also frequently recur after neck lifting. [12] [13] [14]"}
+{"id": "article-102110_33", "title": "Neck Rejuvenation -- Complications", "content": "Non-surgical modalities can result in complications as well, including commonly the complaint that results fell short of expectations. Laser resurfacing may cause burns or scars if the settings are too aggressive; patients should be counseled to stay out of the sun for several months after laser treatments to help prevent any pigmentary abnormalities, either hyperpigmentation or hypopigmentation, that may occur during healing. Hyperpigmentation is most often temporary and is more common than hypopigmentation. Hypopigmentation is less common, but more likely to be persistent and is more difficult to treat. [15]", "contents": "Neck Rejuvenation -- Complications. Non-surgical modalities can result in complications as well, including commonly the complaint that results fell short of expectations. Laser resurfacing may cause burns or scars if the settings are too aggressive; patients should be counseled to stay out of the sun for several months after laser treatments to help prevent any pigmentary abnormalities, either hyperpigmentation or hypopigmentation, that may occur during healing. Hyperpigmentation is most often temporary and is more common than hypopigmentation. Hypopigmentation is less common, but more likely to be persistent and is more difficult to treat. [15]"}
+{"id": "article-102110_34", "title": "Neck Rejuvenation -- Complications", "content": "Injections may produce local reactions, and deoxycholic acid is known for causing significant edema as the adipocytes lyse. Botulinum toxin injection is generally very well tolerated, although if injected too superiorly, it may weaken the lower lip depressors and cause an asymmetric smile. Lastly, in rare cases, cryotherapy may cause paradoxical lipohypertrophy, which will require liposuction to treat.", "contents": "Neck Rejuvenation -- Complications. Injections may produce local reactions, and deoxycholic acid is known for causing significant edema as the adipocytes lyse. Botulinum toxin injection is generally very well tolerated, although if injected too superiorly, it may weaken the lower lip depressors and cause an asymmetric smile. Lastly, in rare cases, cryotherapy may cause paradoxical lipohypertrophy, which will require liposuction to treat."}
+{"id": "article-102110_35", "title": "Neck Rejuvenation -- Clinical Significance", "content": "In cosmetic surgery practices, aging of the neck is a very common complaint due to the frequency with which skin and muscle laxity develops over time. Accumulation of submental fat, in both the subdermal and subplatysmal compartments, further compounds the issue in most cases.\u00a0Because\u00a0there are so many options for addressing the aging neck, operative and non-operative, there is a role for a great number of clinicians of different specialties and levels of training in the management of patients with this chief complaint. Aestheticians, nurses, physician assistants, and nurse practitioners can all provide non-surgical treatment, and some may also assist in the operating room, or provide care that supports or supplements surgery.\u00a0From 2019 to 2020, necklifts accounted for between 160,000 and 180,000 surgeries in the United States alone. Bearing in mind that the necklift often constitutes a key component of facelifting, that number could possibly be closer to 400,000 cases per year, making it a hugely popular surgical option. For this reason, it important for clincians outside of cosmetic practices to at the very least be aware of what options may be available to their patients, and more importantly, how to recognize complications from these treatments.", "contents": "Neck Rejuvenation -- Clinical Significance. In cosmetic surgery practices, aging of the neck is a very common complaint due to the frequency with which skin and muscle laxity develops over time. Accumulation of submental fat, in both the subdermal and subplatysmal compartments, further compounds the issue in most cases.\u00a0Because\u00a0there are so many options for addressing the aging neck, operative and non-operative, there is a role for a great number of clinicians of different specialties and levels of training in the management of patients with this chief complaint. Aestheticians, nurses, physician assistants, and nurse practitioners can all provide non-surgical treatment, and some may also assist in the operating room, or provide care that supports or supplements surgery.\u00a0From 2019 to 2020, necklifts accounted for between 160,000 and 180,000 surgeries in the United States alone. Bearing in mind that the necklift often constitutes a key component of facelifting, that number could possibly be closer to 400,000 cases per year, making it a hugely popular surgical option. For this reason, it important for clincians outside of cosmetic practices to at the very least be aware of what options may be available to their patients, and more importantly, how to recognize complications from these treatments."}
+{"id": "article-102110_36", "title": "Neck Rejuvenation -- Enhancing Healthcare Team Outcomes", "content": "Because of the wide variety of modalities available for neck rejuvenation, an interprofessional team is an optimal method of providing comprehensive care to the cosmetic patient, ensuring that all pertinent options are presented and discussed appropriately. Experts in all relevant fields should participate in inpatient counseling to determine goals and set reasonable, attainable expectations. Surgeons, dermatologists, nurses, and anesthesia providers all have major roles to play before, during, and after rejuvenation of the aging neck. [16]", "contents": "Neck Rejuvenation -- Enhancing Healthcare Team Outcomes. Because of the wide variety of modalities available for neck rejuvenation, an interprofessional team is an optimal method of providing comprehensive care to the cosmetic patient, ensuring that all pertinent options are presented and discussed appropriately. Experts in all relevant fields should participate in inpatient counseling to determine goals and set reasonable, attainable expectations. Surgeons, dermatologists, nurses, and anesthesia providers all have major roles to play before, during, and after rejuvenation of the aging neck. [16]"}
+{"id": "article-102110_37", "title": "Neck Rejuvenation -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Neck Rejuvenation -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

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+{"id": "article-102378_0", "title": "TORCH Complex -- Continuing Education Activity", "content": "The term TORCH complex or TORCHes infection includes toxoplasmosis, others (syphilis, hepatitis B), rubella, cytomegalovirus, herpes simplex. These are caused by toxoplasma gondii, treponema pallidum, hepatitis B virus, rubella virus, cytomegalovirus, and herpes simplex virus (HSV), respectively. Human immunodeficiency virus and Zika virus are sometimes included in this grouping. This activity highlights the role of interprofessional team in evaluation and management of patients with TORCH complex.", "contents": "TORCH Complex -- Continuing Education Activity. The term TORCH complex or TORCHes infection includes toxoplasmosis, others (syphilis, hepatitis B), rubella, cytomegalovirus, herpes simplex. These are caused by toxoplasma gondii, treponema pallidum, hepatitis B virus, rubella virus, cytomegalovirus, and herpes simplex virus (HSV), respectively. Human immunodeficiency virus and Zika virus are sometimes included in this grouping. This activity highlights the role of interprofessional team in evaluation and management of patients with TORCH complex."}
+{"id": "article-102378_1", "title": "TORCH Complex -- Continuing Education Activity", "content": "Objectives: Identify the etiologic agents of TORCH infections. Describe the clinical manifestations of the TORCH complex in neonates. Summarize the management of congenital infections. Access free multiple choice questions on this topic.", "contents": "TORCH Complex -- Continuing Education Activity. Objectives: Identify the etiologic agents of TORCH infections. Describe the clinical manifestations of the TORCH complex in neonates. Summarize the management of congenital infections. Access free multiple choice questions on this topic."}
+{"id": "article-102378_2", "title": "TORCH Complex -- Introduction", "content": "The term TORCH complex or TORCHes infection refers to the congenital infections of toxoplasmosis, others(Syphilis, Hepatitis B), rubella, Cytomegalovirus (CMV), and herpes simplex. These are caused by Toxoplasma gondii, Treponema pallidum , Hepatitis B virus, Rubella virus, cytomegalovirus, and herpes virus simplex (HSV) viruses respectively. Other pathogens associated with congenital infections include human immunodeficiency virus (HIV), parvovirus, and varicella virus.", "contents": "TORCH Complex -- Introduction. The term TORCH complex or TORCHes infection refers to the congenital infections of toxoplasmosis, others(Syphilis, Hepatitis B), rubella, Cytomegalovirus (CMV), and herpes simplex. These are caused by Toxoplasma gondii, Treponema pallidum , Hepatitis B virus, Rubella virus, cytomegalovirus, and herpes virus simplex (HSV) viruses respectively. Other pathogens associated with congenital infections include human immunodeficiency virus (HIV), parvovirus, and varicella virus."}
+{"id": "article-102378_3", "title": "TORCH Complex -- Introduction", "content": "It is the intrauterine transmission of these infections to the fetus which produces multiple symptoms when the child is born. Maternal risk factors include lapsed immunizations, sexually transmitted infections, and animal exposures during pregnancy. The timing of maternal infection if a key epidemiologic factor\u00a0because fetal damage usually depends on the gestational age. With the exception of HSV, infections during the first trimester have the worst outcome.", "contents": "TORCH Complex -- Introduction. It is the intrauterine transmission of these infections to the fetus which produces multiple symptoms when the child is born. Maternal risk factors include lapsed immunizations, sexually transmitted infections, and animal exposures during pregnancy. The timing of maternal infection if a key epidemiologic factor\u00a0because fetal damage usually depends on the gestational age. With the exception of HSV, infections during the first trimester have the worst outcome."}
+{"id": "article-102378_4", "title": "TORCH Complex -- Etiology", "content": "The TORCH infections include causative organisms Toxoplasma gondii , rubella virus, cytomegalovirus, HSV\u00a01 and 2, hepatitis B virus, HIV, and others like syphilis, parvovirus, and varicella. Transmission of the pathogens may occur prenatally by the transplacental route, perinatally by blood or vaginal secretions. Postnatal infections tend to be less impactful. Others, such as HIV, hepatitis B, and syphilis, can be transmitted via sexual contact to a susceptible mother. Rubella and varicella can be prevented by properly immunizing mothers. [1]", "contents": "TORCH Complex -- Etiology. The TORCH infections include causative organisms Toxoplasma gondii , rubella virus, cytomegalovirus, HSV\u00a01 and 2, hepatitis B virus, HIV, and others like syphilis, parvovirus, and varicella. Transmission of the pathogens may occur prenatally by the transplacental route, perinatally by blood or vaginal secretions. Postnatal infections tend to be less impactful. Others, such as HIV, hepatitis B, and syphilis, can be transmitted via sexual contact to a susceptible mother. Rubella and varicella can be prevented by properly immunizing mothers. [1]"}
+{"id": "article-102378_5", "title": "TORCH Complex -- Epidemiology", "content": "Approximately 2% to 3% of all congenital anomalies are attributed\u00a0to perinatal infections. [2] Initial evidence of infection may be seen during the intrauterine period, at birth, in infancy, or not even until years later. Intrauterine manifestations of congenital infections include abnormal growth parameters or developmental abnormalities. The infected newborn infants may show abnormal growth, developmental anomalies, or multiple clinical and laboratory abnormalities.", "contents": "TORCH Complex -- Epidemiology. Approximately 2% to 3% of all congenital anomalies are attributed\u00a0to perinatal infections. [2] Initial evidence of infection may be seen during the intrauterine period, at birth, in infancy, or not even until years later. Intrauterine manifestations of congenital infections include abnormal growth parameters or developmental abnormalities. The infected newborn infants may show abnormal growth, developmental anomalies, or multiple clinical and laboratory abnormalities."}
+{"id": "article-102378_6", "title": "TORCH Complex -- Epidemiology", "content": "Many of the clinical syndromes for those viruses that present in the immediate neonatal period overlap with each other. They usually cause a rash, which can be maculopapular, petechial (blueberry muffin rash), or purpuric. Microcephaly, sensorineural hearing loss (particularly with CMV), and chorioretinitis may be present. Hepatosplenomegaly and cardiac anomalies are also frequent findings. [3]", "contents": "TORCH Complex -- Epidemiology. Many of the clinical syndromes for those viruses that present in the immediate neonatal period overlap with each other. They usually cause a rash, which can be maculopapular, petechial (blueberry muffin rash), or purpuric. Microcephaly, sensorineural hearing loss (particularly with CMV), and chorioretinitis may be present. Hepatosplenomegaly and cardiac anomalies are also frequent findings. [3]"}
+{"id": "article-102378_7", "title": "TORCH Complex -- Epidemiology", "content": "The incidence of maternal CMV and toxoplasmosis\u00a0are 2\u00a0to 10 per 1000 births. [4] Rubella is common in countries where mothers are unvaccinated but only occurs in the United States in cases of imported disease\u00a0after universal immunization. Humans are the natural hosts for the herpes virus, and the newborns usually get HSV-2 as it predominantly causes genital infections. Risk factors for toxoplasmosis include exposure to cats and the ingestion of improperly prepared foods such as undercooked meat or unpasteurized dairy products. [5] [6] Raw vegetables served in the restaurant probably caused toxoplasmosis in Brazil. [7]", "contents": "TORCH Complex -- Epidemiology. The incidence of maternal CMV and toxoplasmosis\u00a0are 2\u00a0to 10 per 1000 births. [4] Rubella is common in countries where mothers are unvaccinated but only occurs in the United States in cases of imported disease\u00a0after universal immunization. Humans are the natural hosts for the herpes virus, and the newborns usually get HSV-2 as it predominantly causes genital infections. Risk factors for toxoplasmosis include exposure to cats and the ingestion of improperly prepared foods such as undercooked meat or unpasteurized dairy products. [5] [6] Raw vegetables served in the restaurant probably caused toxoplasmosis in Brazil. [7]"}
+{"id": "article-102378_8", "title": "TORCH Complex -- Pathophysiology", "content": "Toxoplasma gondii oocysts transmission occurs by ingesting the infected tissue or inhaling the fecal particles. Transplacental transmission causes congenital toxoplasmosis. This is most commonly\u00a0occurs in the third trimester of pregnancy. However, earlier the infection, more severe will be the congenital malformations. [8] Syphilis is transmitted through the placenta or vertically in the birth canal. The transmission rate is more than 80% in recently infected mothers. [9] Rubella is transmitted to the mother by aerosols and to the fetus through the placenta. [10]", "contents": "TORCH Complex -- Pathophysiology. Toxoplasma gondii oocysts transmission occurs by ingesting the infected tissue or inhaling the fecal particles. Transplacental transmission causes congenital toxoplasmosis. This is most commonly\u00a0occurs in the third trimester of pregnancy. However, earlier the infection, more severe will be the congenital malformations. [8] Syphilis is transmitted through the placenta or vertically in the birth canal. The transmission rate is more than 80% in recently infected mothers. [9] Rubella is transmitted to the mother by aerosols and to the fetus through the placenta. [10]"}
+{"id": "article-102378_9", "title": "TORCH Complex -- Pathophysiology", "content": "CMV transmits to the mother by blood transfusion, organ transplants, or most commonly through the mucus membrane exposure. It then passes either through the placenta, birth canal, or breast milk to the fetus or neonate. CMV infection rates in primary infection\u00a0have long been proposed to be greater than secondary infection, but there has been some recent analysis that this may not be as significant as previously thought. [11] [12]", "contents": "TORCH Complex -- Pathophysiology. CMV transmits to the mother by blood transfusion, organ transplants, or most commonly through the mucus membrane exposure. It then passes either through the placenta, birth canal, or breast milk to the fetus or neonate. CMV infection rates in primary infection\u00a0have long been proposed to be greater than secondary infection, but there has been some recent analysis that this may not be as significant as previously thought. [11] [12]"}
+{"id": "article-102378_10", "title": "TORCH Complex -- Pathophysiology", "content": "HSV transmits to the mother by sexual contact and later to the fetus via either ascending infection or exposure during parturition. Maternal primary\u00a0infection during the third trimester has the highest percentage of neonatal infection. [13] Secondary reactivation of HSV is 10 to 30 times less likely to result in transmission to the infant. [14] HIV transmission to infants can occur either in transplacentally in utero, during parturition, or via post-natal maternal exposures like breast milk. [15]", "contents": "TORCH Complex -- Pathophysiology. HSV transmits to the mother by sexual contact and later to the fetus via either ascending infection or exposure during parturition. Maternal primary\u00a0infection during the third trimester has the highest percentage of neonatal infection. [13] Secondary reactivation of HSV is 10 to 30 times less likely to result in transmission to the infant. [14] HIV transmission to infants can occur either in transplacentally in utero, during parturition, or via post-natal maternal exposures like breast milk. [15]"}
+{"id": "article-102378_11", "title": "TORCH Complex -- History and Physical", "content": "Maternal history is a key area of investigation for patients who have a concern for congenital infections. The history of a febrile illness with or without rashes and poor maternal weight gain could raise concern for clinicians. Furthermore, fetal abnormalities such as intracranial calcifications may be detected in routine, or specific maternal testing may occur. Fetal loss can occur, particularly with infections during the first trimester.", "contents": "TORCH Complex -- History and Physical. Maternal history is a key area of investigation for patients who have a concern for congenital infections. The history of a febrile illness with or without rashes and poor maternal weight gain could raise concern for clinicians. Furthermore, fetal abnormalities such as intracranial calcifications may be detected in routine, or specific maternal testing may occur. Fetal loss can occur, particularly with infections during the first trimester."}
+{"id": "article-102378_12", "title": "TORCH Complex -- History and Physical", "content": "The history and physical findings for each individual TORCH pathogen are listed below: In general, a physical exam may reveal rashes, low birth weight, microcephaly, findings suggestive of cardiac abnormalities (murmurs), chorioretinitis and cataracts, and intracranial calcifications.", "contents": "TORCH Complex -- History and Physical. The history and physical findings for each individual TORCH pathogen are listed below: In general, a physical exam may reveal rashes, low birth weight, microcephaly, findings suggestive of cardiac abnormalities (murmurs), chorioretinitis and cataracts, and intracranial calcifications."}
+{"id": "article-102378_13", "title": "TORCH Complex -- History and Physical", "content": "Toxoplasmosis: The primary manifestations of congenital toxoplasmosis include intrauterine growth restriction and low birth weight, hepatosplenomegaly, jaundice, chorioretinitis, intraparenchymal calcifications, and anemia. Less commonly, petechiae, hydrocephalus, and microcephaly can be found.", "contents": "TORCH Complex -- History and Physical. Toxoplasmosis: The primary manifestations of congenital toxoplasmosis include intrauterine growth restriction and low birth weight, hepatosplenomegaly, jaundice, chorioretinitis, intraparenchymal calcifications, and anemia. Less commonly, petechiae, hydrocephalus, and microcephaly can be found."}
+{"id": "article-102378_14", "title": "TORCH Complex -- History and Physical", "content": "Congenital rubella syndrome: It includes low birth weight, hepatosplenomegaly, cataracts, congenital heart disease (patent ductus arteriosus, and ventricular septal defect), and a petechial rash. Congenital sensorineural hearing loss is very common. [16]", "contents": "TORCH Complex -- History and Physical. Congenital rubella syndrome: It includes low birth weight, hepatosplenomegaly, cataracts, congenital heart disease (patent ductus arteriosus, and ventricular septal defect), and a petechial rash. Congenital sensorineural hearing loss is very common. [16]"}
+{"id": "article-102378_15", "title": "TORCH Complex -- History and Physical", "content": "Herpes simplex virus: HSV rarely presents with in utero infection but instead presents due to perinatal exposure. Therefore, clinical manifestations normally will present ten to twenty-one days after infection. There are three major manifestations: Skin-eye-mucous membranes (SEM), central nervous system (CNS), and disseminated disease. All will often present with fever in the neonatal period. The disseminated disease will present earliest after approximately one week of age. These children will present with a sepsis-like syndrome with skin lesions to include vesicles, hypotension, hepatosplenomegaly, and lethargy. These patients often have evidence of meningoencephalitis. \u00a0SEM disease is thought to be limited to a rash, normally vesicular, and is often noted in areas of trauma such as fetal scalp electrodes or the use of forceps with delivery. CNS disease is more likely to present with lethargies or perhaps seizures. All patients should be evaluated for evidence of disease, including the CNS.", "contents": "TORCH Complex -- History and Physical. Herpes simplex virus: HSV rarely presents with in utero infection but instead presents due to perinatal exposure. Therefore, clinical manifestations normally will present ten to twenty-one days after infection. There are three major manifestations: Skin-eye-mucous membranes (SEM), central nervous system (CNS), and disseminated disease. All will often present with fever in the neonatal period. The disseminated disease will present earliest after approximately one week of age. These children will present with a sepsis-like syndrome with skin lesions to include vesicles, hypotension, hepatosplenomegaly, and lethargy. These patients often have evidence of meningoencephalitis. \u00a0SEM disease is thought to be limited to a rash, normally vesicular, and is often noted in areas of trauma such as fetal scalp electrodes or the use of forceps with delivery. CNS disease is more likely to present with lethargies or perhaps seizures. All patients should be evaluated for evidence of disease, including the CNS."}
+{"id": "article-102378_16", "title": "TORCH Complex -- History and Physical", "content": "Cytomegalovirus: CMV is the most common congenital infection. It will present with intrauterine growth restriction and low birth weight, hepatosplenomegaly, jaundice, paraventricular\u00a0calcifications, cataracts, and sensorineural hearing loss and bone marrow suppression that will present with thrombocytopenia and anemia. Patients often have a petechial rash at birth. HIV: Patients with congenital HIV rarely have any evidence of outward manifestations at birth. They may have a low birth weight and hepatosplenomegaly at birth.", "contents": "TORCH Complex -- History and Physical. Cytomegalovirus: CMV is the most common congenital infection. It will present with intrauterine growth restriction and low birth weight, hepatosplenomegaly, jaundice, paraventricular\u00a0calcifications, cataracts, and sensorineural hearing loss and bone marrow suppression that will present with thrombocytopenia and anemia. Patients often have a petechial rash at birth. HIV: Patients with congenital HIV rarely have any evidence of outward manifestations at birth. They may have a low birth weight and hepatosplenomegaly at birth."}
+{"id": "article-102378_17", "title": "TORCH Complex -- History and Physical", "content": "Syphilis: In utero, there may be fetal loss or hydrops fetalis . In the neonatal period, children with primary syphilis may present with cutaneous lesions on the palms and soles, hepatosplenomegaly, jaundice, inflammation of the umbilical cord (funisitis) and discharge from the nose (sniffles). Periostitis may be found on x-rays of the bones. Late findings include frontal bossing, high palatal arch, sensorineural hearing loss, a saddle nose, perioral fissures, and Hutchinson teeth.", "contents": "TORCH Complex -- History and Physical. Syphilis: In utero, there may be fetal loss or hydrops fetalis . In the neonatal period, children with primary syphilis may present with cutaneous lesions on the palms and soles, hepatosplenomegaly, jaundice, inflammation of the umbilical cord (funisitis) and discharge from the nose (sniffles). Periostitis may be found on x-rays of the bones. Late findings include frontal bossing, high palatal arch, sensorineural hearing loss, a saddle nose, perioral fissures, and Hutchinson teeth."}
+{"id": "article-102378_18", "title": "TORCH Complex -- Evaluation", "content": "The TORCH titer is a test that is often run in this setting. Basically, it is usually a panel of IgG tests for the pathogens noted. It may provide some useful insight into whether a mother has been infected if high titers are detected, it is not that useful in making a definitive diagnosis of any pathogen associated with congenital infections. Therefore, the investigation of each pathogen is warranted if the clinical syndrome is suggestive of that disease. The evaluation of each illness is noted in the following passages.", "contents": "TORCH Complex -- Evaluation. The TORCH titer is a test that is often run in this setting. Basically, it is usually a panel of IgG tests for the pathogens noted. It may provide some useful insight into whether a mother has been infected if high titers are detected, it is not that useful in making a definitive diagnosis of any pathogen associated with congenital infections. Therefore, the investigation of each pathogen is warranted if the clinical syndrome is suggestive of that disease. The evaluation of each illness is noted in the following passages."}
+{"id": "article-102378_19", "title": "TORCH Complex -- Evaluation", "content": "Toxoplasmosis: In newborns with a concern for congenital toxoplasmosis, evaluation should include laboratory testing, consultations, and radiologic studies. Due to the possibility of ocular involvement, an ophthalmologist should be consulted to assess for possible chorioretinitis. Neuroimaging studies should be conducted to assess intracranial calcifications and/or hydrocephalus. Laboratory testing can be a bit complicated. The most sensitive and specific testing includes a mixture of tests to assess for IgA, IgG, and IgM. Most experts recommend the use of a reference laboratory that can assess the newborn with IgG (Dye test), IgM ISAGA, and IgA ELISA. If the child has not been born, maternal testing can also be conducted, which may include either an Avidity panel or a differential agglutination test depending on the week of pregnancy. [17]", "contents": "TORCH Complex -- Evaluation. Toxoplasmosis: In newborns with a concern for congenital toxoplasmosis, evaluation should include laboratory testing, consultations, and radiologic studies. Due to the possibility of ocular involvement, an ophthalmologist should be consulted to assess for possible chorioretinitis. Neuroimaging studies should be conducted to assess intracranial calcifications and/or hydrocephalus. Laboratory testing can be a bit complicated. The most sensitive and specific testing includes a mixture of tests to assess for IgA, IgG, and IgM. Most experts recommend the use of a reference laboratory that can assess the newborn with IgG (Dye test), IgM ISAGA, and IgA ELISA. If the child has not been born, maternal testing can also be conducted, which may include either an Avidity panel or a differential agglutination test depending on the week of pregnancy. [17]"}
+{"id": "article-102378_20", "title": "TORCH Complex -- Evaluation", "content": "Congenital rubella syndrome: If concerns exist for this infectious syndrome, consultations with specialists and laboratory testing should occur. In order to investigate for clinical stigmata, ophthalmology (cataracts, glaucoma) and cardiology (patent ductus arteriosus (PDA), ventriculoseptal defect (VSD), and pulmonary artery stenosis) should be consulted early in the patient's course. As hearing loss is very common, audiology consultation with hearing tests should be conducted in all patients. Laboratory testing could include attempts to culture the virus from the nasopharynx or the assessment for IgM in the newborn. [18]", "contents": "TORCH Complex -- Evaluation. Congenital rubella syndrome: If concerns exist for this infectious syndrome, consultations with specialists and laboratory testing should occur. In order to investigate for clinical stigmata, ophthalmology (cataracts, glaucoma) and cardiology (patent ductus arteriosus (PDA), ventriculoseptal defect (VSD), and pulmonary artery stenosis) should be consulted early in the patient's course. As hearing loss is very common, audiology consultation with hearing tests should be conducted in all patients. Laboratory testing could include attempts to culture the virus from the nasopharynx or the assessment for IgM in the newborn. [18]"}
+{"id": "article-102378_21", "title": "TORCH Complex -- Evaluation", "content": "Congenital cytomegalovirus: Evaluation of the being considered for the diagnosis of congenital CMV, should begin with confirmation of CMV infection. Infection is usually confirmed by the isolation of the virus within the first month of life. While any sterile site can be used, the urine is the most common source of isolation. Traditional viral culture or PCR testing is sufficient. CMV has been found in the blood and CSF as well. After confirmation, subspecialty consultation with ophthalmology (cataracts, chorioretinitis) and audiology (hearing loss) are essential. The workup usually includes neuroimaging to assess for the presence or absence of intracranial, periventricular calcifications. Laboratory evaluation should include assessment for liver transaminitis as well as liver function and bone marrow suppression by obtaining chemistries, liver function tests, PT/PTT, and a complete blood count. [19]", "contents": "TORCH Complex -- Evaluation. Congenital cytomegalovirus: Evaluation of the being considered for the diagnosis of congenital CMV, should begin with confirmation of CMV infection. Infection is usually confirmed by the isolation of the virus within the first month of life. While any sterile site can be used, the urine is the most common source of isolation. Traditional viral culture or PCR testing is sufficient. CMV has been found in the blood and CSF as well. After confirmation, subspecialty consultation with ophthalmology (cataracts, chorioretinitis) and audiology (hearing loss) are essential. The workup usually includes neuroimaging to assess for the presence or absence of intracranial, periventricular calcifications. Laboratory evaluation should include assessment for liver transaminitis as well as liver function and bone marrow suppression by obtaining chemistries, liver function tests, PT/PTT, and a complete blood count. [19]"}
+{"id": "article-102378_22", "title": "TORCH Complex -- Evaluation", "content": "Herpes simplex virus infections: Any child who presents with a concern for neonatal HSV should be aggressively evaluated. They should undergo a complete sepsis evaluation to include a lumbar puncture. It is recommended that swabs from the mouth, nasopharynx, conjunctivae, and anus. Be obtained for HSV culture and PCR. If skin vesicles are present, they should be unroofed and sent for culture and PCR as well. CSF and whole blood should also be sent for HSV culture and PCR. Measurement of liver transaminases should be conducted as they are an early clue that disseminated disease may be present. Further evaluation and consultation may depend on the type of infection the child has to include consultation with ophthalmology, neurology, and audiology. Hearing tests must be conducted as they may help with decision-making with regard to treatment. [20]", "contents": "TORCH Complex -- Evaluation. Herpes simplex virus infections: Any child who presents with a concern for neonatal HSV should be aggressively evaluated. They should undergo a complete sepsis evaluation to include a lumbar puncture. It is recommended that swabs from the mouth, nasopharynx, conjunctivae, and anus. Be obtained for HSV culture and PCR. If skin vesicles are present, they should be unroofed and sent for culture and PCR as well. CSF and whole blood should also be sent for HSV culture and PCR. Measurement of liver transaminases should be conducted as they are an early clue that disseminated disease may be present. Further evaluation and consultation may depend on the type of infection the child has to include consultation with ophthalmology, neurology, and audiology. Hearing tests must be conducted as they may help with decision-making with regard to treatment. [20]"}
+{"id": "article-102378_23", "title": "TORCH Complex -- Evaluation", "content": "HIV: Patients with concern for mother-to-child transmission of HIV should be evaluated. Children should have a PCR test sent at birth as infants will receive transplacental antibodies from their mothers. The first PCR can be sent within the first two days of life to determine if in utero infection occurred. Children are considered HIV negative if they have two tests conducted, and negative, after two weeks of age with one after four weeks of age. Alternatively, one negative PCR obtained after eight weeks is sufficient. Children should not breastfeed. Obtaining a complete blood count and baseline chemistries to include renal and hepatic function is also warranted. Complete guidance can be found at the U.S. Department of Health and Human Services.", "contents": "TORCH Complex -- Evaluation. HIV: Patients with concern for mother-to-child transmission of HIV should be evaluated. Children should have a PCR test sent at birth as infants will receive transplacental antibodies from their mothers. The first PCR can be sent within the first two days of life to determine if in utero infection occurred. Children are considered HIV negative if they have two tests conducted, and negative, after two weeks of age with one after four weeks of age. Alternatively, one negative PCR obtained after eight weeks is sufficient. Children should not breastfeed. Obtaining a complete blood count and baseline chemistries to include renal and hepatic function is also warranted. Complete guidance can be found at the U.S. Department of Health and Human Services."}
+{"id": "article-102378_24", "title": "TORCH Complex -- Evaluation", "content": "Syphilis: The evaluation of a child with congenital syphilis depends on whether the mother was diagnosed during pregnancy and properly treated or not. All children should have a rapid plasma reagin (RPR) to be compared to the mother's RPR titer. If a mother is inadequately treated during pregnancy or the child has evidence of an elevated RPR with findings consistent with syphilis, the child needs a robust evaluation. The evaluation includes a complete blood count, CSF examination for cell count, protein, and venereal disease research laboratory (VDRL). Additionally, long bone radiographs, neuroimaging, ophthalmologic examination, liver function testing, and hearing tests can be conducted. [21]", "contents": "TORCH Complex -- Evaluation. Syphilis: The evaluation of a child with congenital syphilis depends on whether the mother was diagnosed during pregnancy and properly treated or not. All children should have a rapid plasma reagin (RPR) to be compared to the mother's RPR titer. If a mother is inadequately treated during pregnancy or the child has evidence of an elevated RPR with findings consistent with syphilis, the child needs a robust evaluation. The evaluation includes a complete blood count, CSF examination for cell count, protein, and venereal disease research laboratory (VDRL). Additionally, long bone radiographs, neuroimaging, ophthalmologic examination, liver function testing, and hearing tests can be conducted. [21]"}
+{"id": "article-102378_25", "title": "TORCH Complex -- Treatment / Management", "content": "Here are the management considerations for TORCH infections:", "contents": "TORCH Complex -- Treatment / Management. Here are the management considerations for TORCH infections:"}
+{"id": "article-102378_26", "title": "TORCH Complex -- Treatment / Management", "content": "There are no programs on a large scale that offer both maternal or neonatal screening to identify infection in mothers and infants. No vaccines are present to prevent infection, and no efficacious and safe therapies are available for the treatment of maternal or fetal CMV infection. [22] In some setups, gancyclovir is being given.", "contents": "TORCH Complex -- Treatment / Management. There are no programs on a large scale that offer both maternal or neonatal screening to identify infection in mothers and infants. No vaccines are present to prevent infection, and no efficacious and safe therapies are available for the treatment of maternal or fetal CMV infection. [22] In some setups, gancyclovir is being given."}
+{"id": "article-102378_27", "title": "TORCH Complex -- Treatment / Management", "content": "For toxoplasmosis, observational studies have demonstrated an effective reduction in transplacental transmission and/or severity of clinical manifestations in symptomatic infants. The two regimens often used are spiramycin (fetal prophylaxis preventing intrauterine infection) and combined pyrimethamine/sulfadiazine/ folinic acid (treatment of evolving fetal infection). [8]", "contents": "TORCH Complex -- Treatment / Management. For toxoplasmosis, observational studies have demonstrated an effective reduction in transplacental transmission and/or severity of clinical manifestations in symptomatic infants. The two regimens often used are spiramycin (fetal prophylaxis preventing intrauterine infection) and combined pyrimethamine/sulfadiazine/ folinic acid (treatment of evolving fetal infection). [8]"}
+{"id": "article-102378_28", "title": "TORCH Complex -- Treatment / Management", "content": "Congenital rubella, once developed, cannot be treated. But it is the most common vaccine-preventable neonatal disease. A single dose of rubella vaccine to mother can produce life long immunity. [16] Mothers should have their immunity checked at the beginning of a pregnancy.", "contents": "TORCH Complex -- Treatment / Management. Congenital rubella, once developed, cannot be treated. But it is the most common vaccine-preventable neonatal disease. A single dose of rubella vaccine to mother can produce life long immunity. [16] Mothers should have their immunity checked at the beginning of a pregnancy."}
+{"id": "article-102378_29", "title": "TORCH Complex -- Treatment / Management", "content": "Patients with neonatal HSV should be treated aggressively. Clinical trials have demonstrated that high-dose intravenous acyclovir (60 mg/kg/day intravenously divided three times daily) for acute therapy. The length of this therapy varies from fourteen\u00a0to twenty-one days depending on the severity of disease (10 for SEM/21 for disseminated and CNS) followed by long-term oral acyclovir suppressive therapy (300 mg/m/dose, given orally\u00a0three times daily for six months is best for the management of neonatal herpes infection. This work has dramatically reduced morbidity and mortality from neonatal HSV. [23] Complete blood counts and renal function should be monitored. Dosing should be adjusted as the infant grows.", "contents": "TORCH Complex -- Treatment / Management. Patients with neonatal HSV should be treated aggressively. Clinical trials have demonstrated that high-dose intravenous acyclovir (60 mg/kg/day intravenously divided three times daily) for acute therapy. The length of this therapy varies from fourteen\u00a0to twenty-one days depending on the severity of disease (10 for SEM/21 for disseminated and CNS) followed by long-term oral acyclovir suppressive therapy (300 mg/m/dose, given orally\u00a0three times daily for six months is best for the management of neonatal herpes infection. This work has dramatically reduced morbidity and mortality from neonatal HSV. [23] Complete blood counts and renal function should be monitored. Dosing should be adjusted as the infant grows."}
+{"id": "article-102378_30", "title": "TORCH Complex -- Treatment / Management", "content": "Patients with symptomatic cytomegalovirus infections should be treated with ganciclovir and valganciclovir. The primary reason for this therapy is to preserve hearing. Neonates with symptomatic congenital CMV disease with or without central nervous system (CNS) involvement show better\u00a0outcomes at two years when treated with oral valganciclovir (16 mg/kg/dose, administered orally twice daily) for six months.\u00a0Dosing should be adjusted as the infant grows. [24]", "contents": "TORCH Complex -- Treatment / Management. Patients with symptomatic cytomegalovirus infections should be treated with ganciclovir and valganciclovir. The primary reason for this therapy is to preserve hearing. Neonates with symptomatic congenital CMV disease with or without central nervous system (CNS) involvement show better\u00a0outcomes at two years when treated with oral valganciclovir (16 mg/kg/dose, administered orally twice daily) for six months.\u00a0Dosing should be adjusted as the infant grows. [24]"}
+{"id": "article-102378_31", "title": "TORCH Complex -- Treatment / Management", "content": "The treatment of HIV to prevent mother-to-child transmission depends on whether the mother was treated with viral suppression during the pregnancy. Therapy for children born to well-controlled mothers should include the treatment of the infant with zidovudine (4 mg/kg, twice daily) for the first 4\u00a0to 6 weeks of life for term children. Multiple drug regimens are recommended for children whose mother was not on antiretroviral therapy during pregnancy.", "contents": "TORCH Complex -- Treatment / Management. The treatment of HIV to prevent mother-to-child transmission depends on whether the mother was treated with viral suppression during the pregnancy. Therapy for children born to well-controlled mothers should include the treatment of the infant with zidovudine (4 mg/kg, twice daily) for the first 4\u00a0to 6 weeks of life for term children. Multiple drug regimens are recommended for children whose mother was not on antiretroviral therapy during pregnancy."}
+{"id": "article-102378_32", "title": "TORCH Complex -- Treatment / Management", "content": "Syphilis must be diagnosed and treated immediately. Expectant mothers should be tested during pregnancy and, if positive, treated. [25] Treatment of the neonate will depend on whether the mother was treated appropriately during pregnancy. Normal neonates born to mothers adequately treated during pregnancy and greater than four weeks before delivery or have a non-reactive RPR but were born to mothers not treated properly should receive a single intramuscular injection of benzathine penicillin G (50,000\u00a0U/kg), although no evaluation is required or recommended. Infants with serologic tests that confirm congenital syphilis should receive aqueous penicillin g\u00a0(200,000\u00a0to 300,000\u00a0units/kg/day IV, administered as 50,000\u00a0units/kg every 4\u00a0to 6 hours for ten days). If the child has a negative evaluation for clinical and laboratory evidence of syphilis, treatment with up to 3 weekly doses of benzathine penicillin G (50,000\u00a0U/kg IM) can be considered. [21]", "contents": "TORCH Complex -- Treatment / Management. Syphilis must be diagnosed and treated immediately. Expectant mothers should be tested during pregnancy and, if positive, treated. [25] Treatment of the neonate will depend on whether the mother was treated appropriately during pregnancy. Normal neonates born to mothers adequately treated during pregnancy and greater than four weeks before delivery or have a non-reactive RPR but were born to mothers not treated properly should receive a single intramuscular injection of benzathine penicillin G (50,000\u00a0U/kg), although no evaluation is required or recommended. Infants with serologic tests that confirm congenital syphilis should receive aqueous penicillin g\u00a0(200,000\u00a0to 300,000\u00a0units/kg/day IV, administered as 50,000\u00a0units/kg every 4\u00a0to 6 hours for ten days). If the child has a negative evaluation for clinical and laboratory evidence of syphilis, treatment with up to 3 weekly doses of benzathine penicillin G (50,000\u00a0U/kg IM) can be considered. [21]"}
+{"id": "article-102378_33", "title": "TORCH Complex -- Differential Diagnosis", "content": "As many of these illnesses have similar manifestations, they are often all considered as a possible diagnosis when a child presents with signs and symptoms suggestive of congenital infection. Therefore, in a child who presents small for gestational age with additional clinical findings such as a rash or heart murmur or ocular findings, all of the TORCH complex pathogens should be considered. In addition to those mentioned, the new pathogen Zika virus can cause significant disease in newborns. [26] In particular, the virus causes CNS disease that is significant and can present with intracranial calcifications. Parvovirus B19 infection can also cause fetal hydrops fetalis and can present with profound bone marrow suppression. [27]", "contents": "TORCH Complex -- Differential Diagnosis. As many of these illnesses have similar manifestations, they are often all considered as a possible diagnosis when a child presents with signs and symptoms suggestive of congenital infection. Therefore, in a child who presents small for gestational age with additional clinical findings such as a rash or heart murmur or ocular findings, all of the TORCH complex pathogens should be considered. In addition to those mentioned, the new pathogen Zika virus can cause significant disease in newborns. [26] In particular, the virus causes CNS disease that is significant and can present with intracranial calcifications. Parvovirus B19 infection can also cause fetal hydrops fetalis and can present with profound bone marrow suppression. [27]"}
+{"id": "article-102378_34", "title": "TORCH Complex -- Differential Diagnosis", "content": "Maternal factors such as preeclampsia, hypertension, smoking, drug and medication use, and anemia may contribute to growth problems. Additionally, many metabolic and genetic syndromes can present in a similar manner to a TORCH infection. [28] These may range from common issues like hypothyroidism to much more complex and rare genetic syndromes.", "contents": "TORCH Complex -- Differential Diagnosis. Maternal factors such as preeclampsia, hypertension, smoking, drug and medication use, and anemia may contribute to growth problems. Additionally, many metabolic and genetic syndromes can present in a similar manner to a TORCH infection. [28] These may range from common issues like hypothyroidism to much more complex and rare genetic syndromes."}
+{"id": "article-102378_35", "title": "TORCH Complex -- Prognosis", "content": "The prognosis for congenital infections will vary depending on the severity of the initial presentation. For toxoplasmosis, there may be findings at birth, such as intracranial calcifications and chorioretinitis, which may suggest a poor prognosis with seizures and developmental delay likely. [29] Unfortunately, there may be some long-term problems detected, such as school dysfunction, hearing and visual issues, and gross motor problems that require close monitoring.\u00a0Patients with congenital rubella syndrome continue to have a poor prognosis with multiple organ systems impacted to include cardiac malformations, hearing loss, cataracts, and brain anomalies. [30] Long-term followup portends a poor prognosis, particularly in children with cardiac disease. [31]", "contents": "TORCH Complex -- Prognosis. The prognosis for congenital infections will vary depending on the severity of the initial presentation. For toxoplasmosis, there may be findings at birth, such as intracranial calcifications and chorioretinitis, which may suggest a poor prognosis with seizures and developmental delay likely. [29] Unfortunately, there may be some long-term problems detected, such as school dysfunction, hearing and visual issues, and gross motor problems that require close monitoring.\u00a0Patients with congenital rubella syndrome continue to have a poor prognosis with multiple organ systems impacted to include cardiac malformations, hearing loss, cataracts, and brain anomalies. [30] Long-term followup portends a poor prognosis, particularly in children with cardiac disease. [31]"}
+{"id": "article-102378_36", "title": "TORCH Complex -- Prognosis", "content": "The prognosis of patients with congenital cytomegalovirus is variable. Some patients with a congenital infection have extremely good outcomes and are relatively asymptomatic. On the other hand, children with CNS disease at presentation are at high risk for sensorineural hearing loss and developmental delays. If valganciclovir can be administered to symptomatic newborns in a timely manner, it has shown value. [32] [24]", "contents": "TORCH Complex -- Prognosis. The prognosis of patients with congenital cytomegalovirus is variable. Some patients with a congenital infection have extremely good outcomes and are relatively asymptomatic. On the other hand, children with CNS disease at presentation are at high risk for sensorineural hearing loss and developmental delays. If valganciclovir can be administered to symptomatic newborns in a timely manner, it has shown value. [32] [24]"}
+{"id": "article-102378_37", "title": "TORCH Complex -- Prognosis", "content": "Patients with neonatal HSV infections will have an outcome that is dependent on the presentation as well. With the advent of the aggressive use of acyclovir in the neonatal period plus the use of suppressive acyclovir for six months, long-term outcomes have improved for neurologic outcomes. [33] The outcome for patients presenting with the disseminated disease remains grim. [34] Patients with syphilis will have good outcomes as long as they are recognized and diagnosed at birth and receive the correct and prompt therapy. [35]", "contents": "TORCH Complex -- Prognosis. Patients with neonatal HSV infections will have an outcome that is dependent on the presentation as well. With the advent of the aggressive use of acyclovir in the neonatal period plus the use of suppressive acyclovir for six months, long-term outcomes have improved for neurologic outcomes. [33] The outcome for patients presenting with the disseminated disease remains grim. [34] Patients with syphilis will have good outcomes as long as they are recognized and diagnosed at birth and receive the correct and prompt therapy. [35]"}
+{"id": "article-102378_38", "title": "TORCH Complex -- Complications", "content": "Complications\u00a0are intrauterine\u00a0and postnatal. In utero complications\u00a0include intrauterine growth retardation, hydrops fetalis, and intrauterine death. Postnatal complications include failure to thrive, ophthalmologic disease, developmental delay, paralysis, seizure disorders, hearing loss, congenital heart diseases, and death. [36] Congenital infections are the number one cause of sensorineural hearing loss in children.", "contents": "TORCH Complex -- Complications. Complications\u00a0are intrauterine\u00a0and postnatal. In utero complications\u00a0include intrauterine growth retardation, hydrops fetalis, and intrauterine death. Postnatal complications include failure to thrive, ophthalmologic disease, developmental delay, paralysis, seizure disorders, hearing loss, congenital heart diseases, and death. [36] Congenital infections are the number one cause of sensorineural hearing loss in children."}
+{"id": "article-102378_39", "title": "TORCH Complex -- Consultations", "content": "Children who are noted to be suffering from intrauterine growth restriction should be followed by a perinatologist to investigate reasons for this finding to include TORCH pathogens. \u00a0Neonatology should be consulted as they may be needed to assist with delivery and care after the birth of the child. \u00a0A pediatric infectious disease physician should be consulted to assist with testing and potential treatment of pathogens. Due to the findings that are common with TORCH infections, consultation with ophthalmology, audiology, radiology, cardiology, gastroenterology, and hematology/oncology may be warranted.", "contents": "TORCH Complex -- Consultations. Children who are noted to be suffering from intrauterine growth restriction should be followed by a perinatologist to investigate reasons for this finding to include TORCH pathogens. \u00a0Neonatology should be consulted as they may be needed to assist with delivery and care after the birth of the child. \u00a0A pediatric infectious disease physician should be consulted to assist with testing and potential treatment of pathogens. Due to the findings that are common with TORCH infections, consultation with ophthalmology, audiology, radiology, cardiology, gastroenterology, and hematology/oncology may be warranted."}
+{"id": "article-102378_40", "title": "TORCH Complex -- Deterrence and Patient Education", "content": "Maternal education and early in utero diagnosis is very important in\u00a0diagnosing a child with a TORCH infection.\u00a0 Early intervention may allow for the treatment during pregnancy (toxoplasmosis and syphilis) or prophylaxis at delivery (HSV) to help eliminate risk to the newborn.\u00a0 Regular prenatal care and maternal health are key elements for any pregnancy.\u00a0 All\u00a0women of childbearing age should ensure that they have their immunizations up to date as this can prevent any possibility of congenital rubella syndrome. [37]", "contents": "TORCH Complex -- Deterrence and Patient Education. Maternal education and early in utero diagnosis is very important in\u00a0diagnosing a child with a TORCH infection.\u00a0 Early intervention may allow for the treatment during pregnancy (toxoplasmosis and syphilis) or prophylaxis at delivery (HSV) to help eliminate risk to the newborn.\u00a0 Regular prenatal care and maternal health are key elements for any pregnancy.\u00a0 All\u00a0women of childbearing age should ensure that they have their immunizations up to date as this can prevent any possibility of congenital rubella syndrome. [37]"}
+{"id": "article-102378_41", "title": "TORCH Complex -- Deterrence and Patient Education", "content": "Safe sexual practices can help eliminate the risk of the acquisition of syphilis, HIV, and HSV during pregnancy.\u00a0\u00a0Expectant mothers who have a febrile illness during pregnancy should be sure to report that illness to their physicians.\u00a0 Safe eating practices such as the avoidance of processed foods (deli meats) and eating thoroughly cooked foods can help prevent the transmission of toxoplasmosis.\u00a0 Similarly, expectant mothers should refrain from cleaning the cat litter boxes during pregnancy to prevent the transmission of toxoplasmosis. [38] The prevention of cytomegalovirus has focused on the area of hygiene, encouraging expectant mothers to avoid situations such as child care settings or nursing care when possible. When not possible, hand hygiene is essential.\u00a0 Some recent reports have looked at the use of immunoglobulin to prevent the transmission of CMV to the fetus and show some promise. [39] [40]", "contents": "TORCH Complex -- Deterrence and Patient Education. Safe sexual practices can help eliminate the risk of the acquisition of syphilis, HIV, and HSV during pregnancy.\u00a0\u00a0Expectant mothers who have a febrile illness during pregnancy should be sure to report that illness to their physicians.\u00a0 Safe eating practices such as the avoidance of processed foods (deli meats) and eating thoroughly cooked foods can help prevent the transmission of toxoplasmosis.\u00a0 Similarly, expectant mothers should refrain from cleaning the cat litter boxes during pregnancy to prevent the transmission of toxoplasmosis. [38] The prevention of cytomegalovirus has focused on the area of hygiene, encouraging expectant mothers to avoid situations such as child care settings or nursing care when possible. When not possible, hand hygiene is essential.\u00a0 Some recent reports have looked at the use of immunoglobulin to prevent the transmission of CMV to the fetus and show some promise. [39] [40]"}
+{"id": "article-102378_42", "title": "TORCH Complex -- Enhancing Healthcare Team Outcomes", "content": "Interprofessional relation between obstetricians and neonatologists is critical in maternal and fetal management. Early recognition of the disease and appropriate management may reduce maternal and fetal morbidity and mortality. Prevention guidelines should be given to mothers by their obstetrician. Radiologists can identify defects in the pregnancy and report to the parents so that they can make informed choices. Neonatologists can easily identify the defects in the child and counsel parents. \u00a0Intradisciplinary communication is paramount as a large number of consultations may be necessary and coordinated communication within the healthcare team, and with parents will be necessary.", "contents": "TORCH Complex -- Enhancing Healthcare Team Outcomes. Interprofessional relation between obstetricians and neonatologists is critical in maternal and fetal management. Early recognition of the disease and appropriate management may reduce maternal and fetal morbidity and mortality. Prevention guidelines should be given to mothers by their obstetrician. Radiologists can identify defects in the pregnancy and report to the parents so that they can make informed choices. Neonatologists can easily identify the defects in the child and counsel parents. \u00a0Intradisciplinary communication is paramount as a large number of consultations may be necessary and coordinated communication within the healthcare team, and with parents will be necessary."}
+{"id": "article-102378_43", "title": "TORCH Complex -- Enhancing Healthcare Team Outcomes", "content": "Evidence levels exist at many levels. \u00a0The evaluation and treatment of toxoplasmosis, syphilis, CMV, and HSV are all supported by large randomized clinical trials with clear cut results. \u00a0There are also many cohort and case-control studies and historical cohort or case-control studies that support the information given in this paper.", "contents": "TORCH Complex -- Enhancing Healthcare Team Outcomes. Evidence levels exist at many levels. \u00a0The evaluation and treatment of toxoplasmosis, syphilis, CMV, and HSV are all supported by large randomized clinical trials with clear cut results. \u00a0There are also many cohort and case-control studies and historical cohort or case-control studies that support the information given in this paper."}
+{"id": "article-102378_44", "title": "TORCH Complex -- Review Questions", "content": "Access free multiple choice questions on this topic. Click here for a simplified version. Comment on this article.", "contents": "TORCH Complex -- Review Questions. Access free multiple choice questions on this topic. Click here for a simplified version. Comment on this article."}

statpearls/chunk/article-102389.jsonl

@@ -0,0 +1,80 @@
+{"id": "article-102389_0", "title": "Benign Essential Blepharospasm -- Continuing Education Activity", "content": "Benign essential blepharospasm is a focal cranial dystonia characterized by involuntary contractions of orbicularis oculi muscle contractions, resulting in involuntary eye closure. Its etiology is poorly understood, but many pathophysiological mechanisms have been postulated. This activity highlights the role of the interprofessional team in the evaluation and management of benign essential blepharospasm.", "contents": "Benign Essential Blepharospasm -- Continuing Education Activity. Benign essential blepharospasm is a focal cranial dystonia characterized by involuntary contractions of orbicularis oculi muscle contractions, resulting in involuntary eye closure. Its etiology is poorly understood, but many pathophysiological mechanisms have been postulated. This activity highlights the role of the interprofessional team in the evaluation and management of benign essential blepharospasm."}
+{"id": "article-102389_1", "title": "Benign Essential Blepharospasm -- Continuing Education Activity", "content": "Objectives: Describe the proposed pathophysiological mechanisms implicated in the development of benign essential blepharospasm. Review the risk factors involved in the development of benign essential blepharospasm. Summarize the management options available for benign essential blepharospasm. Access free multiple choice questions on this topic.", "contents": "Benign Essential Blepharospasm -- Continuing Education Activity. Objectives: Describe the proposed pathophysiological mechanisms implicated in the development of benign essential blepharospasm. Review the risk factors involved in the development of benign essential blepharospasm. Summarize the management options available for benign essential blepharospasm. Access free multiple choice questions on this topic."}
+{"id": "article-102389_2", "title": "Benign Essential Blepharospasm -- Introduction", "content": "Blepharospasm is a disease that results in an increased rate of bilateral eyelid closure, mainly attributed to the involuntary contraction of the orbicularis oculi muscles. Blepharospasm is a type of dystonia. Dystonia falls under the classification of movement disorders and is characterized by either sustained or intermittent contraction of a muscle. This leads to abnormal repetitive movements or postures, which tend to have a certain pattern and may be twisting or tremulous. In most dystonias, voluntary action typically leads to exacerbation of dystonia due to overactivation of muscles. [1] Dystonia can potentially affect any part of the body and can present at a wide range of ages. [2] Dystonia can be classified according to its distribution across the body:", "contents": "Benign Essential Blepharospasm -- Introduction. Blepharospasm is a disease that results in an increased rate of bilateral eyelid closure, mainly attributed to the involuntary contraction of the orbicularis oculi muscles. Blepharospasm is a type of dystonia. Dystonia falls under the classification of movement disorders and is characterized by either sustained or intermittent contraction of a muscle. This leads to abnormal repetitive movements or postures, which tend to have a certain pattern and may be twisting or tremulous. In most dystonias, voluntary action typically leads to exacerbation of dystonia due to overactivation of muscles. [1] Dystonia can potentially affect any part of the body and can present at a wide range of ages. [2] Dystonia can be classified according to its distribution across the body:"}
+{"id": "article-102389_3", "title": "Benign Essential Blepharospasm -- Introduction", "content": "Focal dystonia refers to dystonia that affects only one isolated region of the body. Segmental dystonia refers to dystonia that affects 2 or more contiguous regions of the body. Multifocal dystonia refers to dystonia which affects 2 or more non-contiguous regions. Hemidystonia refers to dystonia, which affects half of the body. Generalized dystonia refers to dystonia, which affects the trunk along with 3 other sites. Dystonia can have a static or progressive course of the disease. Furthermore, the variability of symptoms can be classified according to how often they occur: [1] Persistent dystonia refers to dystonia that persists to the same extent throughout the day. Action-specific dystonia refers to dystonia that only occurs when performing a certain activity. Diurnal fluctuation refers to dystonia, which fluctuates throughout the day with a circadian variation in severity. Paroxysmal dystonia refers to sudden episodes of dystonia typically induced by a trigger.", "contents": "Benign Essential Blepharospasm -- Introduction. Focal dystonia refers to dystonia that affects only one isolated region of the body. Segmental dystonia refers to dystonia that affects 2 or more contiguous regions of the body. Multifocal dystonia refers to dystonia which affects 2 or more non-contiguous regions. Hemidystonia refers to dystonia, which affects half of the body. Generalized dystonia refers to dystonia, which affects the trunk along with 3 other sites. Dystonia can have a static or progressive course of the disease. Furthermore, the variability of symptoms can be classified according to how often they occur: [1] Persistent dystonia refers to dystonia that persists to the same extent throughout the day. Action-specific dystonia refers to dystonia that only occurs when performing a certain activity. Diurnal fluctuation refers to dystonia, which fluctuates throughout the day with a circadian variation in severity. Paroxysmal dystonia refers to sudden episodes of dystonia typically induced by a trigger."}
+{"id": "article-102389_4", "title": "Benign Essential Blepharospasm -- Introduction", "content": "Examples of focal dystonia include blepharospasm, oromandibular dystonia, writer's cramp, spasmodic dysphonia, and torticollis.", "contents": "Benign Essential Blepharospasm -- Introduction. Examples of focal dystonia include blepharospasm, oromandibular dystonia, writer's cramp, spasmodic dysphonia, and torticollis."}
+{"id": "article-102389_5", "title": "Benign Essential Blepharospasm -- Introduction", "content": "Blepharospasm is a focal dystonia characterized by the simultaneous contraction of agonist and antagonist muscles, resulting in involuntary eyelid closure; the first report of patients with blepharospasm comes from a description of 10 patients, made by Henri Meige in 1910: these patients had involuntary eyelid closure in association with contraction of the muscles of the jaw. In his paper, Meige named this phenomenon \"Convulsions de la Face\" (convulsions of the face). [3] This article will review the etiology, epidemiology, history, evaluation, and management of blepharospasm.", "contents": "Benign Essential Blepharospasm -- Introduction. Blepharospasm is a focal dystonia characterized by the simultaneous contraction of agonist and antagonist muscles, resulting in involuntary eyelid closure; the first report of patients with blepharospasm comes from a description of 10 patients, made by Henri Meige in 1910: these patients had involuntary eyelid closure in association with contraction of the muscles of the jaw. In his paper, Meige named this phenomenon \"Convulsions de la Face\" (convulsions of the face). [3] This article will review the etiology, epidemiology, history, evaluation, and management of blepharospasm."}
+{"id": "article-102389_6", "title": "Benign Essential Blepharospasm -- Etiology", "content": "The etiology of blepharospasm\u00a0is not well understood. Some gene mutations have been implicated in the development of the disease: 20% to 30 % of cases have a positive family history of benign essential blepharospasm (BEB), and some genes have been associated with a greater susceptibility for developing the disease. [4] Other factors thought to be implicated in the pathogenesis of the disease are neurotransmitter dysregulations, structural damage, and previous underlying eye disorders. [5] [6]", "contents": "Benign Essential Blepharospasm -- Etiology. The etiology of blepharospasm\u00a0is not well understood. Some gene mutations have been implicated in the development of the disease: 20% to 30 % of cases have a positive family history of benign essential blepharospasm (BEB), and some genes have been associated with a greater susceptibility for developing the disease. [4] Other factors thought to be implicated in the pathogenesis of the disease are neurotransmitter dysregulations, structural damage, and previous underlying eye disorders. [5] [6]"}
+{"id": "article-102389_7", "title": "Benign Essential Blepharospasm -- Etiology -- Non-inherited Risk Factors", "content": "Many environmental risk factors are associated with an increased risk of developing benign essential blepharospasm. These include high levels of urbanization and those working 'white-collar' jobs associated with a stressful lifestyle.", "contents": "Benign Essential Blepharospasm -- Etiology -- Non-inherited Risk Factors. Many environmental risk factors are associated with an increased risk of developing benign essential blepharospasm. These include high levels of urbanization and those working 'white-collar' jobs associated with a stressful lifestyle."}
+{"id": "article-102389_8", "title": "Benign Essential Blepharospasm -- Etiology -- Non-inherited Risk Factors", "content": "There are other factors\u00a0that are loosely associated with an increased risk of developing blepharospasm, such as reading, watching television, and computer screen use. [7] It is believed that eye strain while watching television, reading, or using the computer may lead to aggravation of blepharospasm. [8] Furthermore, patients suffering from psychiatric conditions such as obsessive-compulsive disorder, depression, and anxiety appear to have an increased risk of developing blepharospasm. [9]", "contents": "Benign Essential Blepharospasm -- Etiology -- Non-inherited Risk Factors. There are other factors\u00a0that are loosely associated with an increased risk of developing blepharospasm, such as reading, watching television, and computer screen use. [7] It is believed that eye strain while watching television, reading, or using the computer may lead to aggravation of blepharospasm. [8] Furthermore, patients suffering from psychiatric conditions such as obsessive-compulsive disorder, depression, and anxiety appear to have an increased risk of developing blepharospasm. [9]"}
+{"id": "article-102389_9", "title": "Benign Essential Blepharospasm -- Etiology -- Non-inherited Risk Factors", "content": "It has been shown by Conte et al. that 40% to 60% of patients present with ophthalmic symptoms such as burning, dryness, or grittiness, which precedes the development of blepharospasm. Furthermore, there is an association between diseases of the anterior segment, such as keratoconjunctivitis/blepharitis, and an increased risk of developing blepharospasm, although this is more correctly termed \"secondary blepharospasm\" as the condition improves when the underlying conditions have been appropriately treated. [10] [11] [10]", "contents": "Benign Essential Blepharospasm -- Etiology -- Non-inherited Risk Factors. It has been shown by Conte et al. that 40% to 60% of patients present with ophthalmic symptoms such as burning, dryness, or grittiness, which precedes the development of blepharospasm. Furthermore, there is an association between diseases of the anterior segment, such as keratoconjunctivitis/blepharitis, and an increased risk of developing blepharospasm, although this is more correctly termed \"secondary blepharospasm\" as the condition improves when the underlying conditions have been appropriately treated. [10] [11] [10]"}
+{"id": "article-102389_10", "title": "Benign Essential Blepharospasm -- Etiology -- Inherited Risk Factors", "content": "Genetic contribution to the disease is suggested by the finding of multiple affected individuals within families. In such cases, the inheritance pattern appears to be autosomal dominant with reduced penetrance. GNAL, CIZ1, TOR1A, DRD5, and REEP4 are genes reported to play a role in the development of BEB. [12] [13] [14] GNAL:", "contents": "Benign Essential Blepharospasm -- Etiology -- Inherited Risk Factors. Genetic contribution to the disease is suggested by the finding of multiple affected individuals within families. In such cases, the inheritance pattern appears to be autosomal dominant with reduced penetrance. GNAL, CIZ1, TOR1A, DRD5, and REEP4 are genes reported to play a role in the development of BEB. [12] [13] [14] GNAL:"}
+{"id": "article-102389_11", "title": "Benign Essential Blepharospasm -- Etiology -- Inherited Risk Factors", "content": "The GNAL gene encodes for the G alpha subunit of the G protein receptor. It is found in the olfactory epithelium and helps to mediate odorant signaling. [14] It is also expressed in striatal neurons found in the basal ganglia. Mouse models have shown that it has a role in the coupling of adenyl cyclase in response to dopamine and adenosine via the Drd1 and Adora2a receptors. [15]", "contents": "Benign Essential Blepharospasm -- Etiology -- Inherited Risk Factors. The GNAL gene encodes for the G alpha subunit of the G protein receptor. It is found in the olfactory epithelium and helps to mediate odorant signaling. [14] It is also expressed in striatal neurons found in the basal ganglia. Mouse models have shown that it has a role in the coupling of adenyl cyclase in response to dopamine and adenosine via the Drd1 and Adora2a receptors. [15]"}
+{"id": "article-102389_12", "title": "Benign Essential Blepharospasm -- Etiology -- Inherited Risk Factors", "content": "Mutations in the GNAL gene have been shown to be associated with autosomal dominant dystonia-25,\u00a0and it is thought that mutations in GNAL leading to abnormalities in the function of DRD1/Adora2a contribute to the development of dystonia. [16] CIZ1:", "contents": "Benign Essential Blepharospasm -- Etiology -- Inherited Risk Factors. Mutations in the GNAL gene have been shown to be associated with autosomal dominant dystonia-25,\u00a0and it is thought that mutations in GNAL leading to abnormalities in the function of DRD1/Adora2a contribute to the development of dystonia. [16] CIZ1:"}
+{"id": "article-102389_13", "title": "Benign Essential Blepharospasm -- Etiology -- Inherited Risk Factors", "content": "The CIZ1 gene encodes for the CKDN1A-interacting zinc finger protein 1. [17] This protein interacts with CIP1 to regulate the distribution of CIP1. CIZ1 has been found to be associated with autosomal dominant cervical dystonia. [13] TOR1A:", "contents": "Benign Essential Blepharospasm -- Etiology -- Inherited Risk Factors. The CIZ1 gene encodes for the CKDN1A-interacting zinc finger protein 1. [17] This protein interacts with CIP1 to regulate the distribution of CIP1. CIZ1 has been found to be associated with autosomal dominant cervical dystonia. [13] TOR1A:"}
+{"id": "article-102389_14", "title": "Benign Essential Blepharospasm -- Etiology -- Inherited Risk Factors", "content": "The TOR1A gene encodes for torsin-1A, otherwise known as DYT1. This is an adenosine triphosphatase that aids with a wide range of cellular activities. [18] TOR1A has high levels of expression in melanized neurons found in the pars compacta (substantia nigra), dentate gyrus, cerebellum, and stratum pyramidale of CA3 (hippocampus). [19] It is thought that a mutation in the TOR1A gene may lead to changes in interactions involving TOR1A in the nuclear envelope. [20] Therefore, it is thought that mutations in TOR1A contribute to dystonia through defects in the structure and function of the nuclear membrane. TOR1A mutations are associated with torsion dystonia and are inherited in an autosomal dominant pattern. [21] DRD5:", "contents": "Benign Essential Blepharospasm -- Etiology -- Inherited Risk Factors. The TOR1A gene encodes for torsin-1A, otherwise known as DYT1. This is an adenosine triphosphatase that aids with a wide range of cellular activities. [18] TOR1A has high levels of expression in melanized neurons found in the pars compacta (substantia nigra), dentate gyrus, cerebellum, and stratum pyramidale of CA3 (hippocampus). [19] It is thought that a mutation in the TOR1A gene may lead to changes in interactions involving TOR1A in the nuclear envelope. [20] Therefore, it is thought that mutations in TOR1A contribute to dystonia through defects in the structure and function of the nuclear membrane. TOR1A mutations are associated with torsion dystonia and are inherited in an autosomal dominant pattern. [21] DRD5:"}
+{"id": "article-102389_15", "title": "Benign Essential Blepharospasm -- Etiology -- Inherited Risk Factors", "content": "DRD5 encodes for the dopamine receptor D1B. DRD5 functions to increase adenylate cyclase activity, leading to the accumulation of intracellular cAMP. [22] Polymorphisms in the D5 receptor gene have been shown to be associated with blepharospasm. [14] [23]", "contents": "Benign Essential Blepharospasm -- Etiology -- Inherited Risk Factors. DRD5 encodes for the dopamine receptor D1B. DRD5 functions to increase adenylate cyclase activity, leading to the accumulation of intracellular cAMP. [22] Polymorphisms in the D5 receptor gene have been shown to be associated with blepharospasm. [14] [23]"}
+{"id": "article-102389_16", "title": "Benign Essential Blepharospasm -- Epidemiology", "content": "The estimated prevalence of benign essential blepharospasm worldwide is 20\u00a0to 133 cases per million and varies with geographic area. [24] Blepharospasm is less common than cervical dystonia in the United States and Europe. However, blepharospasm is more common in Italy and Japan than cervical dystonia. [6]", "contents": "Benign Essential Blepharospasm -- Epidemiology. The estimated prevalence of benign essential blepharospasm worldwide is 20\u00a0to 133 cases per million and varies with geographic area. [24] Blepharospasm is less common than cervical dystonia in the United States and Europe. However, blepharospasm is more common in Italy and Japan than cervical dystonia. [6]"}
+{"id": "article-102389_17", "title": "Benign Essential Blepharospasm -- Epidemiology -- Gender", "content": "There is a preponderance of blepharospasm in women. [6] It is thought that one of the contributing factors to an increased risk of blepharospasm in women is menopause. [25] The ratio of blepharospasm in women to\u00a0men is 2.3:1. [8] [26] Women may also present with a higher symptom frequency and severity. [27]", "contents": "Benign Essential Blepharospasm -- Epidemiology -- Gender. There is a preponderance of blepharospasm in women. [6] It is thought that one of the contributing factors to an increased risk of blepharospasm in women is menopause. [25] The ratio of blepharospasm in women to\u00a0men is 2.3:1. [8] [26] Women may also present with a higher symptom frequency and severity. [27]"}
+{"id": "article-102389_18", "title": "Benign Essential Blepharospasm -- Epidemiology -- Age", "content": "Blepharospasm peaks between the ages of 50 to 70. [6]", "contents": "Benign Essential Blepharospasm -- Epidemiology -- Age. Blepharospasm peaks between the ages of 50 to 70. [6]"}
+{"id": "article-102389_19", "title": "Benign Essential Blepharospasm -- Pathophysiology", "content": "Blepharospasm is a disease that results in an increased rate of bilateral eyelid closure, mainly attributed to the involuntary contraction of the orbicularis oculi muscles. [28] The exact pathophysiology of the disease remains unknown. Many pathophysiological mechanisms have been suggested. Pathophysiologic mechanisms involved can be grouped into several categories: genetic, environmental, functional, and structural, which are not mutually exclusive. In fact, within a single subject, many of these factors must be present in order for the disease to develop. This is supported by what is called the two-hit hypothesis, which proposes that a predisposing factor and an environmental trigger must be present concomitantly for the disease to develop. [5] [29] The role of environmental factors in BEB is supported by studies showing the association of underlying eye disease and the antecedent of a traumatic stressor as triggers of the disease. [30] [31]", "contents": "Benign Essential Blepharospasm -- Pathophysiology. Blepharospasm is a disease that results in an increased rate of bilateral eyelid closure, mainly attributed to the involuntary contraction of the orbicularis oculi muscles. [28] The exact pathophysiology of the disease remains unknown. Many pathophysiological mechanisms have been suggested. Pathophysiologic mechanisms involved can be grouped into several categories: genetic, environmental, functional, and structural, which are not mutually exclusive. In fact, within a single subject, many of these factors must be present in order for the disease to develop. This is supported by what is called the two-hit hypothesis, which proposes that a predisposing factor and an environmental trigger must be present concomitantly for the disease to develop. [5] [29] The role of environmental factors in BEB is supported by studies showing the association of underlying eye disease and the antecedent of a traumatic stressor as triggers of the disease. [30] [31]"}
+{"id": "article-102389_20", "title": "Benign Essential Blepharospasm -- Pathophysiology", "content": "Structural and functional mechanisms are thought to occur together as the condition is thought to be due to a structural defect that leads to neurotransmitter dysregulation.", "contents": "Benign Essential Blepharospasm -- Pathophysiology. Structural and functional mechanisms are thought to occur together as the condition is thought to be due to a structural defect that leads to neurotransmitter dysregulation."}
+{"id": "article-102389_21", "title": "Benign Essential Blepharospasm -- Pathophysiology -- Blink Reflex", "content": "Patients with BEB have an increased blinking rate and an increased response in the R2 phase of the trigeminal blinking reflex (TBR). TBR is a physiologic response that consists of two phases: phase R1 begins with corneal stimulation and consists of an afferent pathway that travels through the ophthalmic branch of the trigeminal nerve to reach the trigeminal nucleus in the brainstem. This phase is unilateral. After reaching the trigeminal nucleus, signals are sent to the facial nucleus bilaterally, which results in the R2 phase of the TBR.", "contents": "Benign Essential Blepharospasm -- Pathophysiology -- Blink Reflex. Patients with BEB have an increased blinking rate and an increased response in the R2 phase of the trigeminal blinking reflex (TBR). TBR is a physiologic response that consists of two phases: phase R1 begins with corneal stimulation and consists of an afferent pathway that travels through the ophthalmic branch of the trigeminal nerve to reach the trigeminal nucleus in the brainstem. This phase is unilateral. After reaching the trigeminal nucleus, signals are sent to the facial nucleus bilaterally, which results in the R2 phase of the TBR."}
+{"id": "article-102389_22", "title": "Benign Essential Blepharospasm -- Pathophysiology -- Blink Reflex", "content": "The R2 phase is the efferent phase of the reflex, and it is carried by the zygomatic, buccal, and temporal branches of the facial nerve to reach the muscles of facial expression and result in their contraction bilaterally. As previously mentioned, patients with BEB exhibit a more intense R2 phase of the TBR as compared to healthy subjects. [32] [33] Similarly, as there is a reflex that results in the stimulation of orbicularis oculi muscles, there is also a reflex for inhibition of the levator palpebrae superioris(LPS). This inhibition reflex is also composed of two phases: SP1 and SP2, the latter being more intense and of longer duration than the former. In healthy subjects, inhibition of LPS occurs synchronically with orbicularis oculi muscle action. [31] Whether or not a pathological response of the inhibitory reflex of LPS plays a role in the pathophysiology of BEB is not yet known.", "contents": "Benign Essential Blepharospasm -- Pathophysiology -- Blink Reflex. The R2 phase is the efferent phase of the reflex, and it is carried by the zygomatic, buccal, and temporal branches of the facial nerve to reach the muscles of facial expression and result in their contraction bilaterally. As previously mentioned, patients with BEB exhibit a more intense R2 phase of the TBR as compared to healthy subjects. [32] [33] Similarly, as there is a reflex that results in the stimulation of orbicularis oculi muscles, there is also a reflex for inhibition of the levator palpebrae superioris(LPS). This inhibition reflex is also composed of two phases: SP1 and SP2, the latter being more intense and of longer duration than the former. In healthy subjects, inhibition of LPS occurs synchronically with orbicularis oculi muscle action. [31] Whether or not a pathological response of the inhibitory reflex of LPS plays a role in the pathophysiology of BEB is not yet known."}
+{"id": "article-102389_23", "title": "Benign Essential Blepharospasm -- Pathophysiology -- Blink Reflex", "content": "Specific changes in brain structures have been reported by many authors. In one study performed by Etgen et al.,\u00a0it was found that patients with BEB exhibit gray matter increase bilaterally at the level of the putamen independent of the duration of the blepharospasm and a gray matter decrease in parietal\u00a0lobes that appear to correlate with BEB duration. This finding is also supported by the fact that there is an increased glucose metabolism in the thalamus, as was evidenced by Suzuki et al. [34] [35] [34]", "contents": "Benign Essential Blepharospasm -- Pathophysiology -- Blink Reflex. Specific changes in brain structures have been reported by many authors. In one study performed by Etgen et al.,\u00a0it was found that patients with BEB exhibit gray matter increase bilaterally at the level of the putamen independent of the duration of the blepharospasm and a gray matter decrease in parietal\u00a0lobes that appear to correlate with BEB duration. This finding is also supported by the fact that there is an increased glucose metabolism in the thalamus, as was evidenced by Suzuki et al. [34] [35] [34]"}
+{"id": "article-102389_24", "title": "Benign Essential Blepharospasm -- Pathophysiology -- Blink Reflex", "content": "Functional magnetic resonance imaging has also been used to evaluate patients with BEB. When compared with healthy subjects, it was found that the anterior visual cortex, the thalamus, anterior cingulate cortex, primary motor cortex, and superior cerebellum exhibit a greater activation with voluntary and involuntary blinking. [36] Dopamine also appears to play a role in the pathogenesis of the disease. It was found in one study that these patients appear to have a decreased binding of dopamine to D2 receptors at the striatum when compared with healthy subjects. [37]", "contents": "Benign Essential Blepharospasm -- Pathophysiology -- Blink Reflex. Functional magnetic resonance imaging has also been used to evaluate patients with BEB. When compared with healthy subjects, it was found that the anterior visual cortex, the thalamus, anterior cingulate cortex, primary motor cortex, and superior cerebellum exhibit a greater activation with voluntary and involuntary blinking. [36] Dopamine also appears to play a role in the pathogenesis of the disease. It was found in one study that these patients appear to have a decreased binding of dopamine to D2 receptors at the striatum when compared with healthy subjects. [37]"}
+{"id": "article-102389_25", "title": "Benign Essential Blepharospasm -- Pathophysiology -- Anterior Segment Disease", "content": "As there is an association between prior anterior segment diseases of the eye and an increased risk of developing blepharospasm, it is thought that in people who are predisposed to blepharospasm, because of either genetic abnormalities or abnormalities in neurological signaling, there is a failure to regulate the blinking reflex leading to the development of trigeminal hyperexcitability and involuntary eyelid closure. [38]", "contents": "Benign Essential Blepharospasm -- Pathophysiology -- Anterior Segment Disease. As there is an association between prior anterior segment diseases of the eye and an increased risk of developing blepharospasm, it is thought that in people who are predisposed to blepharospasm, because of either genetic abnormalities or abnormalities in neurological signaling, there is a failure to regulate the blinking reflex leading to the development of trigeminal hyperexcitability and involuntary eyelid closure. [38]"}
+{"id": "article-102389_26", "title": "Benign Essential Blepharospasm -- History and Physical", "content": "BEB is an underdiagnosed entity. A study performed in Japan reported that 60% of patients see at least five physicians before they receive a definitive diagnosis. One-third of patients are diagnosed within the first year of symptom onset, one-third in a period between one and five years, and in one-third of patients, it takes more than five years before they are diagnosed with BEB. [39]", "contents": "Benign Essential Blepharospasm -- History and Physical. BEB is an underdiagnosed entity. A study performed in Japan reported that 60% of patients see at least five physicians before they receive a definitive diagnosis. One-third of patients are diagnosed within the first year of symptom onset, one-third in a period between one and five years, and in one-third of patients, it takes more than five years before they are diagnosed with BEB. [39]"}
+{"id": "article-102389_27", "title": "Benign Essential Blepharospasm -- History and Physical -- Precipitating Factors", "content": "Lee et al. have shown that 42.6%\u00a0of patients experienced some sort of stressful life event before the onset of symptoms. This included major life events such as divorce (19.8%), problems at work (13.9%), illness of a family member (2%), death of a parent (1%), moving house (1%), head trauma (1%), traffic accident (1%) and cerebral infarction (1%).\u00a0In a study in Tokyo that involved 1,116 participants, 9.7% reported symptoms following surgery: the most common surgery performed was cataract surgery. [30] [39]", "contents": "Benign Essential Blepharospasm -- History and Physical -- Precipitating Factors. Lee et al. have shown that 42.6%\u00a0of patients experienced some sort of stressful life event before the onset of symptoms. This included major life events such as divorce (19.8%), problems at work (13.9%), illness of a family member (2%), death of a parent (1%), moving house (1%), head trauma (1%), traffic accident (1%) and cerebral infarction (1%).\u00a0In a study in Tokyo that involved 1,116 participants, 9.7% reported symptoms following surgery: the most common surgery performed was cataract surgery. [30] [39]"}
+{"id": "article-102389_28", "title": "Benign Essential Blepharospasm -- History and Physical -- Motor Manifestations", "content": "The spasm associated with blepharospasm tends to be synchronous and bilateral, affecting the orbicularis oculi muscle.", "contents": "Benign Essential Blepharospasm -- History and Physical -- Motor Manifestations. The spasm associated with blepharospasm tends to be synchronous and bilateral, affecting the orbicularis oculi muscle."}
+{"id": "article-102389_29", "title": "Benign Essential Blepharospasm -- History and Physical -- Motor Manifestations", "content": "Symptom severity is highly variable, and it can range from mild symptoms with increased blinking rate to functional blindness due to persistent muscle contraction. In many cases, the course of the disease is progressive, initially presenting with contractions limited to the orbicularis oculi muscles and later extending to the musculature of the lower face and neck, which is known as Meige syndrome. [33]", "contents": "Benign Essential Blepharospasm -- History and Physical -- Motor Manifestations. Symptom severity is highly variable, and it can range from mild symptoms with increased blinking rate to functional blindness due to persistent muscle contraction. In many cases, the course of the disease is progressive, initially presenting with contractions limited to the orbicularis oculi muscles and later extending to the musculature of the lower face and neck, which is known as Meige syndrome. [33]"}
+{"id": "article-102389_30", "title": "Benign Essential Blepharospasm -- History and Physical -- Apraxia of Eyelid Opening", "content": "Some patients suffering from blepharospasm may also present with apraxia of eyelid opening (AEO). This presents with an inability to reopen the eyes in the absence of orbicularis oculi muscle spasm. This occurs as a result of a spasm of the pretarsal orbicularis oculi muscle, which acts against the opening of the eyelid. [40]", "contents": "Benign Essential Blepharospasm -- History and Physical -- Apraxia of Eyelid Opening. Some patients suffering from blepharospasm may also present with apraxia of eyelid opening (AEO). This presents with an inability to reopen the eyes in the absence of orbicularis oculi muscle spasm. This occurs as a result of a spasm of the pretarsal orbicularis oculi muscle, which acts against the opening of the eyelid. [40]"}
+{"id": "article-102389_31", "title": "Benign Essential Blepharospasm -- History and Physical -- Non-motor Manifestations", "content": "It is important to keep in mind that depression and anxiety are commonly present in patients with BEB. These occur either before the disease or as a consequence of it. This\u00a0should be sought during evaluation and psychiatric consultation considered. [8] Half of the patients with BEB have accompanying ocular symptoms, with most reporting eye dryness and photophobia. [41]", "contents": "Benign Essential Blepharospasm -- History and Physical -- Non-motor Manifestations. It is important to keep in mind that depression and anxiety are commonly present in patients with BEB. These occur either before the disease or as a consequence of it. This\u00a0should be sought during evaluation and psychiatric consultation considered. [8] Half of the patients with BEB have accompanying ocular symptoms, with most reporting eye dryness and photophobia. [41]"}
+{"id": "article-102389_32", "title": "Benign Essential Blepharospasm -- History and Physical -- Relieving Factors", "content": "There are particular things some patients can do to help relieve their blepharospasm. This includes resting (35.6%), concentrating on work (12.9%), and various other things such as singing, talking, eating, sleep, and exercise, which were all reported at a rate of 2%.\u00a0However, 31.7% of patients could not identify a\u00a0relieving factor. [30]", "contents": "Benign Essential Blepharospasm -- History and Physical -- Relieving Factors. There are particular things some patients can do to help relieve their blepharospasm. This includes resting (35.6%), concentrating on work (12.9%), and various other things such as singing, talking, eating, sleep, and exercise, which were all reported at a rate of 2%.\u00a0However, 31.7% of patients could not identify a\u00a0relieving factor. [30]"}
+{"id": "article-102389_33", "title": "Benign Essential Blepharospasm -- History and Physical -- Aggravating Factors", "content": "Things that have been shown to aggravate the symptoms of blepharospasm include fatigue (55.4%), stressful events (46.5%), watching television (27.7%), bright lights (18.9%), dry eye symptoms (14.9%), feeling sick (10.9%) or reading a book (8.9%).", "contents": "Benign Essential Blepharospasm -- History and Physical -- Aggravating Factors. Things that have been shown to aggravate the symptoms of blepharospasm include fatigue (55.4%), stressful events (46.5%), watching television (27.7%), bright lights (18.9%), dry eye symptoms (14.9%), feeling sick (10.9%) or reading a book (8.9%)."}
+{"id": "article-102389_34", "title": "Benign Essential Blepharospasm -- Evaluation", "content": "The diagnosis of blepharospasm is mainly based on clinical assessment.", "contents": "Benign Essential Blepharospasm -- Evaluation. The diagnosis of blepharospasm is mainly based on clinical assessment."}
+{"id": "article-102389_35", "title": "Benign Essential Blepharospasm -- Evaluation -- Clinical Assessment", "content": "A clinical history determining the nature of the eyelid spasm is highly important. Patients suffering from blepharospasm will complain of bilateral, synchronous, stereotyped spasms of the orbicularis oculi muscle. These spasms may present with brief and repetitive blinking or persistent closure of the eyes, leading to functional impairment. There is a diagnostic algorithm that is based on the presence of bilateral, synchronous, and stereotyped movements of the orbicularis oculi muscle, the presence of a sensory trick, or increased blinking. This diagnostic algorithm has been shown to have a sensitivity of 93% and a specificity of 90% in differentiating BEB from other similar conditions. [42] [43] [44]", "contents": "Benign Essential Blepharospasm -- Evaluation -- Clinical Assessment. A clinical history determining the nature of the eyelid spasm is highly important. Patients suffering from blepharospasm will complain of bilateral, synchronous, stereotyped spasms of the orbicularis oculi muscle. These spasms may present with brief and repetitive blinking or persistent closure of the eyes, leading to functional impairment. There is a diagnostic algorithm that is based on the presence of bilateral, synchronous, and stereotyped movements of the orbicularis oculi muscle, the presence of a sensory trick, or increased blinking. This diagnostic algorithm has been shown to have a sensitivity of 93% and a specificity of 90% in differentiating BEB from other similar conditions. [42] [43] [44]"}
+{"id": "article-102389_36", "title": "Benign Essential Blepharospasm -- Evaluation -- Clinical Assessment", "content": "Furthermore, as mentioned before, patients suffering from blepharospasm may also suffer from related non-motor manifestations such as psychiatric disorders, sleep disorders, sensory symptoms, and cognitive disturbances. Sensory symptoms such as a sensation of dry eye or photophobia have been identified to be associated with a specificity of 94% and a sensitivity of 77% in patients suffering from BEB. [45] Psychiatric disorders, such as anxiety and depression, are associated with BEB. However, other related conditions\u00a0are also associated with higher rates of anxiety and depression. [28]", "contents": "Benign Essential Blepharospasm -- Evaluation -- Clinical Assessment. Furthermore, as mentioned before, patients suffering from blepharospasm may also suffer from related non-motor manifestations such as psychiatric disorders, sleep disorders, sensory symptoms, and cognitive disturbances. Sensory symptoms such as a sensation of dry eye or photophobia have been identified to be associated with a specificity of 94% and a sensitivity of 77% in patients suffering from BEB. [45] Psychiatric disorders, such as anxiety and depression, are associated with BEB. However, other related conditions\u00a0are also associated with higher rates of anxiety and depression. [28]"}
+{"id": "article-102389_37", "title": "Benign Essential Blepharospasm -- Evaluation -- Severity Assessment", "content": "In order to assess the severity of the disease, many scales have been developed. These include The Jankovic Rating Scale (JRC), The Blepharospasm Severity Scale (BSS), The Blepharospasm Disability Scale (BDS), and The Blepharospasm Disability Index (BDI). [33]", "contents": "Benign Essential Blepharospasm -- Evaluation -- Severity Assessment. In order to assess the severity of the disease, many scales have been developed. These include The Jankovic Rating Scale (JRC), The Blepharospasm Severity Scale (BSS), The Blepharospasm Disability Scale (BDS), and The Blepharospasm Disability Index (BDI). [33]"}
+{"id": "article-102389_38", "title": "Benign Essential Blepharospasm -- Evaluation -- Severity Assessment", "content": "The most widely used scale is the\u00a0Jankovic Rating Scale. This is commonly used during the initial assessment and to monitor treatment response during patient follow-up. This scale assesses severity and frequency separately, giving a score of 0 to 4 for each one of these, as shown in Table 1. [46]", "contents": "Benign Essential Blepharospasm -- Evaluation -- Severity Assessment. The most widely used scale is the\u00a0Jankovic Rating Scale. This is commonly used during the initial assessment and to monitor treatment response during patient follow-up. This scale assesses severity and frequency separately, giving a score of 0 to 4 for each one of these, as shown in Table 1. [46]"}
+{"id": "article-102389_39", "title": "Benign Essential Blepharospasm -- Evaluation -- Severity Assessment", "content": "There also exist scales for severity grading of focal dystonia not specific for blepharospasm, but that are commonly used by some physicians when assessing patients with BEB. These include The Global Dystonia Rating Scale, The Burke-Fahn-Marsden Dystonia Rating Scale, and The Unified Dystonia Rating Scale. [42] Direct comparison of these grading scales has not been performed, and which one to use is determined by physician preference.", "contents": "Benign Essential Blepharospasm -- Evaluation -- Severity Assessment. There also exist scales for severity grading of focal dystonia not specific for blepharospasm, but that are commonly used by some physicians when assessing patients with BEB. These include The Global Dystonia Rating Scale, The Burke-Fahn-Marsden Dystonia Rating Scale, and The Unified Dystonia Rating Scale. [42] Direct comparison of these grading scales has not been performed, and which one to use is determined by physician preference."}
+{"id": "article-102389_40", "title": "Benign Essential Blepharospasm -- Evaluation -- Electromyography", "content": "Dystonia presents with the contraction of antagonistic muscles. Electromyography studies can be used to identify such abnormalities. However, in practice, this is not always used.", "contents": "Benign Essential Blepharospasm -- Evaluation -- Electromyography. Dystonia presents with the contraction of antagonistic muscles. Electromyography studies can be used to identify such abnormalities. However, in practice, this is not always used."}
+{"id": "article-102389_41", "title": "Benign Essential Blepharospasm -- Evaluation -- Blink Reflex", "content": "Assessment of the blink reflex is useful in the evaluation of BEB. The tapping of the forehead (glabella reflex) may be done to induce reflexive blinking. By repeatedly tapping the forehead, it is possible to assess the patient's ability to inhibit the glabella reflex. This is known as Myerson's maneuver. [28] Another way to induce reflexive blinking is the use of a startling stimulus, such as visual or auditory stimuli.", "contents": "Benign Essential Blepharospasm -- Evaluation -- Blink Reflex. Assessment of the blink reflex is useful in the evaluation of BEB. The tapping of the forehead (glabella reflex) may be done to induce reflexive blinking. By repeatedly tapping the forehead, it is possible to assess the patient's ability to inhibit the glabella reflex. This is known as Myerson's maneuver. [28] Another way to induce reflexive blinking is the use of a startling stimulus, such as visual or auditory stimuli."}
+{"id": "article-102389_42", "title": "Benign Essential Blepharospasm -- Evaluation -- Blink Reflex", "content": "In practice, the most frequently used method of inducing the blink reflex is electrical stimulation of the supraorbital nerve while performing an EMG on the orbicularis oculi muscle. [28] As mentioned earlier, the trigemino-facial blink reflex consists of an early ipsilateral R1 component and a late bilateral R2 component. The R1 component is facilitated by the pons, whereas the R2 component is dependent on both the pons and the lateral medulla.", "contents": "Benign Essential Blepharospasm -- Evaluation -- Blink Reflex. In practice, the most frequently used method of inducing the blink reflex is electrical stimulation of the supraorbital nerve while performing an EMG on the orbicularis oculi muscle. [28] As mentioned earlier, the trigemino-facial blink reflex consists of an early ipsilateral R1 component and a late bilateral R2 component. The R1 component is facilitated by the pons, whereas the R2 component is dependent on both the pons and the lateral medulla."}
+{"id": "article-102389_43", "title": "Benign Essential Blepharospasm -- Evaluation -- Blink Reflex", "content": "The blink reflex can be assessed by using the paired shock technique. Both of the supraorbital nerves are stimulated with an impulse of identical intensity. [47] The first stimulus used induces a change in the excitability of the reflex circuits (conditioning), whereas the second stimulus (test), which is delivered at varying intervals (100\u00a0to 1000ms), is used as a probe stimulus. The size of the induced response is measured, and the test stimulus is compared to the conditioning stimulus. This is done for varying stimulus intervals. A normal patient will present with no R2 response during small intervals (100\u00a0to 200 ms), whereas a patient suffering from blepharospasm may have an R2 response with small intervals (100\u00a0to 200 ms). [28] This test does not have high specificity for dystonia but can be used to rule out psychogenic dystonia, which will present with normal features.", "contents": "Benign Essential Blepharospasm -- Evaluation -- Blink Reflex. The blink reflex can be assessed by using the paired shock technique. Both of the supraorbital nerves are stimulated with an impulse of identical intensity. [47] The first stimulus used induces a change in the excitability of the reflex circuits (conditioning), whereas the second stimulus (test), which is delivered at varying intervals (100\u00a0to 1000ms), is used as a probe stimulus. The size of the induced response is measured, and the test stimulus is compared to the conditioning stimulus. This is done for varying stimulus intervals. A normal patient will present with no R2 response during small intervals (100\u00a0to 200 ms), whereas a patient suffering from blepharospasm may have an R2 response with small intervals (100\u00a0to 200 ms). [28] This test does not have high specificity for dystonia but can be used to rule out psychogenic dystonia, which will present with normal features."}
+{"id": "article-102389_44", "title": "Benign Essential Blepharospasm -- Treatment / Management", "content": "The exact cause of benign essential blepharospasm is not well understood, and, as such, there is no definitive cure for BEB. However, there is a range of treatment options available.", "contents": "Benign Essential Blepharospasm -- Treatment / Management. The exact cause of benign essential blepharospasm is not well understood, and, as such, there is no definitive cure for BEB. However, there is a range of treatment options available."}
+{"id": "article-102389_45", "title": "Benign Essential Blepharospasm -- Treatment / Management -- Photochromatic Modulation", "content": "It has been shown that patients suffering from blepharospasm are able to tolerate light intensities similar to those tolerated by patients without blepharospasm. However, when particular wavelengths were blocked out using lens tints, the patients suffering from blepharospasm were no longer able to tolerate similar light intensities. This implies that photophobia in blepharospasm is dependent on both light intensity and wavelength.", "contents": "Benign Essential Blepharospasm -- Treatment / Management -- Photochromatic Modulation. It has been shown that patients suffering from blepharospasm are able to tolerate light intensities similar to those tolerated by patients without blepharospasm. However, when particular wavelengths were blocked out using lens tints, the patients suffering from blepharospasm were no longer able to tolerate similar light intensities. This implies that photophobia in blepharospasm is dependent on both light intensity and wavelength."}
+{"id": "article-102389_46", "title": "Benign Essential Blepharospasm -- Treatment / Management -- Photochromatic Modulation", "content": "Multiple studies have shown symptomatic improvement in patients treated with photochromatic modulation. [48] In particular, the FL-41 lens tint has been shown to reduce symptoms of photophobia in patients suffering from blepharospasm. [49] [50]", "contents": "Benign Essential Blepharospasm -- Treatment / Management -- Photochromatic Modulation. Multiple studies have shown symptomatic improvement in patients treated with photochromatic modulation. [48] In particular, the FL-41 lens tint has been shown to reduce symptoms of photophobia in patients suffering from blepharospasm. [49] [50]"}
+{"id": "article-102389_47", "title": "Benign Essential Blepharospasm -- Treatment / Management -- Botulinum Toxin injections", "content": "Botulinum toxins:", "contents": "Benign Essential Blepharospasm -- Treatment / Management -- Botulinum Toxin injections. Botulinum toxins:"}
+{"id": "article-102389_48", "title": "Benign Essential Blepharospasm -- Treatment / Management -- Botulinum Toxin injections", "content": "There are seven\u00a0serotypes of the botulinum toxin (A, B, C, D, E, F, G),\u00a0but only serotypes A and B are available for use. [51] In the United States, the only botulinum toxin products approved for use in blepharospasm are\u00a0abobotulinumtoxinA, onabotulinumtoxinA, and incobotulinumtoxinA. [52] Studies have shown that\u00a0abobotulinumtoxinA may have a longer duration of action\u00a0compared to\u00a0incobotulinumtoxinA. [53] Mode of action:", "contents": "Benign Essential Blepharospasm -- Treatment / Management -- Botulinum Toxin injections. There are seven\u00a0serotypes of the botulinum toxin (A, B, C, D, E, F, G),\u00a0but only serotypes A and B are available for use. [51] In the United States, the only botulinum toxin products approved for use in blepharospasm are\u00a0abobotulinumtoxinA, onabotulinumtoxinA, and incobotulinumtoxinA. [52] Studies have shown that\u00a0abobotulinumtoxinA may have a longer duration of action\u00a0compared to\u00a0incobotulinumtoxinA. [53] Mode of action:"}
+{"id": "article-102389_49", "title": "Benign Essential Blepharospasm -- Treatment / Management -- Botulinum Toxin injections", "content": "Botulinum toxin injection is the standard treatment for patients with BEB. It exerts its effect by inhibiting acetylcholine release at the neuromuscular junction, which leads to decreased muscle contraction. [54] Technique:", "contents": "Benign Essential Blepharospasm -- Treatment / Management -- Botulinum Toxin injections. Botulinum toxin injection is the standard treatment for patients with BEB. It exerts its effect by inhibiting acetylcholine release at the neuromuscular junction, which leads to decreased muscle contraction. [54] Technique:"}
+{"id": "article-102389_50", "title": "Benign Essential Blepharospasm -- Treatment / Management -- Botulinum Toxin injections", "content": "Approximately 1.25-5 units of botulinum toxin are used per injection site. [53] However, with repeated injections, increasingly larger doses may be needed due to the formation of antibodies against the botulinum toxin in a few patients,\u00a0along with the worsening of the underlying condition.\u00a0The injection sites that are typically used include the lateral lower and upper eyelid margins, the lateral canthi, and the medial upper eyelid. [55] The toxin\u00a0is typically injected into the procerus, corrugator, and orbicularis oculi muscles.\u00a0The\u00a0dose of botulinum toxin should not exceed more than 200 units (of onabotulinumtoxinA) within 30 days. [53]", "contents": "Benign Essential Blepharospasm -- Treatment / Management -- Botulinum Toxin injections. Approximately 1.25-5 units of botulinum toxin are used per injection site. [53] However, with repeated injections, increasingly larger doses may be needed due to the formation of antibodies against the botulinum toxin in a few patients,\u00a0along with the worsening of the underlying condition.\u00a0The injection sites that are typically used include the lateral lower and upper eyelid margins, the lateral canthi, and the medial upper eyelid. [55] The toxin\u00a0is typically injected into the procerus, corrugator, and orbicularis oculi muscles.\u00a0The\u00a0dose of botulinum toxin should not exceed more than 200 units (of onabotulinumtoxinA) within 30 days. [53]"}
+{"id": "article-102389_51", "title": "Benign Essential Blepharospasm -- Treatment / Management -- Botulinum Toxin injections", "content": "It usually takes 48 hours from injection to clinical response.\u00a0However, the response to treatment is highly variable. Nevertheless, the reduction of abnormal movements is seen in all subjects. Treatment response and duration of the effect appear to be dose-related, and the latter may be as long as 170 days. [56] On average, most patients become significantly symptomatic about 90 days after injection.", "contents": "Benign Essential Blepharospasm -- Treatment / Management -- Botulinum Toxin injections. It usually takes 48 hours from injection to clinical response.\u00a0However, the response to treatment is highly variable. Nevertheless, the reduction of abnormal movements is seen in all subjects. Treatment response and duration of the effect appear to be dose-related, and the latter may be as long as 170 days. [56] On average, most patients become significantly symptomatic about 90 days after injection."}
+{"id": "article-102389_52", "title": "Benign Essential Blepharospasm -- Treatment / Management -- Botulinum Toxin injections", "content": "Botulinum toxin injections are recommended every three to four months. Some authors report a more intense effect seen with the first round of injections and decreasing efficacy with subsequent doses. [48]", "contents": "Benign Essential Blepharospasm -- Treatment / Management -- Botulinum Toxin injections. Botulinum toxin injections are recommended every three to four months. Some authors report a more intense effect seen with the first round of injections and decreasing efficacy with subsequent doses. [48]"}
+{"id": "article-102389_53", "title": "Benign Essential Blepharospasm -- Treatment / Management -- Botulinum Toxin injections", "content": "Potential reasons for a poor response to botulinum toxin injections include the development of antibodies against the botulinum toxin, poor injection technique, and the presence of apraxia of eyelid opening. [51] Antibodies against the botulinum toxin are more likely to develop if there is a short interval between injections, with the use of 'booster' injections, increasingly larger doses over time, and an early onset of botulinum toxin injection therapy. [57]", "contents": "Benign Essential Blepharospasm -- Treatment / Management -- Botulinum Toxin injections. Potential reasons for a poor response to botulinum toxin injections include the development of antibodies against the botulinum toxin, poor injection technique, and the presence of apraxia of eyelid opening. [51] Antibodies against the botulinum toxin are more likely to develop if there is a short interval between injections, with the use of 'booster' injections, increasingly larger doses over time, and an early onset of botulinum toxin injection therapy. [57]"}
+{"id": "article-102389_54", "title": "Benign Essential Blepharospasm -- Treatment / Management -- Oral Pharmacotherapy", "content": "Oral pharmacotherapy for BEB has failed to show persistent relief from symptoms and tends to vary in effectiveness between patients. [48]", "contents": "Benign Essential Blepharospasm -- Treatment / Management -- Oral Pharmacotherapy. Oral pharmacotherapy for BEB has failed to show persistent relief from symptoms and tends to vary in effectiveness between patients. [48]"}
+{"id": "article-102389_55", "title": "Benign Essential Blepharospasm -- Treatment / Management -- Oral Pharmacotherapy", "content": "This includes medications such as benzodiazepines, anticholinergics (benztropine and trihexyphenidyl), levodopa, baclofen, VMAT2 inhibitors (tetrabenazine), lithium, valproate, methylphenidate, zolpidem amongst others. All of these have a limited role but might be considered for refractory disease before taking patients to the operating room for a more invasive strategy and as an adjunct to botulinum toxin injections. Oral pharmacotherapy is also associated with potentially undesirable side effects, which are not associated with botulinum toxin injection, along with the potential risk of developing dependence on benzodiazepines. [33] [48] [58]", "contents": "Benign Essential Blepharospasm -- Treatment / Management -- Oral Pharmacotherapy. This includes medications such as benzodiazepines, anticholinergics (benztropine and trihexyphenidyl), levodopa, baclofen, VMAT2 inhibitors (tetrabenazine), lithium, valproate, methylphenidate, zolpidem amongst others. All of these have a limited role but might be considered for refractory disease before taking patients to the operating room for a more invasive strategy and as an adjunct to botulinum toxin injections. Oral pharmacotherapy is also associated with potentially undesirable side effects, which are not associated with botulinum toxin injection, along with the potential risk of developing dependence on benzodiazepines. [33] [48] [58]"}
+{"id": "article-102389_56", "title": "Benign Essential Blepharospasm -- Treatment / Management -- Surgical Management", "content": "Surgical intervention is indicated in patients who fail to show a response to medical therapy and have persisting symptoms. Surgical management is performed with the intent to improve functionality and reduce the frequency of spasms.", "contents": "Benign Essential Blepharospasm -- Treatment / Management -- Surgical Management. Surgical intervention is indicated in patients who fail to show a response to medical therapy and have persisting symptoms. Surgical management is performed with the intent to improve functionality and reduce the frequency of spasms."}
+{"id": "article-102389_57", "title": "Benign Essential Blepharospasm -- Treatment / Management -- Surgical Management", "content": "In patients whose disease is refractory to standard measures, neurectomies, myomectomies, and deep brain stimulation (DBS) represent appropriate treatment alternatives. About half of patients treated with myomectomies or neurectomies will require botulinum toxin injection five years after surgery, but at lower doses than previously needed. Evidence supporting the use of DBS for BEB is not robust and should be considered a\u00a0last resort. Surgical myectomy:", "contents": "Benign Essential Blepharospasm -- Treatment / Management -- Surgical Management. In patients whose disease is refractory to standard measures, neurectomies, myomectomies, and deep brain stimulation (DBS) represent appropriate treatment alternatives. About half of patients treated with myomectomies or neurectomies will require botulinum toxin injection five years after surgery, but at lower doses than previously needed. Evidence supporting the use of DBS for BEB is not robust and should be considered a\u00a0last resort. Surgical myectomy:"}
+{"id": "article-102389_58", "title": "Benign Essential Blepharospasm -- Treatment / Management -- Surgical Management", "content": "Surgical myectomy involves the resection of the protractor muscles (corrugator supercili, orbicularis oculi, procerus, and depressor supercili). Gillum and Anderson\u00a0described the surgical technique for full myectomy, which succeeds in controlling blepharospasm as there is an 88% improvement in patients with blepharospasm\u00a0but may be associated with postoperative lymphedema, lagophthalmos, and facial anesthesia. Currently, modified and partial myectomy is the preferred technique. This is performed in addition to correcting the effects of blepharospasm, which include brow ptosis, ptosis, dermatochalasis, and lateral canthal dystopia. [48] [59] [60]", "contents": "Benign Essential Blepharospasm -- Treatment / Management -- Surgical Management. Surgical myectomy involves the resection of the protractor muscles (corrugator supercili, orbicularis oculi, procerus, and depressor supercili). Gillum and Anderson\u00a0described the surgical technique for full myectomy, which succeeds in controlling blepharospasm as there is an 88% improvement in patients with blepharospasm\u00a0but may be associated with postoperative lymphedema, lagophthalmos, and facial anesthesia. Currently, modified and partial myectomy is the preferred technique. This is performed in addition to correcting the effects of blepharospasm, which include brow ptosis, ptosis, dermatochalasis, and lateral canthal dystopia. [48] [59] [60]"}
+{"id": "article-102389_59", "title": "Benign Essential Blepharospasm -- Differential Diagnosis", "content": "There are many conditions that may present in a somewhat similar fashion to BEB. It is important to differentiate between these conditions and recognize their differences.", "contents": "Benign Essential Blepharospasm -- Differential Diagnosis. There are many conditions that may present in a somewhat similar fashion to BEB. It is important to differentiate between these conditions and recognize their differences."}
+{"id": "article-102389_60", "title": "Benign Essential Blepharospasm -- Differential Diagnosis -- Apraxia of Eyelid Opening (AEO)", "content": "Most cases of AEO present in the context of extrapyramidal disorders. However, there are reports of AEO as an isolated finding in healthy individuals.", "contents": "Benign Essential Blepharospasm -- Differential Diagnosis -- Apraxia of Eyelid Opening (AEO). Most cases of AEO present in the context of extrapyramidal disorders. However, there are reports of AEO as an isolated finding in healthy individuals."}
+{"id": "article-102389_61", "title": "Benign Essential Blepharospasm -- Differential Diagnosis -- Apraxia of Eyelid Opening (AEO)", "content": "AEO shares many demographic aspects with BEB: its incidence is greater in the sixth decade of life, and it also has a female predominance (2:1). It tends to be bilateral, and most patients exhibit sensory tricks. Anxiety and depression are also common before and after diagnosis. In patients with isolated AEO, instead of contraction of the orbicularis oculi muscle, frontalis muscle contraction is seen in an effort to open the eyes.", "contents": "Benign Essential Blepharospasm -- Differential Diagnosis -- Apraxia of Eyelid Opening (AEO). AEO shares many demographic aspects with BEB: its incidence is greater in the sixth decade of life, and it also has a female predominance (2:1). It tends to be bilateral, and most patients exhibit sensory tricks. Anxiety and depression are also common before and after diagnosis. In patients with isolated AEO, instead of contraction of the orbicularis oculi muscle, frontalis muscle contraction is seen in an effort to open the eyes."}
+{"id": "article-102389_62", "title": "Benign Essential Blepharospasm -- Differential Diagnosis -- Apraxia of Eyelid Opening (AEO)", "content": "In some cases, it is not possible to differentiate between BEB and AEO since many patients with BEB also have AEO, and some that initially present as AEO later develop blepharospasm, usually after 1.5 years. AEO is also treated with botulinum toxin injections, and surgery is reserved for refractory cases. [61]", "contents": "Benign Essential Blepharospasm -- Differential Diagnosis -- Apraxia of Eyelid Opening (AEO). In some cases, it is not possible to differentiate between BEB and AEO since many patients with BEB also have AEO, and some that initially present as AEO later develop blepharospasm, usually after 1.5 years. AEO is also treated with botulinum toxin injections, and surgery is reserved for refractory cases. [61]"}
+{"id": "article-102389_63", "title": "Benign Essential Blepharospasm -- Differential Diagnosis -- Hemifacial Spasm", "content": "Hemifacial spasm has the same female-to-male distribution (2 to 1), and the age at onset is between 40 to 59 years. The estimated prevalence of hemifacial spasm is\u00a011 per 100,000 people, 7.4 per 100,000 in men, and 14.5 per 100,000 in women. [62]", "contents": "Benign Essential Blepharospasm -- Differential Diagnosis -- Hemifacial Spasm. Hemifacial spasm has the same female-to-male distribution (2 to 1), and the age at onset is between 40 to 59 years. The estimated prevalence of hemifacial spasm is\u00a011 per 100,000 people, 7.4 per 100,000 in men, and 14.5 per 100,000 in women. [62]"}
+{"id": "article-102389_64", "title": "Benign Essential Blepharospasm -- Differential Diagnosis -- Hemifacial Spasm", "content": "It is characterized by involuntary muscle contractions, but in this case, limited to one side of the face. These muscle contractions are typically intermittent, clonic, or tonic in nature. The muscle is relaxed in between the spasm episodes. It is aggravated by voluntary movement of the face, fatigue, stress, or a change in head position. Patients may complain of hemifacial spasms persisting in their sleep. [63] (In contrast, blepharospasm is not seen in sleep). Hemifacial spasms may be relieved by the consumption of alcohol, relaxation, or touching of the affected areas. [64] Hemifacial spasms may be associated with low-pitched tinnitus, which is thought to occur due to contraction of the stapedius muscle. [65] The most common underlying cause of hemifacial spasm is compression by an ectatic vessel, typically the vertebral artery or the anterior/posterior cerebellar artery. [63]", "contents": "Benign Essential Blepharospasm -- Differential Diagnosis -- Hemifacial Spasm. It is characterized by involuntary muscle contractions, but in this case, limited to one side of the face. These muscle contractions are typically intermittent, clonic, or tonic in nature. The muscle is relaxed in between the spasm episodes. It is aggravated by voluntary movement of the face, fatigue, stress, or a change in head position. Patients may complain of hemifacial spasms persisting in their sleep. [63] (In contrast, blepharospasm is not seen in sleep). Hemifacial spasms may be relieved by the consumption of alcohol, relaxation, or touching of the affected areas. [64] Hemifacial spasms may be associated with low-pitched tinnitus, which is thought to occur due to contraction of the stapedius muscle. [65] The most common underlying cause of hemifacial spasm is compression by an ectatic vessel, typically the vertebral artery or the anterior/posterior cerebellar artery. [63]"}
+{"id": "article-102389_65", "title": "Benign Essential Blepharospasm -- Differential Diagnosis -- Hemifacial Spasm", "content": "Following botulinum toxin injection, 85\u00a0to 90% of patients experience improvement in their symptoms. Patients refractory to botulinum toxin injection may benefit from vascular decompression. [62]", "contents": "Benign Essential Blepharospasm -- Differential Diagnosis -- Hemifacial Spasm. Following botulinum toxin injection, 85\u00a0to 90% of patients experience improvement in their symptoms. Patients refractory to botulinum toxin injection may benefit from vascular decompression. [62]"}
+{"id": "article-102389_66", "title": "Benign Essential Blepharospasm -- Differential Diagnosis -- Post Facial Palsy Synkinesis", "content": "Nerve regeneration occurs after an episode of facial nerve palsy. If there is aberrant muscle reinnervation, synkinesis between the lower and upper facial muscles following facial palsy may occur. This generally tends to occur six months after an episode of Bell palsy. [66] It does not tend to present with spontaneous spasms. [67] The prevalence of synkinesis following an episode of facial nerve palsy ranges from 8.9 to 51 percent. [68] Furthermore, postparalytic synkinesis has been shown to be associated with infectious and idiopathic causes of facial nerve palsy and patients who have had partial paralysis without the need for reanimation surgery. [68]", "contents": "Benign Essential Blepharospasm -- Differential Diagnosis -- Post Facial Palsy Synkinesis. Nerve regeneration occurs after an episode of facial nerve palsy. If there is aberrant muscle reinnervation, synkinesis between the lower and upper facial muscles following facial palsy may occur. This generally tends to occur six months after an episode of Bell palsy. [66] It does not tend to present with spontaneous spasms. [67] The prevalence of synkinesis following an episode of facial nerve palsy ranges from 8.9 to 51 percent. [68] Furthermore, postparalytic synkinesis has been shown to be associated with infectious and idiopathic causes of facial nerve palsy and patients who have had partial paralysis without the need for reanimation surgery. [68]"}
+{"id": "article-102389_67", "title": "Benign Essential Blepharospasm -- Differential Diagnosis -- Post Facial Palsy Synkinesis", "content": "A patient suffering from post-facial palsy synkinesis will present with abnormal involuntary facial movements. There are different patterns of synkinesis, such as oral-ocular, which presents with non-intended eye closure on voluntary movement of the muscles of the mouth. Ocular-oral synkinesis occurs when voluntary eye movements lead to non-intended movements of the muscles of the mouth. [69]", "contents": "Benign Essential Blepharospasm -- Differential Diagnosis -- Post Facial Palsy Synkinesis. A patient suffering from post-facial palsy synkinesis will present with abnormal involuntary facial movements. There are different patterns of synkinesis, such as oral-ocular, which presents with non-intended eye closure on voluntary movement of the muscles of the mouth. Ocular-oral synkinesis occurs when voluntary eye movements lead to non-intended movements of the muscles of the mouth. [69]"}
+{"id": "article-102389_68", "title": "Benign Essential Blepharospasm -- Differential Diagnosis -- Psychogenic facial spasm:", "content": "Studies have shown that the mean age of psychogenic spasms is 34.6 years of age. [70]", "contents": "Benign Essential Blepharospasm -- Differential Diagnosis -- Psychogenic facial spasm:. Studies have shown that the mean age of psychogenic spasms is 34.6 years of age. [70]"}
+{"id": "article-102389_69", "title": "Benign Essential Blepharospasm -- Differential Diagnosis -- Psychogenic facial spasm:", "content": "A patient suffering from psychogenic facial spasm will present with a non-patterned, variable facial spasm. [66] The facial spasm is distractable such that asking the patient to perform a task will lead to a reduction in symptoms. It also tends to be bilateral and asynchronous. It is worsened by anxiety and stress. [63]", "contents": "Benign Essential Blepharospasm -- Differential Diagnosis -- Psychogenic facial spasm:. A patient suffering from psychogenic facial spasm will present with a non-patterned, variable facial spasm. [66] The facial spasm is distractable such that asking the patient to perform a task will lead to a reduction in symptoms. It also tends to be bilateral and asynchronous. It is worsened by anxiety and stress. [63]"}
+{"id": "article-102389_70", "title": "Benign Essential Blepharospasm -- Differential Diagnosis -- Psychogenic facial spasm:", "content": "Patients suffering from psychogenic facial spasms may be differentiated from dystonic conditions by the presence of particular clinical signs. Psychogenic facial spasm tends to involve the muscles of the lower face (downward deviation of the angle of the mouth). Furthermore, the 'brow-lift sign' may be seen, which consists of the frontalis and orbicularis oculi muscles contracting, leading to a raising of the eyebrow during occlusion of the eye.", "contents": "Benign Essential Blepharospasm -- Differential Diagnosis -- Psychogenic facial spasm:. Patients suffering from psychogenic facial spasms may be differentiated from dystonic conditions by the presence of particular clinical signs. Psychogenic facial spasm tends to involve the muscles of the lower face (downward deviation of the angle of the mouth). Furthermore, the 'brow-lift sign' may be seen, which consists of the frontalis and orbicularis oculi muscles contracting, leading to a raising of the eyebrow during occlusion of the eye."}
+{"id": "article-102389_71", "title": "Benign Essential Blepharospasm -- Differential Diagnosis -- Facial Motor Tics", "content": "Facial motor tics tend to be short-lived, brief, and stereotyped in nature. The motor tic may resemble a normal coordinated voluntary movement. A patient\u00a0with\u00a0facial motor tics may have a sudden urge or premonitory feeling to perform the movement. As such, the patient may be able to suppress the movement with effort. [63] These motor tics may be associated with motor tics of the limbs, along with other features of Tourettes syndrome.", "contents": "Benign Essential Blepharospasm -- Differential Diagnosis -- Facial Motor Tics. Facial motor tics tend to be short-lived, brief, and stereotyped in nature. The motor tic may resemble a normal coordinated voluntary movement. A patient\u00a0with\u00a0facial motor tics may have a sudden urge or premonitory feeling to perform the movement. As such, the patient may be able to suppress the movement with effort. [63] These motor tics may be associated with motor tics of the limbs, along with other features of Tourettes syndrome."}
+{"id": "article-102389_72", "title": "Benign Essential Blepharospasm -- Differential Diagnosis -- Facial Myokymia", "content": "A myokymia is an undulating, rippling movement that affects individual muscle fascicles, which may affect the upper or lower eyelid. This is associated with sleep deprivation, excessive caffeine consumption, and excessive fatigue. [66] An EMG performed on a patient suffering from facial myokymia will show brief, sudden bursts of doublets, triplets, or multiples originating from repetitively firing motor unit potentials. Facial myokymia is usually self-limiting but may need botulinum toxin injections in some cases. In most patients, one injection tends to cure the condition.", "contents": "Benign Essential Blepharospasm -- Differential Diagnosis -- Facial Myokymia. A myokymia is an undulating, rippling movement that affects individual muscle fascicles, which may affect the upper or lower eyelid. This is associated with sleep deprivation, excessive caffeine consumption, and excessive fatigue. [66] An EMG performed on a patient suffering from facial myokymia will show brief, sudden bursts of doublets, triplets, or multiples originating from repetitively firing motor unit potentials. Facial myokymia is usually self-limiting but may need botulinum toxin injections in some cases. In most patients, one injection tends to cure the condition."}
+{"id": "article-102389_73", "title": "Benign Essential Blepharospasm -- Differential Diagnosis -- Tardive Dyskinesia", "content": "Tardive dyskinesia presents with repetitive, involuntary movements around the orofacial region. There may be smacking of the lips, protraction of the tongue, or excessive blinking of the eyes. These movements tend to be irregular and asynchronous and involve muscles that are not innervated by the facial nerve, such as the masseter muscle or the external muscles of the tongue. Tardive dyskinesia is a potential complication of long-term neuroleptic use. [66]", "contents": "Benign Essential Blepharospasm -- Differential Diagnosis -- Tardive Dyskinesia. Tardive dyskinesia presents with repetitive, involuntary movements around the orofacial region. There may be smacking of the lips, protraction of the tongue, or excessive blinking of the eyes. These movements tend to be irregular and asynchronous and involve muscles that are not innervated by the facial nerve, such as the masseter muscle or the external muscles of the tongue. Tardive dyskinesia is a potential complication of long-term neuroleptic use. [66]"}
+{"id": "article-102389_74", "title": "Benign Essential Blepharospasm -- Prognosis", "content": "The life expectancy of patients with isolated BEB appears not to be affected by the disease. However, it poses a tremendous impact on the quality of life. In a series of 238 patients with the diagnosis of BEB or Meige syndrome reported by Castelbuono and Miller,\u00a0it was\u00a0found that 27(11.3%) patients experienced spontaneous remission and good quality of life. However, this is not the case for the majority of patients who experience a constant fear of the disease worsening, reaching a point where they need increasing doses of botulinum toxin to achieve symptom improvement or worsen to a level where the response to the botulinum toxin is inadequate. There is also a sense of insecurity and embarrassment when performing social tasks, which, in turn, results in social withdrawal. [71] [72] [73]", "contents": "Benign Essential Blepharospasm -- Prognosis. The life expectancy of patients with isolated BEB appears not to be affected by the disease. However, it poses a tremendous impact on the quality of life. In a series of 238 patients with the diagnosis of BEB or Meige syndrome reported by Castelbuono and Miller,\u00a0it was\u00a0found that 27(11.3%) patients experienced spontaneous remission and good quality of life. However, this is not the case for the majority of patients who experience a constant fear of the disease worsening, reaching a point where they need increasing doses of botulinum toxin to achieve symptom improvement or worsen to a level where the response to the botulinum toxin is inadequate. There is also a sense of insecurity and embarrassment when performing social tasks, which, in turn, results in social withdrawal. [71] [72] [73]"}
+{"id": "article-102389_75", "title": "Benign Essential Blepharospasm -- Complications", "content": "Botulinum toxin injection can lead to a wide range of complications, such as ptosis, diplopia, photophobia, ecchymosis, epiphora, and blurred vision, among others. The likelihood of complications of botulinum toxin injection reduces with\u00a0repeated injection episodes. [51]", "contents": "Benign Essential Blepharospasm -- Complications. Botulinum toxin injection can lead to a wide range of complications, such as ptosis, diplopia, photophobia, ecchymosis, epiphora, and blurred vision, among others. The likelihood of complications of botulinum toxin injection reduces with\u00a0repeated injection episodes. [51]"}
+{"id": "article-102389_76", "title": "Benign Essential Blepharospasm -- Complications", "content": "The most frequently reported side effect is ptosis. Ptosis following botulinum toxin injection may occur due to the migration of the botulinum toxin into the levator palpebrae superioris muscle, leading to ptosis. [53] The incidence of ptosis following botulinum toxin injection to treat blepharospasm\u00a0has been shown to vary between studies (5.88% to 20%), and it is thought that this variance exists due to differences in injection technique and the amount of botulinum toxin injected. Methods that have been shown to reduce the likelihood of ptosis following botulinum toxin injection include staying away from the eyelid center when injecting the toxin. A weakness of the orbicularis oculi muscle may result in lagophthalmos. This can result in dry eye and exposure keratitis.", "contents": "Benign Essential Blepharospasm -- Complications. The most frequently reported side effect is ptosis. Ptosis following botulinum toxin injection may occur due to the migration of the botulinum toxin into the levator palpebrae superioris muscle, leading to ptosis. [53] The incidence of ptosis following botulinum toxin injection to treat blepharospasm\u00a0has been shown to vary between studies (5.88% to 20%), and it is thought that this variance exists due to differences in injection technique and the amount of botulinum toxin injected. Methods that have been shown to reduce the likelihood of ptosis following botulinum toxin injection include staying away from the eyelid center when injecting the toxin. A weakness of the orbicularis oculi muscle may result in lagophthalmos. This can result in dry eye and exposure keratitis."}
+{"id": "article-102389_77", "title": "Benign Essential Blepharospasm -- Complications", "content": "As many patients with blepharospasm have a variable degree of apraxia of eyelid opening, most patients need injections into the pretarsal orbicularis oculi muscle. Therefore, we always remind patients to apply lubricating ointment into the eyes for the first two to three weeks after injections and to increase the use of topical lubrication to the eyes for that period. Botulinum toxin injection has been shown to cause reduced lacrimal drainage as a result of a lower blink rate and laxity of the lower eyelid due to paralysis of the lacrimal portion of the orbicularis oculi muscle. [55]", "contents": "Benign Essential Blepharospasm -- Complications. As many patients with blepharospasm have a variable degree of apraxia of eyelid opening, most patients need injections into the pretarsal orbicularis oculi muscle. Therefore, we always remind patients to apply lubricating ointment into the eyes for the first two to three weeks after injections and to increase the use of topical lubrication to the eyes for that period. Botulinum toxin injection has been shown to cause reduced lacrimal drainage as a result of a lower blink rate and laxity of the lower eyelid due to paralysis of the lacrimal portion of the orbicularis oculi muscle. [55]"}
+{"id": "article-102389_78", "title": "Benign Essential Blepharospasm -- Enhancing Healthcare Team Outcomes", "content": "Interprofessional management of patients with BEB is recommended, Neurology consultation is the basis of treatment for the disease, particularly a movement disorder specialist. Ophthalmology consultation should be considered early in the disease, in order to address underlying eye disease, psychiatry consultation is also part of the evaluation of these patients, once diagnosed patients should be evaluated by a psychiatrist to rule out depression and anxiety disorders, and follow up visits must continue. [72] [41] [Level\u00a05]", "contents": "Benign Essential Blepharospasm -- Enhancing Healthcare Team Outcomes. Interprofessional management of patients with BEB is recommended, Neurology consultation is the basis of treatment for the disease, particularly a movement disorder specialist. Ophthalmology consultation should be considered early in the disease, in order to address underlying eye disease, psychiatry consultation is also part of the evaluation of these patients, once diagnosed patients should be evaluated by a psychiatrist to rule out depression and anxiety disorders, and follow up visits must continue. [72] [41] [Level\u00a05]"}
+{"id": "article-102389_79", "title": "Benign Essential Blepharospasm -- Review Questions", "content": "Access free multiple choice questions on this topic. Click here for a simplified version. Comment on this article.", "contents": "Benign Essential Blepharospasm -- Review Questions. Access free multiple choice questions on this topic. Click here for a simplified version. Comment on this article."}

statpearls/chunk/article-102950.jsonl

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+{"id": "article-102950_0", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Continuing Education Activity", "content": "Neck pain is a pervasive\u00a0condition\u00a0with primarily musculoskeletal causes. This activity\u00a0discusses the role of\u00a0clinicians in evaluating and treating patients with cervical muscle energy techniques. These conditions are characterized by heightened muscle tension, sensitivity changes, asymmetry, and restricted range of motion.\u00a0The MET approach directly engages dysfunctional muscles during treatment, effectively managing various somatic dysfunctions. Participants gain insights into MET's physiological principles, including post-isometric relaxation, crossed reflex, extensor reflex, isolytic lengthening, isokinetic strengthening, joint mobilization using muscle force, respiratory assistance, oculocephalic reflex, and reciprocal inhibition.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Continuing Education Activity. Neck pain is a pervasive\u00a0condition\u00a0with primarily musculoskeletal causes. This activity\u00a0discusses the role of\u00a0clinicians in evaluating and treating patients with cervical muscle energy techniques. These conditions are characterized by heightened muscle tension, sensitivity changes, asymmetry, and restricted range of motion.\u00a0The MET approach directly engages dysfunctional muscles during treatment, effectively managing various somatic dysfunctions. Participants gain insights into MET's physiological principles, including post-isometric relaxation, crossed reflex, extensor reflex, isolytic lengthening, isokinetic strengthening, joint mobilization using muscle force, respiratory assistance, oculocephalic reflex, and reciprocal inhibition."}
+{"id": "article-102950_1", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Continuing Education Activity", "content": "Additionally, participants will gain an understanding of the etiology of neck pain and its\u00a0various contributing factors. This activity highlights the significance of manual and exercise therapies in treating neck pain and the pivotal role played by\u00a0clinicians\u00a0in applying MET to correct somatic dysfunctions, offering valuable insights into enhancing patient care and outcomes.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Continuing Education Activity. Additionally, participants will gain an understanding of the etiology of neck pain and its\u00a0various contributing factors. This activity highlights the significance of manual and exercise therapies in treating neck pain and the pivotal role played by\u00a0clinicians\u00a0in applying MET to correct somatic dysfunctions, offering valuable insights into enhancing patient care and outcomes."}
+{"id": "article-102950_2", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Continuing Education Activity", "content": "Objectives: Identify\u00a0the steps to perform cervical muscle energy techniques. Identify the common indications for cervical muscle energy techniques. Determine\u00a0the absolute and relative contraindications for cervical muscle energy techniques. Develop\u00a0collaboration and communication amongst the interprofessional team to improve outcomes for patients affected by chronic neck pain. Access free multiple choice questions on this topic.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Continuing Education Activity. Objectives: Identify\u00a0the steps to perform cervical muscle energy techniques. Identify the common indications for cervical muscle energy techniques. Determine\u00a0the absolute and relative contraindications for cervical muscle energy techniques. Develop\u00a0collaboration and communication amongst the interprofessional team to improve outcomes for patients affected by chronic neck pain. Access free multiple choice questions on this topic."}
+{"id": "article-102950_3", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Introduction", "content": "Dr. Fred Mitchell Sr. worked out the motions of the pelvis in the 1950s, and using this knowledge, he\u00a0began to treat dysfunctions using muscle action. This style of treatment was named muscle energy technique, or MET. Muscle energy is a direct technique that the dysfunctional muscle actively engages during treatment, and it is now a well-established osteopathic technique used to address a variety\u00a0of somatic dysfunctions. [1] Somatic dysfunctions are defined as changes to the structure and function of the somatic system, composed of muscle, fascia, nerves, and vasculature. In the cervical region, this typically presents as\u00a0\"increased muscle tension, sensitivity changes, asymmetry, and restriction of range of motion.\" [2]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Introduction. Dr. Fred Mitchell Sr. worked out the motions of the pelvis in the 1950s, and using this knowledge, he\u00a0began to treat dysfunctions using muscle action. This style of treatment was named muscle energy technique, or MET. Muscle energy is a direct technique that the dysfunctional muscle actively engages during treatment, and it is now a well-established osteopathic technique used to address a variety\u00a0of somatic dysfunctions. [1] Somatic dysfunctions are defined as changes to the structure and function of the somatic system, composed of muscle, fascia, nerves, and vasculature. In the cervical region, this typically presents as\u00a0\"increased muscle tension, sensitivity changes, asymmetry, and restriction of range of motion.\" [2]"}
+{"id": "article-102950_4", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Introduction", "content": "There are multiple physiologic principles to muscle energy. These include crossed, extensor reflex, isolytic lengthening, isokinetic strengthening, joint mobilization, respiratory assistance, oculocephalic reflex, reciprocal inhibition, post-isometric relaxation, and muscle force in one body region to achieve movement in another. Out of these 10, post-isometric relaxation is the most commonly utilized. Osteopathic physicians typically use the muscle energy technique (MET) to correct somatic dysfunction that causes pain and discomfort, especially in but not limited to the thoracic spine. [3] [1]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Introduction. There are multiple physiologic principles to muscle energy. These include crossed, extensor reflex, isolytic lengthening, isokinetic strengthening, joint mobilization, respiratory assistance, oculocephalic reflex, reciprocal inhibition, post-isometric relaxation, and muscle force in one body region to achieve movement in another. Out of these 10, post-isometric relaxation is the most commonly utilized. Osteopathic physicians typically use the muscle energy technique (MET) to correct somatic dysfunction that causes pain and discomfort, especially in but not limited to the thoracic spine. [3] [1]"}
+{"id": "article-102950_5", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Introduction", "content": "Neck pain is a common presenting symptom affecting approximately 15% of males and 23% of females. [4] [5] The etiology of neck pain can include poor posture, recent or past trauma or surgery, stenosis, malignancy, and neuropathy. However, the cause is usually mechanical. Manual and exercise therapy often treats neck pain arising from mechanical issues. This\u00a0activity\u00a0discusses an osteopathic manual approach to treating neck pain.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Introduction. Neck pain is a common presenting symptom affecting approximately 15% of males and 23% of females. [4] [5] The etiology of neck pain can include poor posture, recent or past trauma or surgery, stenosis, malignancy, and neuropathy. However, the cause is usually mechanical. Manual and exercise therapy often treats neck pain arising from mechanical issues. This\u00a0activity\u00a0discusses an osteopathic manual approach to treating neck pain."}
+{"id": "article-102950_6", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Anatomy and Physiology", "content": "Understanding muscle physiology is essential for\u00a0MET. There are\u00a04 types of muscle contraction: isometric, concentric, eccentric, and isolytic. Isometric contraction is when the muscles contract without having the origin and insertion of the muscle approach each other. Concentric contraction is when the muscles shorten with contraction. Eccentric contraction is when the muscle lengthens with contraction. Finally, isolytic contraction is when an external force lengthens muscle contraction. [6]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Anatomy and Physiology. Understanding muscle physiology is essential for\u00a0MET. There are\u00a04 types of muscle contraction: isometric, concentric, eccentric, and isolytic. Isometric contraction is when the muscles contract without having the origin and insertion of the muscle approach each other. Concentric contraction is when the muscles shorten with contraction. Eccentric contraction is when the muscle lengthens with contraction. Finally, isolytic contraction is when an external force lengthens muscle contraction. [6]"}
+{"id": "article-102950_7", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Anatomy and Physiology", "content": "A muscle is made up of many muscle spindles. Each spindle comprises\u00a03 to 12 intrafusal muscle fibers surrounded by a large extrafusal fiber. Each spindle\u00a0has an efferent and an afferent neural component. Motor nerve fibers innervate the extrafusal fibers through the alpha motor neurons, and the gamma motor neurons innervate the intrafusal fibers. The Ia and II fibers innervate the muscle spindles' afferent (sensory) portions. The Golgi tendon organs (GTOs) in the myotendinous junctions are innervated by the Ib fibers. [7]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Anatomy and Physiology. A muscle is made up of many muscle spindles. Each spindle comprises\u00a03 to 12 intrafusal muscle fibers surrounded by a large extrafusal fiber. Each spindle\u00a0has an efferent and an afferent neural component. Motor nerve fibers innervate the extrafusal fibers through the alpha motor neurons, and the gamma motor neurons innervate the intrafusal fibers. The Ia and II fibers innervate the muscle spindles' afferent (sensory) portions. The Golgi tendon organs (GTOs) in the myotendinous junctions are innervated by the Ib fibers. [7]"}
+{"id": "article-102950_8", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Anatomy and Physiology", "content": "The GTO\u00a0is\u00a0crucial in the MET post-isometric relaxation mechanism and is simulated when muscle tension is elevated. This tension activates a negative feedback loop to prevent contraction via the Ia fibers. [8]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Anatomy and Physiology. The GTO\u00a0is\u00a0crucial in the MET post-isometric relaxation mechanism and is simulated when muscle tension is elevated. This tension activates a negative feedback loop to prevent contraction via the Ia fibers. [8]"}
+{"id": "article-102950_9", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Anatomy and Physiology", "content": "This article will explain the physiology involved in post-isometric relaxation, the most commonly used form of MET. Dr. Mitchell Sr. hypothesized\u00a0that after an isometric contraction, the muscle is in a refractory state where it may be passively stretched without a reflexive contraction. In MET with post-isometric relaxation, the GTO is activated by putting increased tension on the muscle fibers by asking the patient to contract against a barrier. Once activated, there is a reflexive inhibition and relaxation of the muscle through the Ia fibers, and the physician may further passively stretch the muscle due to the refractory state. [8]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Anatomy and Physiology. This article will explain the physiology involved in post-isometric relaxation, the most commonly used form of MET. Dr. Mitchell Sr. hypothesized\u00a0that after an isometric contraction, the muscle is in a refractory state where it may be passively stretched without a reflexive contraction. In MET with post-isometric relaxation, the GTO is activated by putting increased tension on the muscle fibers by asking the patient to contract against a barrier. Once activated, there is a reflexive inhibition and relaxation of the muscle through the Ia fibers, and the physician may further passively stretch the muscle due to the refractory state. [8]"}
+{"id": "article-102950_10", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Anatomy and Physiology", "content": "The cervical spine comprises seven vertebrae, anatomically unique from the other\u00a0vertebral segments. This region's key structural features are the cervical bifid spinous processes, transverse foramina, and triangular vertebral foramen. [9] The upper cervical spine (C1 and C2) consists of the atlas (C1) and the axis (C2). The atlas, a ring-shaped vertebra lacking a body, articulates with the axis by encircling the dens below and the occiput above. The dens of C2 is a\u00a0remnant of the body of the atlas (C1) that ultimately fuses with the body of C2. [10] The facets of cervical spines are typically oriented backward, upward, and medially.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Anatomy and Physiology. The cervical spine comprises seven vertebrae, anatomically unique from the other\u00a0vertebral segments. This region's key structural features are the cervical bifid spinous processes, transverse foramina, and triangular vertebral foramen. [9] The upper cervical spine (C1 and C2) consists of the atlas (C1) and the axis (C2). The atlas, a ring-shaped vertebra lacking a body, articulates with the axis by encircling the dens below and the occiput above. The dens of C2 is a\u00a0remnant of the body of the atlas (C1) that ultimately fuses with the body of C2. [10] The facets of cervical spines are typically oriented backward, upward, and medially."}
+{"id": "article-102950_11", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Anatomy and Physiology", "content": "In contrast to\u00a0C1 and C2, the\u00a05 vertebrae in the lower portion of the cervical spine (C3 to C7) have a vertebral body and an uncinate process, a feature unique to the cervical spine that consists of a hook-shaped process on the superolateral margin designed to\u00a0limit movement of the intervertebral discs during rotation. The uncinate process forms an uncovertebral joint (joint of Lushka) as it articulates with the uncinate process of the subsequent segments. [11] Furthermore, several ligaments connect each spine level, including the anterior and posterior longitudinal ligaments, the ligamentum flavum, and the interspinous ligament. The nuchal and transverse ligaments articulate at the cervical spine level only. [9] The alar ligament originates from the dens of C2 and inserts at the foramen magnum. The transverse ligament starts from the atlas and attaches to the lateral mass of C1 to hold the C2 together, forming the cruciform ligament. [12]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Anatomy and Physiology. In contrast to\u00a0C1 and C2, the\u00a05 vertebrae in the lower portion of the cervical spine (C3 to C7) have a vertebral body and an uncinate process, a feature unique to the cervical spine that consists of a hook-shaped process on the superolateral margin designed to\u00a0limit movement of the intervertebral discs during rotation. The uncinate process forms an uncovertebral joint (joint of Lushka) as it articulates with the uncinate process of the subsequent segments. [11] Furthermore, several ligaments connect each spine level, including the anterior and posterior longitudinal ligaments, the ligamentum flavum, and the interspinous ligament. The nuchal and transverse ligaments articulate at the cervical spine level only. [9] The alar ligament originates from the dens of C2 and inserts at the foramen magnum. The transverse ligament starts from the atlas and attaches to the lateral mass of C1 to hold the C2 together, forming the cruciform ligament. [12]"}
+{"id": "article-102950_12", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Anatomy and Physiology", "content": "Nerve roots exit between the cervical vertebrae. There are\u00a08 cervical nerve roots, 7 of which exit above the corresponding vertebrae. For example, the C6 nerve root will exit between C5 and C6. The last cervical nerve root will\u00a0exit between C7 and T1. Cervical nerve roots will form the brachial plexus from C5 to T1. [13]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Anatomy and Physiology. Nerve roots exit between the cervical vertebrae. There are\u00a08 cervical nerve roots, 7 of which exit above the corresponding vertebrae. For example, the C6 nerve root will exit between C5 and C6. The last cervical nerve root will\u00a0exit between C7 and T1. Cervical nerve roots will form the brachial plexus from C5 to T1. [13]"}
+{"id": "article-102950_13", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Anatomy and Physiology", "content": "The structure of the cervical spine allows for a wide range of motion in all\u00a03 planes (sagittal, transverse, and coronal). Forward flexion and extension of the neck occur in the sagittal plane. Side bending, or flexion to the right or left, occurs in the coronal plane. Rotation to the left or right occurs in the transverse plane. [14] The primary motion of the occipitoatlantal (skull and C1) joint is flexion and extension, the atlantoaxial (AA) joint (C1 and C2) is rotation, C2 to C4 is rotation, and C5 to C7 is side-bending. Most of the flexion and extension of the cervical spine will occur at the occipitoatlantal joint (OA).", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Anatomy and Physiology. The structure of the cervical spine allows for a wide range of motion in all\u00a03 planes (sagittal, transverse, and coronal). Forward flexion and extension of the neck occur in the sagittal plane. Side bending, or flexion to the right or left, occurs in the coronal plane. Rotation to the left or right occurs in the transverse plane. [14] The primary motion of the occipitoatlantal (skull and C1) joint is flexion and extension, the atlantoaxial (AA) joint (C1 and C2) is rotation, C2 to C4 is rotation, and C5 to C7 is side-bending. Most of the flexion and extension of the cervical spine will occur at the occipitoatlantal joint (OA)."}
+{"id": "article-102950_14", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Anatomy and Physiology", "content": "Due to the shape of the semi-lunar articulation between the occiput and the atlas, side bending\u00a0and rotation occur in different directions during flexion and extension. An example of somatic dysfunction at the OA would be flexed, rotated right, and side bent left (F Rr Sl). The atlantoaxial joint is primarily in rotation. To localize motion at the AA joint, the physician should flex the patient's neck to at least 45\u00b0 to lock out motion in the lower cervical spine so that rotation may occur only at the AA joint. The remaining cervical spine exhibits rotation and side bending in the same direction during flexion and extension.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Anatomy and Physiology. Due to the shape of the semi-lunar articulation between the occiput and the atlas, side bending\u00a0and rotation occur in different directions during flexion and extension. An example of somatic dysfunction at the OA would be flexed, rotated right, and side bent left (F Rr Sl). The atlantoaxial joint is primarily in rotation. To localize motion at the AA joint, the physician should flex the patient's neck to at least 45\u00b0 to lock out motion in the lower cervical spine so that rotation may occur only at the AA joint. The remaining cervical spine exhibits rotation and side bending in the same direction during flexion and extension."}
+{"id": "article-102950_15", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Indications", "content": "Indications for using muscle energy to address a cervical somatic dysfunction require a diagnosis with objective physical findings and ensuring that the patient is a candidate for osteopathic manipulative treatment. [15]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Indications. Indications for using muscle energy to address a cervical somatic dysfunction require a diagnosis with objective physical findings and ensuring that the patient is a candidate for osteopathic manipulative treatment. [15]"}
+{"id": "article-102950_16", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Contraindications", "content": "Contraindications to muscle energy techniques are divided into absolute and relative contraindications. Absolute contraindications include trauma, bone fractures, joint dislocation, infection, lack of patient consent, or muscle tears. Relative contraindications include cervical spine instability, internal bleeding, and recent myocardial infarctions or surgery. [16] Rheumatological conditions are also considered a relative contraindication and depend on disease severity and anatomical location of the joints affected. [17]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Contraindications. Contraindications to muscle energy techniques are divided into absolute and relative contraindications. Absolute contraindications include trauma, bone fractures, joint dislocation, infection, lack of patient consent, or muscle tears. Relative contraindications include cervical spine instability, internal bleeding, and recent myocardial infarctions or surgery. [16] Rheumatological conditions are also considered a relative contraindication and depend on disease severity and anatomical location of the joints affected. [17]"}
+{"id": "article-102950_17", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Contraindications", "content": "Upper cervical instability has been\u00a0recorded in many studies of rheumatoid arthritis. [18] [19] When a patient with rheumatoid arthritis presents to the clinic with neck pain, imaging\u00a0to assess for cervical spine instability should be completed first. Down syndrome may also present with upper cervical instability.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Contraindications. Upper cervical instability has been\u00a0recorded in many studies of rheumatoid arthritis. [18] [19] When a patient with rheumatoid arthritis presents to the clinic with neck pain, imaging\u00a0to assess for cervical spine instability should be completed first. Down syndrome may also present with upper cervical instability."}
+{"id": "article-102950_18", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Equipment", "content": "Muscle energy technique (MET) is a hands-on osteopathic manipulative treatment that requires a stable, firm surface and cushioned table for optimal treatment positioning and patient and physician comfort.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Equipment. Muscle energy technique (MET) is a hands-on osteopathic manipulative treatment that requires a stable, firm surface and cushioned table for optimal treatment positioning and patient and physician comfort."}
+{"id": "article-102950_19", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Personnel", "content": "Required personnel include a competent physician trained in muscle energy techniques.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Personnel. Required personnel include a competent physician trained in muscle energy techniques."}
+{"id": "article-102950_20", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Preparation", "content": "Appropriate diagnosis is\u00a0crucial before starting treatment for somatic dysfunctions.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Preparation. Appropriate diagnosis is\u00a0crucial before starting treatment for somatic dysfunctions."}
+{"id": "article-102950_21", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Preparation -- Diagnosis of OA Dysfunction", "content": "1. The patient is supine, and the physician is at the head of the table facing the patient. The patient's head is cupped, so the fingers are under the OA joint.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Preparation -- Diagnosis of OA Dysfunction. 1. The patient is supine, and the physician is at the head of the table facing the patient. The patient's head is cupped, so the fingers are under the OA joint."}
+{"id": "article-102950_22", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Preparation -- Diagnosis of OA Dysfunction", "content": "2. The physician can then induce flexion or extension at the OA and then gently side bend in either direction. Somatic dysfunctions are named towards freedom; it is essential to determine the position of freedom. When the side bending direction of freedom is determined, the physician can deduce the direction of the dysfunctional rotation as it is\u00a0the opposite direction.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Preparation -- Diagnosis of OA Dysfunction. 2. The physician can then induce flexion or extension at the OA and then gently side bend in either direction. Somatic dysfunctions are named towards freedom; it is essential to determine the position of freedom. When the side bending direction of freedom is determined, the physician can deduce the direction of the dysfunctional rotation as it is\u00a0the opposite direction."}
+{"id": "article-102950_23", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Preparation -- Diagnosis of OA Dysfunction", "content": "Another method to determine the diagnosis is to find the side of the rotation first. While cupping the occiput, the physician\u00a0can then palpate for the side of the \"deeper\" OA. The direction with the deeper OA is the direction of rotation; therefore, the side bending will be in the opposite direction. 3. Flexion and extension should be induced before diagnosis.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Preparation -- Diagnosis of OA Dysfunction. Another method to determine the diagnosis is to find the side of the rotation first. While cupping the occiput, the physician\u00a0can then palpate for the side of the \"deeper\" OA. The direction with the deeper OA is the direction of rotation; therefore, the side bending will be in the opposite direction. 3. Flexion and extension should be induced before diagnosis."}
+{"id": "article-102950_24", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Preparation -- Diagnosis of AA Dysfunction", "content": "1. The patient is supine, and the physician is at the head of the table facing the patient. The neck is then flexed 45\u00b0 to lock out the lower cervical segments. 2. Motion is tested by rotating the head in both directions. 3. The lesion is named based on which direction is freer in rotation.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Preparation -- Diagnosis of AA Dysfunction. 1. The patient is supine, and the physician is at the head of the table facing the patient. The neck is then flexed 45\u00b0 to lock out the lower cervical segments. 2. Motion is tested by rotating the head in both directions. 3. The lesion is named based on which direction is freer in rotation."}
+{"id": "article-102950_25", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Preparation -- Diagnosis of C2 to C7 Dysfunction", "content": "1. The patient is supine, and the physician is at the head of the table facing the patient. The lateral edges of the articular pillars are palpated. 2. Side bending of the segments is induced by translating in the opposite direction (right translation will cause left side bending) 3. Flexion and extension are checked in each segment to determine the diagnosis.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Preparation -- Diagnosis of C2 to C7 Dysfunction. 1. The patient is supine, and the physician is at the head of the table facing the patient. The lateral edges of the articular pillars are palpated. 2. Side bending of the segments is induced by translating in the opposite direction (right translation will cause left side bending) 3. Flexion and extension are checked in each segment to determine the diagnosis."}
+{"id": "article-102950_26", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Technique or Treatment", "content": "The technique is explained to the patient as a mutual collaboration between the operator and the patient, which is necessary. Several muscle energy techniques address dysfunction at the OA joint, AA joint, and within the remaining cervical vertebrae.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Technique or Treatment. The technique is explained to the patient as a mutual collaboration between the operator and the patient, which is necessary. Several muscle energy techniques address dysfunction at the OA joint, AA joint, and within the remaining cervical vertebrae."}
+{"id": "article-102950_27", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Technique or Treatment -- Occipitoatlantal Dysfunction Muscle Energy", "content": "Dysfunction of the OA joint should be diagnosed first (ie, OA flexed, rotated left, side bent\u00a0right (F Rl Sr)). Using one hand to hold\u00a0the patient's head, the other is placed at the OA junction to monitor the joint's articulation. The patient's head is placed towards the barrier or in opposition to the diagnosis (ie, if the patient is OA F Rl Sr, the patient should be rotated to the right, side bent to the left, and extended). The patient should be instructed to attempt to move their head back into a neutral position and provide an isometric force for 3\u00a0to 5 seconds. The patient should be repositioned further toward the barrier, and step 4 should be repeated. Repeat steps 4\u00a0and 5, 3 to\u00a05 times, and reevaluate the dysfunction. [20]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Technique or Treatment -- Occipitoatlantal Dysfunction Muscle Energy. Dysfunction of the OA joint should be diagnosed first (ie, OA flexed, rotated left, side bent\u00a0right (F Rl Sr)). Using one hand to hold\u00a0the patient's head, the other is placed at the OA junction to monitor the joint's articulation. The patient's head is placed towards the barrier or in opposition to the diagnosis (ie, if the patient is OA F Rl Sr, the patient should be rotated to the right, side bent to the left, and extended). The patient should be instructed to attempt to move their head back into a neutral position and provide an isometric force for 3\u00a0to 5 seconds. The patient should be repositioned further toward the barrier, and step 4 should be repeated. Repeat steps 4\u00a0and 5, 3 to\u00a05 times, and reevaluate the dysfunction. [20]"}
+{"id": "article-102950_28", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Technique or Treatment -- Atlantoaxial Dysfunction Muscle Energy", "content": "Dysfunction of the AA joint should be diagnosed first (ie, AA rotated left (Rl)). The neck should be flexed to lock out the joints below the level of the AA joint while holding the patient's head with both hands. The patient's head should be rotated toward the barrier (ie, if AA Rl, turn the patient to the right). The patient is then instructed to attempt to move their head back into a neutral position and provide an isometric force for 3\u00a0to 5 seconds. The patient is further repositioned toward the barrier, and step 4 is repeated. Steps 4\u00a0and 5 are repeated 3 to\u00a05 times, and the dysfunction is reevaluated. [3]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Technique or Treatment -- Atlantoaxial Dysfunction Muscle Energy. Dysfunction of the AA joint should be diagnosed first (ie, AA rotated left (Rl)). The neck should be flexed to lock out the joints below the level of the AA joint while holding the patient's head with both hands. The patient's head should be rotated toward the barrier (ie, if AA Rl, turn the patient to the right). The patient is then instructed to attempt to move their head back into a neutral position and provide an isometric force for 3\u00a0to 5 seconds. The patient is further repositioned toward the barrier, and step 4 is repeated. Steps 4\u00a0and 5 are repeated 3 to\u00a05 times, and the dysfunction is reevaluated. [3]"}
+{"id": "article-102950_29", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Technique or Treatment -- C2-C7 Dysfunction Muscle Energy", "content": "First, dysfunction of a vertebra should be diagnosed (e.g., C4 flexed, rotated right, side bent right (C4 F Rr Sr)). While holding the patient's head with one hand, the articular pillars should be\u00a0palpated with the other at the level of the dysfunctional vertebrae. The patient's head is then placed towards the barrier or in opposition to the diagnosis (ie, if the patient is C4\u00a0F Rr Sr, rotate the patient to the left, side bend to the left, and extend). The patient should attempt to move their head back into a neutral position and provide an isometric force for 3 to 5 seconds. The patient is repositioned further toward the barrier, and step 4 is repeated. Steps 4\u00a0and 5 are repeated\u00a03 to\u00a05 times, and the dysfunction is reevaluated. [21]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Technique or Treatment -- C2-C7 Dysfunction Muscle Energy. First, dysfunction of a vertebra should be diagnosed (e.g., C4 flexed, rotated right, side bent right (C4 F Rr Sr)). While holding the patient's head with one hand, the articular pillars should be\u00a0palpated with the other at the level of the dysfunctional vertebrae. The patient's head is then placed towards the barrier or in opposition to the diagnosis (ie, if the patient is C4\u00a0F Rr Sr, rotate the patient to the left, side bend to the left, and extend). The patient should attempt to move their head back into a neutral position and provide an isometric force for 3 to 5 seconds. The patient is repositioned further toward the barrier, and step 4 is repeated. Steps 4\u00a0and 5 are repeated\u00a03 to\u00a05 times, and the dysfunction is reevaluated. [21]"}
+{"id": "article-102950_30", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Complications", "content": "Adverse complications are rare and may include stroke, disc herniation, fractures, or hematomas. [16] In a systematic review, the most frequently described major adverse event was cervical arterial\u00a0dissection (CAD). However, there is currently insufficient\u00a0evidence to establish a risk profile for patients susceptible to this complication. [22]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Complications. Adverse complications are rare and may include stroke, disc herniation, fractures, or hematomas. [16] In a systematic review, the most frequently described major adverse event was cervical arterial\u00a0dissection (CAD). However, there is currently insufficient\u00a0evidence to establish a risk profile for patients susceptible to this complication. [22]"}
+{"id": "article-102950_31", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Clinical Significance", "content": "This type of osteopathic approach is indicated for vertebral release\u00a0and muscle relaxation.\u00a0Very often, the deep muscles of the cervical tract can be a local source of pain and referred pain in the head by irritating the greater occipital nerve. The sub-occipital muscles (3 out of 4) have a myodural bridge, which is innervated and rich in proprioceptors. Contraction of these muscles or the presence of trigger points can\u00a0cause migraines and headaches. In the acute phase, METs can be performed and relieve symptoms.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Clinical Significance. This type of osteopathic approach is indicated for vertebral release\u00a0and muscle relaxation.\u00a0Very often, the deep muscles of the cervical tract can be a local source of pain and referred pain in the head by irritating the greater occipital nerve. The sub-occipital muscles (3 out of 4) have a myodural bridge, which is innervated and rich in proprioceptors. Contraction of these muscles or the presence of trigger points can\u00a0cause migraines and headaches. In the acute phase, METs can be performed and relieve symptoms."}
+{"id": "article-102950_32", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Clinical Significance", "content": "The technique stimulates correct intervention of the parasympathetic system and facilitates the restoration of the passage of fluids (blood and lymph). The MET approach can improve the function of the respiratory accessory muscles of the cervical tract, increasing the ventilatory capacity of patients with fibromyalgia. [23]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Clinical Significance. The technique stimulates correct intervention of the parasympathetic system and facilitates the restoration of the passage of fluids (blood and lymph). The MET approach can improve the function of the respiratory accessory muscles of the cervical tract, increasing the ventilatory capacity of patients with fibromyalgia. [23]"}
+{"id": "article-102950_33", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Clinical Significance", "content": "Chronic neck pain can result from previous trauma; in these cases, the contractile content of the muscles decreases while the fatty tissue increases. This increased fat tissue causes painful local inflammation, and the proprioceptive capacity of the muscular districts decreases with consequent deterioration of the neuromotor coordination. MET can help restore proper spinal joint space and improve muscles' ability to stretch and shorten comprehensively. This last point will allow the neck muscles to implement their function, reducing the causes of the pain. MET can improve the\u00a0curvature of the cervical tract, making it a potential therapy for trauma such as whiplash. [24]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Clinical Significance. Chronic neck pain can result from previous trauma; in these cases, the contractile content of the muscles decreases while the fatty tissue increases. This increased fat tissue causes painful local inflammation, and the proprioceptive capacity of the muscular districts decreases with consequent deterioration of the neuromotor coordination. MET can help restore proper spinal joint space and improve muscles' ability to stretch and shorten comprehensively. This last point will allow the neck muscles to implement their function, reducing the causes of the pain. MET can improve the\u00a0curvature of the cervical tract, making it a potential therapy for trauma such as whiplash. [24]"}
+{"id": "article-102950_34", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Clinical Significance", "content": "Suppose the patient's cervical tract is very painful and not very mobile. In that case, it is possible to start using METs, using the eye muscles in conjunction with the small movements of the head to C2 (oculocephalic reflex).", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Clinical Significance. Suppose the patient's cervical tract is very painful and not very mobile. In that case, it is possible to start using METs, using the eye muscles in conjunction with the small movements of the head to C2 (oculocephalic reflex)."}
+{"id": "article-102950_35", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Enhancing Healthcare Team Outcomes", "content": "Muscle energy of the cervical spine is a non-invasive option for patients diagnosed with somatic dysfunctions.\u00a0While a clinician performs manipulative therapy in an office setting, patient outcomes can be improved by combining exercise with manipulative treatment and employing a multidisciplinary approach. In a systematic review\u00a0by Hidalgo et al, multiple manipulative treatments combined with exercise were more effective at reducing chronic neck pain than manipulative therapies alone.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Enhancing Healthcare Team Outcomes. Muscle energy of the cervical spine is a non-invasive option for patients diagnosed with somatic dysfunctions.\u00a0While a clinician performs manipulative therapy in an office setting, patient outcomes can be improved by combining exercise with manipulative treatment and employing a multidisciplinary approach. In a systematic review\u00a0by Hidalgo et al, multiple manipulative treatments combined with exercise were more effective at reducing chronic neck pain than manipulative therapies alone."}
+{"id": "article-102950_36", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Enhancing Healthcare Team Outcomes", "content": "Chronic neck pain accounts for 25% of all physiotherapy outpatient visits, and 50%\u00a0to 85% of these patients report recurrence. [25] Developing a treatment plan with maximum efficacy is imperative to reduce recurrence rates and improve overall patient outcomes.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Enhancing Healthcare Team Outcomes. Chronic neck pain accounts for 25% of all physiotherapy outpatient visits, and 50%\u00a0to 85% of these patients report recurrence. [25] Developing a treatment plan with maximum efficacy is imperative to reduce recurrence rates and improve overall patient outcomes."}
+{"id": "article-102950_37", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Nursing, Allied Health, and Interprofessional Team Interventions", "content": "The clinician should constantly interact with other health professionals, including the physiotherapist and the speech therapist. In the literature, METs are often combined with non-osteopathic treatments to improve the patient's clinical picture more quickly.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Nursing, Allied Health, and Interprofessional Team Interventions. The clinician should constantly interact with other health professionals, including the physiotherapist and the speech therapist. In the literature, METs are often combined with non-osteopathic treatments to improve the patient's clinical picture more quickly."}
+{"id": "article-102950_38", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Nursing, Allied Health, and Interprofessional Team Monitoring", "content": "Effective osteopathic treatment (in this case, the use of METs) results in a noticeable improvement in\u00a0the patient's health.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Nursing, Allied Health, and Interprofessional Team Monitoring. Effective osteopathic treatment (in this case, the use of METs) results in a noticeable improvement in\u00a0the patient's health."}
+{"id": "article-102950_39", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Cervical Vertebrae -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

statpearls/chunk/article-102951.jsonl

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+{"id": "article-102951_0", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Continuing Education Activity", "content": "The osteopathic manipulative principles for high-velocity low amplitude (HVLA) cervical spine therapy include the indications for treatment, treatment techniques, and the expectations of resolution of symptoms. HVLA cervical manipulation techniques can provide another outlet for patients with cervical neck dysfunction in addition to traditional medical routes. This activity will review the candidacy evaluation of the patient's cervical pathology and provide the significance of communication between the physician and the patient for optimal outcomes of cervical spine HVLA.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Continuing Education Activity. The osteopathic manipulative principles for high-velocity low amplitude (HVLA) cervical spine therapy include the indications for treatment, treatment techniques, and the expectations of resolution of symptoms. HVLA cervical manipulation techniques can provide another outlet for patients with cervical neck dysfunction in addition to traditional medical routes. This activity will review the candidacy evaluation of the patient's cervical pathology and provide the significance of communication between the physician and the patient for optimal outcomes of cervical spine HVLA."}
+{"id": "article-102951_1", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Continuing Education Activity", "content": "Objectives: Outline the steps of the high-velocity low amplitude thrust as an alternate treatment for patients with cervical joint dysfunction. Evaluate the methods of\u00a0high-velocity amplitude thrust treatment for the cervical spine. Assess\u00a0the indications for high-velocity low amplitude thrust treatment of the cervical spine. Access free multiple choice questions on this topic.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Continuing Education Activity. Objectives: Outline the steps of the high-velocity low amplitude thrust as an alternate treatment for patients with cervical joint dysfunction. Evaluate the methods of\u00a0high-velocity amplitude thrust treatment for the cervical spine. Assess\u00a0the indications for high-velocity low amplitude thrust treatment of the cervical spine. Access free multiple choice questions on this topic."}
+{"id": "article-102951_2", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Introduction", "content": "Since the founding of osteopathy by Andrew Taylor Still, M.D., D.O. in 1874, a fundamental principle of osteopathic medicine has been the treatment of somatic dysfunction by using osteopathic manipulative treatment (OMT). [1]  Somatic dysfunction is an impaired function of integral components of the somatic\u00a0system (the body framework). It can include the musculoskeletal, nervous, vascular, and lymphatic systems and combinations of these systems in affected areas of dysfunction. [1] [2]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Introduction. Since the founding of osteopathy by Andrew Taylor Still, M.D., D.O. in 1874, a fundamental principle of osteopathic medicine has been the treatment of somatic dysfunction by using osteopathic manipulative treatment (OMT). [1]  Somatic dysfunction is an impaired function of integral components of the somatic\u00a0system (the body framework). It can include the musculoskeletal, nervous, vascular, and lymphatic systems and combinations of these systems in affected areas of dysfunction. [1] [2]"}
+{"id": "article-102951_3", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Introduction", "content": "High-velocity low amplitude (HVLA)\u00a0OMT is one technique utilized by various practitioners to restore health to the somatic system. \u00a0Specifically, HVLA therapy is a technique used in manual medicine that employs a rapid, therapeutic force of brief duration that travels a short distance within a joint's anatomic range of motion. The force engages a restrictive barrier to elicit a release of the restriction. HVLA treatment is frequently associated with an audible and palpable \"release\" in the form of a \"pop\" accepted to represent cavitation of a spinal intervertebral joint and its subsequent release.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Introduction. High-velocity low amplitude (HVLA)\u00a0OMT is one technique utilized by various practitioners to restore health to the somatic system. \u00a0Specifically, HVLA therapy is a technique used in manual medicine that employs a rapid, therapeutic force of brief duration that travels a short distance within a joint's anatomic range of motion. The force engages a restrictive barrier to elicit a release of the restriction. HVLA treatment is frequently associated with an audible and palpable \"release\" in the form of a \"pop\" accepted to represent cavitation of a spinal intervertebral joint and its subsequent release."}
+{"id": "article-102951_4", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Introduction", "content": "The cervical (neck) region comprises vascular, musculoskeletal, and neural pathways between the cranium and the thorax. It is a common area of injury and somatic dysfunction, resulting in pain and loss of mobility. Understanding the diagnostic approach and the treatment of cervical spinal somatic dysfunction is a cornerstone of\u00a0manual medicine.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Introduction. The cervical (neck) region comprises vascular, musculoskeletal, and neural pathways between the cranium and the thorax. It is a common area of injury and somatic dysfunction, resulting in pain and loss of mobility. Understanding the diagnostic approach and the treatment of cervical spinal somatic dysfunction is a cornerstone of\u00a0manual medicine."}
+{"id": "article-102951_5", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Introduction", "content": "Dysfunction may occur at\u00a01 or many anatomical locations: the atlantooccipital joint, the atlantoaxial joint, the paraspinal musculature, or other cervical vertebral joints.\u00a0OMT may include various myofascial release techniques, muscle energy techniques, strain-counter strain techniques, and HVLA techniques. HVLA is used to relieve movement restrictions by applying a quick, therapeutic force of rapid duration that travels a short distance within the range of motion of a joint. HVLA therapy aims to restore a more \"normal\" range of motion within a joint and alleviate pain.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Introduction. Dysfunction may occur at\u00a01 or many anatomical locations: the atlantooccipital joint, the atlantoaxial joint, the paraspinal musculature, or other cervical vertebral joints.\u00a0OMT may include various myofascial release techniques, muscle energy techniques, strain-counter strain techniques, and HVLA techniques. HVLA is used to relieve movement restrictions by applying a quick, therapeutic force of rapid duration that travels a short distance within the range of motion of a joint. HVLA therapy aims to restore a more \"normal\" range of motion within a joint and alleviate pain."}
+{"id": "article-102951_6", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Introduction", "content": "Neck dysfunction is associated with significant health costs and disability, typically due to work-related injuries and improper ergonomic practices. [3] Cervical musculoskeletal joint dysfunction symptoms include neck pain, stiffness, loss of neck mobility, arm pain, tingling in the upper extremities, weakness, dizziness, and headache.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Introduction. Neck dysfunction is associated with significant health costs and disability, typically due to work-related injuries and improper ergonomic practices. [3] Cervical musculoskeletal joint dysfunction symptoms include neck pain, stiffness, loss of neck mobility, arm pain, tingling in the upper extremities, weakness, dizziness, and headache."}
+{"id": "article-102951_7", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Introduction", "content": "HVLA OMT of the cervical spine is a passive, direct therapy that provides an\u00a0HVLA manually applied force to treat motion loss in a somatic dysfunction. [4] Passive treatment implies that the patient stays inactive throughout this therapy and does not attempt to assist the physician in executing cervical HVLA treatment. This therapy provides direct engagement into the restrictive barrier of the cervical spine. The treatment goal is to forcefully stretch a contracted musculoskeletal system, producing an aggressive response of afferent nerve impulses from the muscle spindles to the central nervous system. The central nervous system\u00a0sends a reflex of inhibitory responses to the muscle spindle, relaxing the muscle. [5] [3]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Introduction. HVLA OMT of the cervical spine is a passive, direct therapy that provides an\u00a0HVLA manually applied force to treat motion loss in a somatic dysfunction. [4] Passive treatment implies that the patient stays inactive throughout this therapy and does not attempt to assist the physician in executing cervical HVLA treatment. This therapy provides direct engagement into the restrictive barrier of the cervical spine. The treatment goal is to forcefully stretch a contracted musculoskeletal system, producing an aggressive response of afferent nerve impulses from the muscle spindles to the central nervous system. The central nervous system\u00a0sends a reflex of inhibitory responses to the muscle spindle, relaxing the muscle. [5] [3]"}
+{"id": "article-102951_8", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Introduction", "content": "HVLA therapy of the cervical spine should be performed only by practitioners who have been educated with this technique and have demonstrated practical and cognitive skills. \u00a0Like any other procedure, education, pre-procedural screening for contraindications, and a detailed review of the risks and benefits are imperative before HVLA treatment.\u00a0Informed consent to medical treatment is fundamental in both ethics and law. Patients can receive advice and ask questions about HVLA treatments to make well-founded decisions. [6]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Introduction. HVLA therapy of the cervical spine should be performed only by practitioners who have been educated with this technique and have demonstrated practical and cognitive skills. \u00a0Like any other procedure, education, pre-procedural screening for contraindications, and a detailed review of the risks and benefits are imperative before HVLA treatment.\u00a0Informed consent to medical treatment is fundamental in both ethics and law. Patients can receive advice and ask questions about HVLA treatments to make well-founded decisions. [6]"}
+{"id": "article-102951_9", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Anatomy and Physiology", "content": "The cervical spine has 7 vertically stacked bones called vertebrae, labeled C1 (cervical 1) through C7 (cervical 7). C1 (called the atlas) connects the top of the cervical spine to the base of the skull, and C7 connects to the upper thoracic spine at about shoulder level. These uniquely shaped bones (the spinal column) protect the spinal cord, a\u00a0cylindrical bundle of nerve fibers and associated nerve roots enclosed within the cervical vertebrae, connecting the body to the brain.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Anatomy and Physiology. The cervical spine has 7 vertically stacked bones called vertebrae, labeled C1 (cervical 1) through C7 (cervical 7). C1 (called the atlas) connects the top of the cervical spine to the base of the skull, and C7 connects to the upper thoracic spine at about shoulder level. These uniquely shaped bones (the spinal column) protect the spinal cord, a\u00a0cylindrical bundle of nerve fibers and associated nerve roots enclosed within the cervical vertebrae, connecting the body to the brain."}
+{"id": "article-102951_10", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Anatomy and Physiology", "content": "The upper cervical spine is unique. The atlas (C1) and axis (C2), functioning together, are primarily responsible for spinal rotation, flexion (bend forward), and extension (bend backward) and are the most mobile part of the entire spine. Roughly 50% of flexion and extension and 50% of neck rotation occur in the areas of C1 and C2. The remainder of the cervical vertebrae (C3-C7) are smaller than the thoracic and lumbar vertebrae. The vertebral bodies are round with a hollow center that continues from C1 and C2 and houses the spinal cord as it travels distally from the brainstem. The cervical intervertebral discs are \"shock-absorbing pads\" between each level starting below C2 (axis). The discs are strong yet flexible tissues composed of fibrocartilage. In the middle of each disc is a nucleus pulposus, a gel-like material surrounded by a strong protective outer layer called the annulus fibrosus.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Anatomy and Physiology. The upper cervical spine is unique. The atlas (C1) and axis (C2), functioning together, are primarily responsible for spinal rotation, flexion (bend forward), and extension (bend backward) and are the most mobile part of the entire spine. Roughly 50% of flexion and extension and 50% of neck rotation occur in the areas of C1 and C2. The remainder of the cervical vertebrae (C3-C7) are smaller than the thoracic and lumbar vertebrae. The vertebral bodies are round with a hollow center that continues from C1 and C2 and houses the spinal cord as it travels distally from the brainstem. The cervical intervertebral discs are \"shock-absorbing pads\" between each level starting below C2 (axis). The discs are strong yet flexible tissues composed of fibrocartilage. In the middle of each disc is a nucleus pulposus, a gel-like material surrounded by a strong protective outer layer called the annulus fibrosus."}
+{"id": "article-102951_11", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Anatomy and Physiology", "content": "At each vertebral level of the spinal column, the discs hold the vertebrae together and absorb shock to the spine. The discs also create spaces (called foramen) between each bony vertebrae, allowing nerves to exit the spinal cord. \u00a0Spinal nerve roots are bundles of nerve fibers that exit (or enter) the spinal cord in pairs from each side of the spinal cord and travel through the foramen to send and receive nerve impulses from the body. Each cervical nerve innervates or provides sensation and motor function to both sides of a corresponding part of the upper body. Muscles, tendons, and ligaments help support the cervical spinal column by limiting excessive movement in all directions.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Anatomy and Physiology. At each vertebral level of the spinal column, the discs hold the vertebrae together and absorb shock to the spine. The discs also create spaces (called foramen) between each bony vertebrae, allowing nerves to exit the spinal cord. \u00a0Spinal nerve roots are bundles of nerve fibers that exit (or enter) the spinal cord in pairs from each side of the spinal cord and travel through the foramen to send and receive nerve impulses from the body. Each cervical nerve innervates or provides sensation and motor function to both sides of a corresponding part of the upper body. Muscles, tendons, and ligaments help support the cervical spinal column by limiting excessive movement in all directions."}
+{"id": "article-102951_12", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Anatomy and Physiology", "content": "Common disc disorders\u00a0include degenerative disc disease and disc herniations (\"ruptured disc\") that can cause adjacent spinal nerve irritation. This can happen when a disc flattens or becomes deformed, as the space for a spinal nerve passing through the foramen is compromised. Nerve compression may cause pain radiating throughout the neck and into the head, back, and arms. Cervical spinal stenosis\u00a0is a narrowing of the hollow center of the spinal canal. It can lead to spinal cord compression and impingement of the nerve roots exiting the spinal cord. Cervical trauma\u00a0may affect the cervical spinal column by causing injury to bones, nerves, muscles, tendons, and ligaments. Trauma can disrupt nerve communication between the brain and various somatic and visceral systems, sometimes resulting in weakness, paralysis, and loss of sensation.\u00a0Cervical strain is typically the result of a stretch injury to the muscles and ligaments of the cervical spine. Oftentimes, it is the result of trauma from sports-related injuries, falls, or motor vehicle accidents. Prolonged improper\u00a0positioning (poor workplace ergonomics) can cause postural deviations, which may eventually result in neck pain even in younger patient populations. [7]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Anatomy and Physiology. Common disc disorders\u00a0include degenerative disc disease and disc herniations (\"ruptured disc\") that can cause adjacent spinal nerve irritation. This can happen when a disc flattens or becomes deformed, as the space for a spinal nerve passing through the foramen is compromised. Nerve compression may cause pain radiating throughout the neck and into the head, back, and arms. Cervical spinal stenosis\u00a0is a narrowing of the hollow center of the spinal canal. It can lead to spinal cord compression and impingement of the nerve roots exiting the spinal cord. Cervical trauma\u00a0may affect the cervical spinal column by causing injury to bones, nerves, muscles, tendons, and ligaments. Trauma can disrupt nerve communication between the brain and various somatic and visceral systems, sometimes resulting in weakness, paralysis, and loss of sensation.\u00a0Cervical strain is typically the result of a stretch injury to the muscles and ligaments of the cervical spine. Oftentimes, it is the result of trauma from sports-related injuries, falls, or motor vehicle accidents. Prolonged improper\u00a0positioning (poor workplace ergonomics) can cause postural deviations, which may eventually result in neck pain even in younger patient populations. [7]"}
+{"id": "article-102951_13", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Anatomy and Physiology", "content": "To be an adequate cervical HVLA OMT provider, the provider must have adequate knowledge of cervical spine and neck anatomy. [8] It should be noted that all cervical vertebrae except C1 and C2 are composed of\u00a02 portions: The body (an anteriorly situated central mass of bone) and a vertebral arch arising posteriorly off the body. The vertebral arch consists of the pedicles that connect the body to the articular processes and the lamina that connects the articular processes to the spinous process on the most posterior aspect of each vertebra. The paired articular processes on each vertebra articulate with an adjacent articular process of a contiguous vertebra to form zygapophyseal joints, allowing motion between the vertebrae in X, Y, and Z planes.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Anatomy and Physiology. To be an adequate cervical HVLA OMT provider, the provider must have adequate knowledge of cervical spine and neck anatomy. [8] It should be noted that all cervical vertebrae except C1 and C2 are composed of\u00a02 portions: The body (an anteriorly situated central mass of bone) and a vertebral arch arising posteriorly off the body. The vertebral arch consists of the pedicles that connect the body to the articular processes and the lamina that connects the articular processes to the spinous process on the most posterior aspect of each vertebra. The paired articular processes on each vertebra articulate with an adjacent articular process of a contiguous vertebra to form zygapophyseal joints, allowing motion between the vertebrae in X, Y, and Z planes."}
+{"id": "article-102951_14", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Anatomy and Physiology", "content": "The transverse processes are small bony projections off each vertebra's right and left sides. The\u00a02 transverse processes of each vertebra function as the site of attachment for muscles. The transverse foramen (foramen transversarium) of the cervical vertebrae is a hole or opening in the t ransverse process of a cervical vertebra for the passage of the vertebral artery and vein and the sympathetic nerve plexus. The paired vertebral arteries (1 on each side) are of particular importance because they provide blood to the brain and spinal cord, and they can be damaged during traumatic events involving the transverse processes. The spinous process is a bone projection off the posterior aspect of a vertebra. It arises from the neural arch at the junction of\u00a02 laminae and provides attachment for muscles concerned with flexion, extension, and spine stability. Efficient and careful palpation of the cervical vertebral elements, particularly the spinous and transverse processes, is essential to establish an accurate diagnosis of cervical somatic dysfunction. Likewise, the same knowledge base is required to provide cervical HVLA OMT for the patient in the safest way possible.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Anatomy and Physiology. The transverse processes are small bony projections off each vertebra's right and left sides. The\u00a02 transverse processes of each vertebra function as the site of attachment for muscles. The transverse foramen (foramen transversarium) of the cervical vertebrae is a hole or opening in the t ransverse process of a cervical vertebra for the passage of the vertebral artery and vein and the sympathetic nerve plexus. The paired vertebral arteries (1 on each side) are of particular importance because they provide blood to the brain and spinal cord, and they can be damaged during traumatic events involving the transverse processes. The spinous process is a bone projection off the posterior aspect of a vertebra. It arises from the neural arch at the junction of\u00a02 laminae and provides attachment for muscles concerned with flexion, extension, and spine stability. Efficient and careful palpation of the cervical vertebral elements, particularly the spinous and transverse processes, is essential to establish an accurate diagnosis of cervical somatic dysfunction. Likewise, the same knowledge base is required to provide cervical HVLA OMT for the patient in the safest way possible."}
+{"id": "article-102951_15", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Indications", "content": "Many manual medicine practitioners use HVLA thrust techniques to treat spinal somatic dysfunction. \u00a0A common indication for HVLA OMT is \"joint fixation,\" a condition where any\u00a02 bones in a joint become misaligned or fixated (stuck). HVLA therapy in the cervical region may effectively resolve neck, shoulder, and head pain. [9] HVLA therapy of the cervical spine is indicated to treat motion loss with associated somatic dysfunction. It is hypothesized that fibrous adhesions develop in zygapophyseal joints during relative immobility periods, restricting joint motion. HVLA therapy is thought to improve symptoms consistent with musculoskeletal joint restriction due to cavitation and adhesions of the zygapophyseal joints. \u00a0HVLA is typically used for patients with local or radiating neck pain in non-acute phases. \u00a0To that extent, it is also used to treat patients with cervicogenic headaches.\u00a0Studies suggest that mobilization or manipulation of the cervical spine may benefit individuals experiencing cervicogenic headaches. [10]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Indications. Many manual medicine practitioners use HVLA thrust techniques to treat spinal somatic dysfunction. \u00a0A common indication for HVLA OMT is \"joint fixation,\" a condition where any\u00a02 bones in a joint become misaligned or fixated (stuck). HVLA therapy in the cervical region may effectively resolve neck, shoulder, and head pain. [9] HVLA therapy of the cervical spine is indicated to treat motion loss with associated somatic dysfunction. It is hypothesized that fibrous adhesions develop in zygapophyseal joints during relative immobility periods, restricting joint motion. HVLA therapy is thought to improve symptoms consistent with musculoskeletal joint restriction due to cavitation and adhesions of the zygapophyseal joints. \u00a0HVLA is typically used for patients with local or radiating neck pain in non-acute phases. \u00a0To that extent, it is also used to treat patients with cervicogenic headaches.\u00a0Studies suggest that mobilization or manipulation of the cervical spine may benefit individuals experiencing cervicogenic headaches. [10]"}
+{"id": "article-102951_16", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Contraindications", "content": "There are\u00a02 types of contraindications in the cervical HVLA OMT: absolute and relative. Absolute contraindications include patients with a medical history of osteoporosis, active osteomyelitis, fractures in the cervical area, severe rheumatoid arthritis, and bone metastasis in the cervical region. Also included are patients with Down Syndrome, as HVLA therapy can lead to rupture of the transverse ligament of the dens process since this population may have increased laxity of the transverse ligament at baseline. [11] Absolute Contraindications: [12] [13] Acute fractures Acute soft tissue injury Acute myelopathy Ankylosing spondylitis Anticoagulant therapy Chiari malformation Connective tissue disease Dislocation Down syndrome Infection Instability Ligament rupture Osteoporosis Patient refusal Recent surgery Rheumatoid arthritis Surgical or pathologic fusion of a joint Tumor/bony malignancy Vertebral artery abnormalities Vascular disease Relative Contraindications: [13]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Contraindications. There are\u00a02 types of contraindications in the cervical HVLA OMT: absolute and relative. Absolute contraindications include patients with a medical history of osteoporosis, active osteomyelitis, fractures in the cervical area, severe rheumatoid arthritis, and bone metastasis in the cervical region. Also included are patients with Down Syndrome, as HVLA therapy can lead to rupture of the transverse ligament of the dens process since this population may have increased laxity of the transverse ligament at baseline. [11] Absolute Contraindications: [12] [13] Acute fractures Acute soft tissue injury Acute myelopathy Ankylosing spondylitis Anticoagulant therapy Chiari malformation Connective tissue disease Dislocation Down syndrome Infection Instability Ligament rupture Osteoporosis Patient refusal Recent surgery Rheumatoid arthritis Surgical or pathologic fusion of a joint Tumor/bony malignancy Vertebral artery abnormalities Vascular disease Relative Contraindications: [13]"}
+{"id": "article-102951_17", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Contraindications", "content": "Acute herniated nucleus pulposis Acute whiplash Any symptom aggravated by movement of the neck Blurred vision Diplopia Dizziness/vertigo Drop attacks Dysarthria Dysphagia Facial/oral paresthesia Hypermobility syndromes Nausea Previous diagnosis of vertebrobasilar insufficiency Tinnitus Visual disturbances Worsening of symptoms with manipulations", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Contraindications. Acute herniated nucleus pulposis Acute whiplash Any symptom aggravated by movement of the neck Blurred vision Diplopia Dizziness/vertigo Drop attacks Dysarthria Dysphagia Facial/oral paresthesia Hypermobility syndromes Nausea Previous diagnosis of vertebrobasilar insufficiency Tinnitus Visual disturbances Worsening of symptoms with manipulations"}
+{"id": "article-102951_18", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Contraindications", "content": "Since a large number of the reported cases of serious adverse outcomes involved cervical HVLA OMT and \"thrust\" techniques involved vertebrobasilar accidents (VBA) and strokes, caution should be used when treating patients with suspected artery disease or vascular anomalies. [14] [15] [16]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Contraindications. Since a large number of the reported cases of serious adverse outcomes involved cervical HVLA OMT and \"thrust\" techniques involved vertebrobasilar accidents (VBA) and strokes, caution should be used when treating patients with suspected artery disease or vascular anomalies. [14] [15] [16]"}
+{"id": "article-102951_19", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Personnel", "content": "The technique requires practitioner training in OMT or hands-on spinal manipulation techniques. To have successful HVLA therapy outcomes, the patient must consent, be cooperative, and be relaxed and\u00a0healthy enough to be placed in the proper position for treatment.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Personnel. The technique requires practitioner training in OMT or hands-on spinal manipulation techniques. To have successful HVLA therapy outcomes, the patient must consent, be cooperative, and be relaxed and\u00a0healthy enough to be placed in the proper position for treatment."}
+{"id": "article-102951_20", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Preparation", "content": "It is encouraged that all practitioners who wish to use cervical manipulation should undertake a formal education program to decrease risks. [12] As with any therapy, awareness and knowledge are important factors in weighing the benefits, managing the risks, and recognizing early warning signs of adverse events. [17] Preparation should begin with a thorough history and complete head-to-toe assessment to minimize the likelihood of complications arising from cervical manipulation. Patients should be thoroughly screened for all potential contraindications and precautions, preferably through screening methods focused on identifying patients who have contraindications to HVLA therapy and may be at risk of adverse outcomes. [12] [13]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Preparation. It is encouraged that all practitioners who wish to use cervical manipulation should undertake a formal education program to decrease risks. [12] As with any therapy, awareness and knowledge are important factors in weighing the benefits, managing the risks, and recognizing early warning signs of adverse events. [17] Preparation should begin with a thorough history and complete head-to-toe assessment to minimize the likelihood of complications arising from cervical manipulation. Patients should be thoroughly screened for all potential contraindications and precautions, preferably through screening methods focused on identifying patients who have contraindications to HVLA therapy and may be at risk of adverse outcomes. [12] [13]"}
+{"id": "article-102951_21", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Preparation", "content": "Since HVLA OMT is considered a procedure, proper consent should be obtained before the initiation of treatment. [18] Providing information about HVLA and assessing the patient's understanding of HVLA is essential to positive outcomes and patient relaxation during the procedure. The practitioner's duty includes the safe and appropriate performance of HVLA therapy and providing pertinent information and advice to enable the patient to make an informed decision regarding their treatment. Failure to inform the patient of the potential risks and benefits and failure to obtain informed consent is a breach of duty. Preparation starts with localizing the correct region in which a cervical\u00a0somatic dysfunction\u00a0exists. To establish this diagnosis, it is necessary to identify the specific cervical spine level at which the segment is causing severe pain on palpation or a restriction of motion. Once identified, the practitioner engages that cervical level in both flexion and extension. The provider then tests the patient's ability to rotate and side-bend each segment to the right and left. Once identifying the restricted barrier, for example, a C4 vertebra that is flexed, rotated left side bent left, the physician would take the restricted barrier into the opposite orientation. For this example, you would engage C4 extended rotated right and side bent right.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Preparation. Since HVLA OMT is considered a procedure, proper consent should be obtained before the initiation of treatment. [18] Providing information about HVLA and assessing the patient's understanding of HVLA is essential to positive outcomes and patient relaxation during the procedure. The practitioner's duty includes the safe and appropriate performance of HVLA therapy and providing pertinent information and advice to enable the patient to make an informed decision regarding their treatment. Failure to inform the patient of the potential risks and benefits and failure to obtain informed consent is a breach of duty. Preparation starts with localizing the correct region in which a cervical\u00a0somatic dysfunction\u00a0exists. To establish this diagnosis, it is necessary to identify the specific cervical spine level at which the segment is causing severe pain on palpation or a restriction of motion. Once identified, the practitioner engages that cervical level in both flexion and extension. The provider then tests the patient's ability to rotate and side-bend each segment to the right and left. Once identifying the restricted barrier, for example, a C4 vertebra that is flexed, rotated left side bent left, the physician would take the restricted barrier into the opposite orientation. For this example, you would engage C4 extended rotated right and side bent right."}
+{"id": "article-102951_22", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Preparation", "content": "Patient positioning is ideal for optimal procedural outcomes. The patient should be supine, and the operator (physician) should be at the head of the table. Patients need to be as relaxed as possible during physical assessment. This is an essential component of treatment for patients to have optimal results and prevent any adverse outcomes. A satisfactory patient-physician relationship and a foundation of trust are imperative to positive outcomes.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Preparation. Patient positioning is ideal for optimal procedural outcomes. The patient should be supine, and the operator (physician) should be at the head of the table. Patients need to be as relaxed as possible during physical assessment. This is an essential component of treatment for patients to have optimal results and prevent any adverse outcomes. A satisfactory patient-physician relationship and a foundation of trust are imperative to positive outcomes."}
+{"id": "article-102951_23", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Technique or Treatment", "content": "A Step-by-step organized procedural pathway is paramount to an ideal outcome for this procedure. The first step is diagnosing the patient's cervical somatic dysfunction. Then, verifying that there are no existing contraindications ensures that the patient is a candidate for HVLA therapy.\u00a0Diagnosing cervical somatic dysfunction involves a careful manual examination of the atlantooccipital joint with the patient in the supine position, comparing the depths of the\u00a0occipital sulci. The atlantoaxial joint is examined by flexing the patient's cervical spine and locking the atlantooccipital and C2-C7 joints. The range of motion of the atlantoaxial joint is then evaluated by slowly rotating the cervical spine from right to left, noting any restricted movement when comparing the rotation to each side. \u00a0C2-C7 are also evaluated with the patient in the supine position, with careful attention directed to the freedom of movement of each segment with palpation to the right and left. \u00a0With the cervical spine positioned in the neutral, flexed, and extended positions, the practitioner should determine which segments are rotationally translated (manually displaced) more easily from\u00a01 side versus the contralateral side. \u00a0A lack of equality at any translation level of an individual vertebra indicates a restriction.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Technique or Treatment. A Step-by-step organized procedural pathway is paramount to an ideal outcome for this procedure. The first step is diagnosing the patient's cervical somatic dysfunction. Then, verifying that there are no existing contraindications ensures that the patient is a candidate for HVLA therapy.\u00a0Diagnosing cervical somatic dysfunction involves a careful manual examination of the atlantooccipital joint with the patient in the supine position, comparing the depths of the\u00a0occipital sulci. The atlantoaxial joint is examined by flexing the patient's cervical spine and locking the atlantooccipital and C2-C7 joints. The range of motion of the atlantoaxial joint is then evaluated by slowly rotating the cervical spine from right to left, noting any restricted movement when comparing the rotation to each side. \u00a0C2-C7 are also evaluated with the patient in the supine position, with careful attention directed to the freedom of movement of each segment with palpation to the right and left. \u00a0With the cervical spine positioned in the neutral, flexed, and extended positions, the practitioner should determine which segments are rotationally translated (manually displaced) more easily from\u00a01 side versus the contralateral side. \u00a0A lack of equality at any translation level of an individual vertebra indicates a restriction."}
+{"id": "article-102951_24", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Technique or Treatment", "content": "HVLA techniques are most successful when the patient is relaxed. Myofascial techniques may be instituted before HVLA therapy to relax muscle groups further. This is achieved by applying a slow and gentle force to loosen hypertonic muscles. By delivering perpendicular and parallel traction and stretching motions with the fingertips, the muscles and soft tissues \"release.\" When the restricted barrier is identified (for example, C4 flexed rotated left, side bent left), the practitioner takes the restricted barrier into the opposite orientation. In this example, the practitioner would engage C4 in the extended, rotated right, and side-bent right position.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Technique or Treatment. HVLA techniques are most successful when the patient is relaxed. Myofascial techniques may be instituted before HVLA therapy to relax muscle groups further. This is achieved by applying a slow and gentle force to loosen hypertonic muscles. By delivering perpendicular and parallel traction and stretching motions with the fingertips, the muscles and soft tissues \"release.\" When the restricted barrier is identified (for example, C4 flexed rotated left, side bent left), the practitioner takes the restricted barrier into the opposite orientation. In this example, the practitioner would engage C4 in the extended, rotated right, and side-bent right position."}
+{"id": "article-102951_25", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Technique or Treatment", "content": "The patient is instructed to relax. If the patient does not adequately relax, the treatment will fail, and the corrective thrust cannot be executed appropriately. The physician should instruct the patient to take multiple deep breaths, further engaging the restrictive barrier in the exhalation phase. The physician then executes a\u00a0short, effective thrust to move the dysfunctional segment through the restriction barrier. The ability to perform a successful adjustment with HVLA therapy sometimes elicits a \"popping\" sound. The restrictive barrier should be engaged entirely before applying the thrust. Finally, after executing the HVLA technique, the practitioner should reassess the range of motion and the somatic dysfunction treated. A successful result would lead to approximately 70% or greater return in the restricted range of motion and/or relief of pain.\u00a0 Patients\u00a0are discharged after thirty minutes of observation with instructions to hydrate appropriately. They follow up in 1\u00a0week for further evaluation and reassessment.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Technique or Treatment. The patient is instructed to relax. If the patient does not adequately relax, the treatment will fail, and the corrective thrust cannot be executed appropriately. The physician should instruct the patient to take multiple deep breaths, further engaging the restrictive barrier in the exhalation phase. The physician then executes a\u00a0short, effective thrust to move the dysfunctional segment through the restriction barrier. The ability to perform a successful adjustment with HVLA therapy sometimes elicits a \"popping\" sound. The restrictive barrier should be engaged entirely before applying the thrust. Finally, after executing the HVLA technique, the practitioner should reassess the range of motion and the somatic dysfunction treated. A successful result would lead to approximately 70% or greater return in the restricted range of motion and/or relief of pain.\u00a0 Patients\u00a0are discharged after thirty minutes of observation with instructions to hydrate appropriately. They follow up in 1\u00a0week for further evaluation and reassessment."}
+{"id": "article-102951_26", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Complications", "content": "Although rare, the risk of catastrophic adverse effects has been associated with manual therapy of the cervical spine. The most serious associated adverse events include cervical artery dissection, vertebrobasilar insufficiency, and artery spasm, all of which can lead to stroke. [19] It is suggested that all practitioners perform a\u00a0Vertebral Artery Test (Wallenberg test), a physical exam for vertebral artery insufficiency before neck manipulation. The Wallenberg test involves\u00a0motion in the cervical spine in the position of rotation, extension, and a combination of both.\u00a0If the patient has vertebral artery insufficiency symptoms during the test (lightheadedness, visual disturbance, or ocular nystagmus), it is considered a positive result, and cervical manipulation should be avoided. [20]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Complications. Although rare, the risk of catastrophic adverse effects has been associated with manual therapy of the cervical spine. The most serious associated adverse events include cervical artery dissection, vertebrobasilar insufficiency, and artery spasm, all of which can lead to stroke. [19] It is suggested that all practitioners perform a\u00a0Vertebral Artery Test (Wallenberg test), a physical exam for vertebral artery insufficiency before neck manipulation. The Wallenberg test involves\u00a0motion in the cervical spine in the position of rotation, extension, and a combination of both.\u00a0If the patient has vertebral artery insufficiency symptoms during the test (lightheadedness, visual disturbance, or ocular nystagmus), it is considered a positive result, and cervical manipulation should be avoided. [20]"}
+{"id": "article-102951_27", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Complications", "content": "Controversy surrounds the dependability of vertebral artery testing before manipulation, with studies concluding that it is impossible to conclude the accuracy of pre-manipulative tests. Studies may indicate that pre-manipulative tests are unreliable screening procedures. [21] Nevertheless, the possibility of vertebral artery disease must be entertained before performing cervical manipulation. Vertebral artery injury is a major complication, usually occurring when cervical HVLA is performed with the neck in the extended position. [22] Vertebral artery dissections may occur due to intimal damage resulting from over-stretching the artery during rotational maneuvers. [23] Intimal injury can lead to bleeding into the wall of the artery, pseudoaneurysm formation, thrombosis, and embolism. [24]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Complications. Controversy surrounds the dependability of vertebral artery testing before manipulation, with studies concluding that it is impossible to conclude the accuracy of pre-manipulative tests. Studies may indicate that pre-manipulative tests are unreliable screening procedures. [21] Nevertheless, the possibility of vertebral artery disease must be entertained before performing cervical manipulation. Vertebral artery injury is a major complication, usually occurring when cervical HVLA is performed with the neck in the extended position. [22] Vertebral artery dissections may occur due to intimal damage resulting from over-stretching the artery during rotational maneuvers. [23] Intimal injury can lead to bleeding into the wall of the artery, pseudoaneurysm formation, thrombosis, and embolism. [24]"}
+{"id": "article-102951_28", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Complications", "content": "Additional complications\u00a0of this procedure, mainly performed by providers without sufficient experience, can include minor soreness or muscle pains. Complications are rare, but the chance of adverse events increases with contraindications. Additional complications can include fractures of cervical vertebrae, spinal cord injury, and other soft tissue injuries. [25] In some cases, subjective pains may be made worse following an HVLA therapy. It is also hypothesized that dural tears may infrequently occur following HVLA treatment and central retinal artery occlusions from patients with atherosclerotic disease of the carotid arteries and spinal cord contusion (Brown-Sequard syndrome). [26] [27] [28]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Complications. Additional complications\u00a0of this procedure, mainly performed by providers without sufficient experience, can include minor soreness or muscle pains. Complications are rare, but the chance of adverse events increases with contraindications. Additional complications can include fractures of cervical vertebrae, spinal cord injury, and other soft tissue injuries. [25] In some cases, subjective pains may be made worse following an HVLA therapy. It is also hypothesized that dural tears may infrequently occur following HVLA treatment and central retinal artery occlusions from patients with atherosclerotic disease of the carotid arteries and spinal cord contusion (Brown-Sequard syndrome). [26] [27] [28]"}
+{"id": "article-102951_29", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Clinical Significance", "content": "Various professions frequently use the HVLA, including physicians, chiropractors, physical therapists, and other manual medicine practitioners. HVLA therapy is also called the \"thrust\" technique since it directs\u00a0a quick, short thrust through a joint, typically in the spine. The\u00a0goal of HVLA OMT of the cervical spine is the resolution of symptoms (reduced pain, increased range of motion).\u00a0The frequently cited therapeutic mechanism of HVLA treatment centers on restoring joint mobility and/or correcting a joint's malalignment. [29] With this in mind, some believe that the therapeutic effect of HVLA therapy is the result of a reduction of pain from some underlying painful biomechanical dysfunction (a corrective treatment of a painful biomechanical lesion). [30]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Clinical Significance. Various professions frequently use the HVLA, including physicians, chiropractors, physical therapists, and other manual medicine practitioners. HVLA therapy is also called the \"thrust\" technique since it directs\u00a0a quick, short thrust through a joint, typically in the spine. The\u00a0goal of HVLA OMT of the cervical spine is the resolution of symptoms (reduced pain, increased range of motion).\u00a0The frequently cited therapeutic mechanism of HVLA treatment centers on restoring joint mobility and/or correcting a joint's malalignment. [29] With this in mind, some believe that the therapeutic effect of HVLA therapy is the result of a reduction of pain from some underlying painful biomechanical dysfunction (a corrective treatment of a painful biomechanical lesion). [30]"}
+{"id": "article-102951_30", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Clinical Significance", "content": "Controversy exists since evidence suggests that treating the asymmetrical movement of a single vertebral segment or multiple segments is unlikely to have a therapeutic effect and that treating spinal segments only produces a \"minor movement\" already observed in the pre-treatment segments. [29] [31] In attempting to describe the mechanism of action of HVLA, researchers propose that HVLA provides relief through a complex reflexive pathway involving afferent and efferent neurons and their effects on local paraspinal regions. Furthermore, HVLA may help decrease pain by triggering serotonin and noradrenaline release on a systemic level. [32] Studies have suggested that osteopathic manipulative treatment, in general, is as efficacious as intramuscular ketorolac in\u00a0providing pain relief. [33] To that extent, it was concluded\u00a0that OMT is a reasonable alternative to parenteral nonsteroidal anti-inflammatory medications for patients with acute neck pain. Nevertheless, there\u00a0is a need for further osteopathic trials with specific outcome measures related to the HVLA technique to define the therapeutic effect better and define what combination therapies might best benefit the patient. [34]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Clinical Significance. Controversy exists since evidence suggests that treating the asymmetrical movement of a single vertebral segment or multiple segments is unlikely to have a therapeutic effect and that treating spinal segments only produces a \"minor movement\" already observed in the pre-treatment segments. [29] [31] In attempting to describe the mechanism of action of HVLA, researchers propose that HVLA provides relief through a complex reflexive pathway involving afferent and efferent neurons and their effects on local paraspinal regions. Furthermore, HVLA may help decrease pain by triggering serotonin and noradrenaline release on a systemic level. [32] Studies have suggested that osteopathic manipulative treatment, in general, is as efficacious as intramuscular ketorolac in\u00a0providing pain relief. [33] To that extent, it was concluded\u00a0that OMT is a reasonable alternative to parenteral nonsteroidal anti-inflammatory medications for patients with acute neck pain. Nevertheless, there\u00a0is a need for further osteopathic trials with specific outcome measures related to the HVLA technique to define the therapeutic effect better and define what combination therapies might best benefit the patient. [34]"}
+{"id": "article-102951_31", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Enhancing Healthcare Team Outcomes", "content": "The patient-physician relationship is built on trust, allowing a physician to provide an accepted standard of care within the practitioner's scope of practice and training. [35] [36] [37] To that extent, communication between the physician providing HVLA OMT and the patient is pivotal for optimizing results. The physician's responsibility is to educate, provide adequate information about the risks and benefits of treatment, and obtain informed consent before this procedure to alleviate anxiety. \u00a0This allows maximal relaxation and comfort, which are essential to proper performance. Successful communication in the patient-physician relationship ensures trust and allows for shared decision-making.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Enhancing Healthcare Team Outcomes. The patient-physician relationship is built on trust, allowing a physician to provide an accepted standard of care within the practitioner's scope of practice and training. [35] [36] [37] To that extent, communication between the physician providing HVLA OMT and the patient is pivotal for optimizing results. The physician's responsibility is to educate, provide adequate information about the risks and benefits of treatment, and obtain informed consent before this procedure to alleviate anxiety. \u00a0This allows maximal relaxation and comfort, which are essential to proper performance. Successful communication in the patient-physician relationship ensures trust and allows for shared decision-making."}
+{"id": "article-102951_32", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Enhancing Healthcare Team Outcomes", "content": "Collaboration amongst the interprofessional team to understand and interpret somatic dysfunctions and HVLA therapy is paramount to guide further diagnostics, therapeutics, and consultations for the patient's overall benefit. Collaboration with other members of the healthcare team (other physicians, as well as physical therapists, occupational therapists, social workers, acupuncturists, counselors, etc) may ensure complementary healthcare modalities, such as dietary changes, nutritional supplements, therapeutic exercises, and medicinal regimes as part of the overall treatment plan.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Enhancing Healthcare Team Outcomes. Collaboration amongst the interprofessional team to understand and interpret somatic dysfunctions and HVLA therapy is paramount to guide further diagnostics, therapeutics, and consultations for the patient's overall benefit. Collaboration with other members of the healthcare team (other physicians, as well as physical therapists, occupational therapists, social workers, acupuncturists, counselors, etc) may ensure complementary healthcare modalities, such as dietary changes, nutritional supplements, therapeutic exercises, and medicinal regimes as part of the overall treatment plan."}
+{"id": "article-102951_33", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Cervical Vertebrae -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

statpearls/chunk/article-102952.jsonl

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+{"id": "article-102952_0", "title": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Continuing Education Activity", "content": "Strain-counterstrain (SCS) of the cervical vertebrae is an indirect technique utilized primarily by osteopathic physicians for the treatment of neck pain and other somatic dysfunctions within the cervical region. Considering at least half of all individuals experience neck pain at some point in their life, SCS is regarded as a gentle and conservative treatment alternative for these patients. This activity reviews the evaluation and treatment of neck pain and highlights the role of the interprofessional team in evaluating and treating patients who undergo strain-counterstrain (SCS) of the cervical vertebrae.", "contents": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Continuing Education Activity. Strain-counterstrain (SCS) of the cervical vertebrae is an indirect technique utilized primarily by osteopathic physicians for the treatment of neck pain and other somatic dysfunctions within the cervical region. Considering at least half of all individuals experience neck pain at some point in their life, SCS is regarded as a gentle and conservative treatment alternative for these patients. This activity reviews the evaluation and treatment of neck pain and highlights the role of the interprofessional team in evaluating and treating patients who undergo strain-counterstrain (SCS) of the cervical vertebrae."}
+{"id": "article-102952_1", "title": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Continuing Education Activity", "content": "Objectives: Describe the pathophysiology of tenderpoints (TPs). Outline the indications for strain-counterstrain (SCS) of the cervical vertebrae. Summarize the typical steps required to perform strain-counterstrain (SCS) of the cervical vertebrae. Access free multiple choice questions on this topic.", "contents": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Continuing Education Activity. Objectives: Describe the pathophysiology of tenderpoints (TPs). Outline the indications for strain-counterstrain (SCS) of the cervical vertebrae. Summarize the typical steps required to perform strain-counterstrain (SCS) of the cervical vertebrae. Access free multiple choice questions on this topic."}
+{"id": "article-102952_2", "title": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Introduction", "content": "Neck\u00a0pain is a\u00a0frequent complaint among the general population and may be attributed to improper posture, inadequate sleep positioning, an acute injury, among other causes. It has been reported that about half of all individuals will suffer from neck pain at some point in their life.\u00a0While numerous treatment options exist for neck pain, only a\u00a0handful of patients seek osteopathic manipulative treatment (OMT).", "contents": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Introduction. Neck\u00a0pain is a\u00a0frequent complaint among the general population and may be attributed to improper posture, inadequate sleep positioning, an acute injury, among other causes. It has been reported that about half of all individuals will suffer from neck pain at some point in their life.\u00a0While numerous treatment options exist for neck pain, only a\u00a0handful of patients seek osteopathic manipulative treatment (OMT)."}
+{"id": "article-102952_3", "title": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Introduction", "content": "OMT remains one of the staples of the osteopathic medical school curriculum and is widely used among practicing osteopathic physicians today for the treatment of neck pain and other musculoskeletal pain. [1] As one of the more gentle techniques within the scope of OMT, strain-counterstrain (SCS), also known as positional release therapy, is an effective and safe alternative treatment option for patients experiencing cervical pain. [2] Despite little research being conducted on this technique, SCS has been utilized clinically by osteopathic physicians for over a half-century. [3]  The technique has shown promise in patients who have failed to achieve relief of symptoms from other treatment methods. [4] Among the approximately 25 OMT techniques that exist, SCS was reported as the fourth most commonly used by a survey of osteopathic providers. [5] Aside from cervical pain, SCS can be used to treat\u00a0several medical conditions,\u00a0especially those involving the musculoskeletal system.", "contents": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Introduction. OMT remains one of the staples of the osteopathic medical school curriculum and is widely used among practicing osteopathic physicians today for the treatment of neck pain and other musculoskeletal pain. [1] As one of the more gentle techniques within the scope of OMT, strain-counterstrain (SCS), also known as positional release therapy, is an effective and safe alternative treatment option for patients experiencing cervical pain. [2] Despite little research being conducted on this technique, SCS has been utilized clinically by osteopathic physicians for over a half-century. [3]  The technique has shown promise in patients who have failed to achieve relief of symptoms from other treatment methods. [4] Among the approximately 25 OMT techniques that exist, SCS was reported as the fourth most commonly used by a survey of osteopathic providers. [5] Aside from cervical pain, SCS can be used to treat\u00a0several medical conditions,\u00a0especially those involving the musculoskeletal system."}
+{"id": "article-102952_4", "title": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Introduction", "content": "Founded in 1955 by Lawrence H. Jones, D.O., the strain-counterstrain (SCS) model has been primarily utilized by osteopathic physicians as a procedure performed to aid in the diagnosis and indirect treatment of a patient's somatic dysfunction. [5] Diagnosis is achieved through a pain scale and tissue texture abnormalities found at associated myofascial tenderpoints (TPs). Examples of tissue texture abnormalities include asymmetry, restriction, changes in tone, or temperature. [6] As an indirect technique,\u00a0SCS attempts to move the affected region in the direction opposite of the restrictive barrier. Treatment is performed by positioning the patient to achieve spontaneous tissue release while the physician simultaneously monitors the TP. In essence, the TP should be relieved by placing the patient in a position-of-comfort,\u00a0holding this position\u00a0for 90 seconds, and slowly returning the patient to a neutral position. SCS, along with all OMT techniques, aims to reduce pain, enhance function, and improve a patient's quality of life. [6] This review\u00a0will discuss the\u00a0use of SCS, particularly involving the cervical vertebrae.", "contents": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Introduction. Founded in 1955 by Lawrence H. Jones, D.O., the strain-counterstrain (SCS) model has been primarily utilized by osteopathic physicians as a procedure performed to aid in the diagnosis and indirect treatment of a patient's somatic dysfunction. [5] Diagnosis is achieved through a pain scale and tissue texture abnormalities found at associated myofascial tenderpoints (TPs). Examples of tissue texture abnormalities include asymmetry, restriction, changes in tone, or temperature. [6] As an indirect technique,\u00a0SCS attempts to move the affected region in the direction opposite of the restrictive barrier. Treatment is performed by positioning the patient to achieve spontaneous tissue release while the physician simultaneously monitors the TP. In essence, the TP should be relieved by placing the patient in a position-of-comfort,\u00a0holding this position\u00a0for 90 seconds, and slowly returning the patient to a neutral position. SCS, along with all OMT techniques, aims to reduce pain, enhance function, and improve a patient's quality of life. [6] This review\u00a0will discuss the\u00a0use of SCS, particularly involving the cervical vertebrae."}
+{"id": "article-102952_5", "title": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Introduction", "content": "The basic steps required to perform\u00a0strain-counterstrain (SCS) in any region of the body are as follows: Find a TP. Assess the tenderness using a pain scale. Passively and gently place the patient in a position-of-comfort that results in the greatest reduction of tenderness at the TP. Approximate the position first, then fine-tune through small arcs of movement.\u00a0Aim to achieve at least 70% tenderness reduction, with the goal of 100%. Maintain the position for 90 seconds while continuing to monitor the patient's TP. Passively return the patient to a neutral position. Re-test for tenderness at the TP.", "contents": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Introduction. The basic steps required to perform\u00a0strain-counterstrain (SCS) in any region of the body are as follows: Find a TP. Assess the tenderness using a pain scale. Passively and gently place the patient in a position-of-comfort that results in the greatest reduction of tenderness at the TP. Approximate the position first, then fine-tune through small arcs of movement.\u00a0Aim to achieve at least 70% tenderness reduction, with the goal of 100%. Maintain the position for 90 seconds while continuing to monitor the patient's TP. Passively return the patient to a neutral position. Re-test for tenderness at the TP."}
+{"id": "article-102952_6", "title": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Anatomy and Physiology", "content": "The cervical spine\u00a0can be divided into the atlas (C1), the axis (C2), and the typical cervical vertebrae (C2-C7).  C1 has no spinous process or vertebral body. C2 has the dens that projects superiorly from its body and articulates with C1. As the union between the head and the atlas, the atlantooccipital (AO) joint's primary motion involves flexion and extension (nodding motion). The atlantoaxial (AA) joint's primary motion involves rotation. The vertebral bodies\u00a0of the typical cervical segments are separated by intervertebral discs. [7] The upper typical cervicals (approximately C2-C4) have a primary motion of rotation. The\u00a0lower typical cervicals (approximately C5-C7) have a primary motion of side-bending. The facet joints are synovial joints that display unique orientation along the cervical spine that aid in movement.\u00a0Studies have determined that particular facet orientation has been correlated with clinical conditions. [8]", "contents": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Anatomy and Physiology. The cervical spine\u00a0can be divided into the atlas (C1), the axis (C2), and the typical cervical vertebrae (C2-C7).  C1 has no spinous process or vertebral body. C2 has the dens that projects superiorly from its body and articulates with C1. As the union between the head and the atlas, the atlantooccipital (AO) joint's primary motion involves flexion and extension (nodding motion). The atlantoaxial (AA) joint's primary motion involves rotation. The vertebral bodies\u00a0of the typical cervical segments are separated by intervertebral discs. [7] The upper typical cervicals (approximately C2-C4) have a primary motion of rotation. The\u00a0lower typical cervicals (approximately C5-C7) have a primary motion of side-bending. The facet joints are synovial joints that display unique orientation along the cervical spine that aid in movement.\u00a0Studies have determined that particular facet orientation has been correlated with clinical conditions. [8]"}
+{"id": "article-102952_7", "title": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Anatomy and Physiology", "content": "The pathophysiology of tenderpoints (TPs) could be explained\u00a0through the interplay of muscle strain and the resulting perception of pain. A sudden muscle strain\u2014from the overstretching of myofascial tissues\u2014is detected by muscle spindle receptors due to the change in length of the muscle fibers that have been affected. Increased firing of the muscle spindle receptors triggers increased gamma motor neuron activity and subsequent contraction of the muscle and affiliated pain.\u00a0The explanation for the effects of strain-counterstrain (SCS) in the treatment of TPs is not entirely clear, but the most common theory proposes that the positioning of the patient minimizes the tension of the tissue of interest and reduces the nociceptive input, thus preventing the pathological neural reflex arc. [5]", "contents": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Anatomy and Physiology. The pathophysiology of tenderpoints (TPs) could be explained\u00a0through the interplay of muscle strain and the resulting perception of pain. A sudden muscle strain\u2014from the overstretching of myofascial tissues\u2014is detected by muscle spindle receptors due to the change in length of the muscle fibers that have been affected. Increased firing of the muscle spindle receptors triggers increased gamma motor neuron activity and subsequent contraction of the muscle and affiliated pain.\u00a0The explanation for the effects of strain-counterstrain (SCS) in the treatment of TPs is not entirely clear, but the most common theory proposes that the positioning of the patient minimizes the tension of the tissue of interest and reduces the nociceptive input, thus preventing the pathological neural reflex arc. [5]"}
+{"id": "article-102952_8", "title": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Anatomy and Physiology", "content": "TPs are most commonly located near bony attachments of tendons, ligaments, or muscle bellies. TPs should not be confused with trigger points, which are normally found within taut musculotendinous tissue bands. [9] TPs can be palpated as tense, small, edematous regions in the soft tissue. TPs only refer to local areas of tenderness; no pain referral should be experienced.\u00a0To date, there have been over 200 anatomical TPs identified by osteopathic physicians. [9] Interestingly, cervical radiculopathy is associated with TPs located on the same side of the apparent radiculopathy. [10] In this review, we will focus on the most common cervical TPs found in the clinical setting.", "contents": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Anatomy and Physiology. TPs are most commonly located near bony attachments of tendons, ligaments, or muscle bellies. TPs should not be confused with trigger points, which are normally found within taut musculotendinous tissue bands. [9] TPs can be palpated as tense, small, edematous regions in the soft tissue. TPs only refer to local areas of tenderness; no pain referral should be experienced.\u00a0To date, there have been over 200 anatomical TPs identified by osteopathic physicians. [9] Interestingly, cervical radiculopathy is associated with TPs located on the same side of the apparent radiculopathy. [10] In this review, we will focus on the most common cervical TPs found in the clinical setting."}
+{"id": "article-102952_9", "title": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Anatomy and Physiology -- Location of Anterior Cervical (AC) TPs:", "content": "Anterior cervical C1 (AC1) TPs are located near the transverse processes of C1, on the posterior edge of the ramus of the mandible. AC2-AC6 TPs are located on the anterolateral tips of the corresponding transverse processes. AC7 TPs are located on the superior surface of the clavicle at the clavicular attachment of the sternocleidomastoid (SCM). AC8 TPs are located at the medial end of the clavicle at the sternal attachment of the SCM.", "contents": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Anatomy and Physiology -- Location of Anterior Cervical (AC) TPs:. Anterior cervical C1 (AC1) TPs are located near the transverse processes of C1, on the posterior edge of the ramus of the mandible. AC2-AC6 TPs are located on the anterolateral tips of the corresponding transverse processes. AC7 TPs are located on the superior surface of the clavicle at the clavicular attachment of the sternocleidomastoid (SCM). AC8 TPs are located at the medial end of the clavicle at the sternal attachment of the SCM."}
+{"id": "article-102952_10", "title": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Anatomy and Physiology -- Location of Posterior Cervical (PC) TPs:", "content": "Posterior cervical C1 (PC1) midline TP is located around the inion. PC1 lateral TPs are located on the occiput, midway between the inion and mastoid process. PC2 midline TP is located on the superior aspect of the spinous process. PC2 lateral TPs are located on the occiput, midway between the inion and PC1 lateral TPs on the occiput. PC3 midline TP is located on the inferolateral aspect of the C2 spinous process. PC3-PC7 lateral TPs are located on the posterolateral surface of the corresponding articular processes. PC4-PC8 midline TPs are located on the inferior aspect of the spinous process of the vertebra directly above the corresponding cervical level.", "contents": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Anatomy and Physiology -- Location of Posterior Cervical (PC) TPs:. Posterior cervical C1 (PC1) midline TP is located around the inion. PC1 lateral TPs are located on the occiput, midway between the inion and mastoid process. PC2 midline TP is located on the superior aspect of the spinous process. PC2 lateral TPs are located on the occiput, midway between the inion and PC1 lateral TPs on the occiput. PC3 midline TP is located on the inferolateral aspect of the C2 spinous process. PC3-PC7 lateral TPs are located on the posterolateral surface of the corresponding articular processes. PC4-PC8 midline TPs are located on the inferior aspect of the spinous process of the vertebra directly above the corresponding cervical level."}
+{"id": "article-102952_11", "title": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Indications", "content": "Acute or chronic somatic dysfunctions Hypertonic muscles Somatic dysfunctions with a neural component (e.g., hypertonic muscle) As primary treatment or in conjunction with any other treatment options", "contents": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Indications. Acute or chronic somatic dysfunctions Hypertonic muscles Somatic dysfunctions with a neural component (e.g., hypertonic muscle) As primary treatment or in conjunction with any other treatment options"}
+{"id": "article-102952_12", "title": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Contraindications", "content": "Strain-counterstrain (SCS)\u00a0is widely regarded as one of the safest osteopathic manipulative treatment options. However, like any physical procedure, contraindications still exist. Contraindications for counterstrain could be divided into\u00a0absolute (do not perform the procedure) and relative (may perform the procedure with caution, depending on the circumstance).", "contents": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Contraindications. Strain-counterstrain (SCS)\u00a0is widely regarded as one of the safest osteopathic manipulative treatment options. However, like any physical procedure, contraindications still exist. Contraindications for counterstrain could be divided into\u00a0absolute (do not perform the procedure) and relative (may perform the procedure with caution, depending on the circumstance)."}
+{"id": "article-102952_13", "title": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Contraindications -- Absolute Contraindications", "content": "Absence of somatic dysfunction Lack of patient consent or cooperation Fracture or torn ligament in the area", "contents": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Contraindications -- Absolute Contraindications. Absence of somatic dysfunction Lack of patient consent or cooperation Fracture or torn ligament in the area"}
+{"id": "article-102952_14", "title": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Contraindications -- Relative Contraindications", "content": "Cervical vertebral artery disease Severe osteoporosis Any rheumatologic conditions such as rheumatoid arthritis Ligamentous instability Severe illness Patient unable to voluntarily relax muscles", "contents": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Contraindications -- Relative Contraindications. Cervical vertebral artery disease Severe osteoporosis Any rheumatologic conditions such as rheumatoid arthritis Ligamentous instability Severe illness Patient unable to voluntarily relax muscles"}
+{"id": "article-102952_15", "title": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Equipment", "content": "The following equipment is needed: Osteopathic manipulative treatment table Stool", "contents": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Equipment. The following equipment is needed: Osteopathic manipulative treatment table Stool"}
+{"id": "article-102952_16", "title": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Preparation", "content": "The principles of diagnosis through the use of\u00a0strain-counterstrain (SCS) involve a\u00a0holistic\u00a0evaluation\u00a0of the patient's history and a thorough observation of body habitus. Before beginning the technique, the provider must assess the patient for any possible contraindications. After a potential dysfunction is determined, the tissue area is evaluated for tenderness and tissue texture abnormalities. It is recommended that the\u00a0amount of pressure\u00a0applied to diagnose a\u00a0TP should typically not exceed the pressure required to blanch the nail-bed of the diagnosing finger. Applying more pressure than what is recommended could elicit pain that may inadvertently be perceived by the patient as a\u00a0TP.", "contents": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Preparation. The principles of diagnosis through the use of\u00a0strain-counterstrain (SCS) involve a\u00a0holistic\u00a0evaluation\u00a0of the patient's history and a thorough observation of body habitus. Before beginning the technique, the provider must assess the patient for any possible contraindications. After a potential dysfunction is determined, the tissue area is evaluated for tenderness and tissue texture abnormalities. It is recommended that the\u00a0amount of pressure\u00a0applied to diagnose a\u00a0TP should typically not exceed the pressure required to blanch the nail-bed of the diagnosing finger. Applying more pressure than what is recommended could elicit pain that may inadvertently be perceived by the patient as a\u00a0TP."}
+{"id": "article-102952_17", "title": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Preparation -- Notable tips to keep in mind while utilizing SCS:", "content": "Anterior TPs typically require flexion. Posterior TPs typically require an extension. Midline points typically require primarily flexion or extension. Lateral points typically require more side-bending and rotation. It is best to use both tissue texture changes and tenderness to find the most suitable treatment position. Adequate myofascial relaxation is typically achieved by the presence of a \"release\" or \"ease\" of tension.", "contents": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Preparation -- Notable tips to keep in mind while utilizing SCS:. Anterior TPs typically require flexion. Posterior TPs typically require an extension. Midline points typically require primarily flexion or extension. Lateral points typically require more side-bending and rotation. It is best to use both tissue texture changes and tenderness to find the most suitable treatment position. Adequate myofascial relaxation is typically achieved by the presence of a \"release\" or \"ease\" of tension."}
+{"id": "article-102952_18", "title": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Technique or Treatment -- Strain-Counterstrain (SCS) Technique for Anterior Cervical C1-C8 (AC1-8) TPs", "content": "With the provider at the head of the table, have the patient lay supine on the treatment table. The provider locates the\u00a0TP. The provider establishes a pain scale with the patient at 10 out of 10. The provider\u00a0gently and passively wraps the patient around the TP, taking them to a position-of-comfort by flexing, side-bending, and rotating the head away (FSARA) from the\u00a0TP\u00a0until the TP pain has reduced to at least a 3 out of 10 (70% tenderness reduction) or better (with the goal of 100% tenderness reduction). The provider reduces\u00a0his/her palpating pressure at the TP and continues to monitor,\u00a0maintaining the patient's position for 90 seconds (do not remove contact with the TP until the technique is complete). After 90 seconds has elapsed, the patient's head\u00a0should be slowly and passively returned to a neutral position. Re-test for tenderness at the TP.", "contents": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Technique or Treatment -- Strain-Counterstrain (SCS) Technique for Anterior Cervical C1-C8 (AC1-8) TPs. With the provider at the head of the table, have the patient lay supine on the treatment table. The provider locates the\u00a0TP. The provider establishes a pain scale with the patient at 10 out of 10. The provider\u00a0gently and passively wraps the patient around the TP, taking them to a position-of-comfort by flexing, side-bending, and rotating the head away (FSARA) from the\u00a0TP\u00a0until the TP pain has reduced to at least a 3 out of 10 (70% tenderness reduction) or better (with the goal of 100% tenderness reduction). The provider reduces\u00a0his/her palpating pressure at the TP and continues to monitor,\u00a0maintaining the patient's position for 90 seconds (do not remove contact with the TP until the technique is complete). After 90 seconds has elapsed, the patient's head\u00a0should be slowly and passively returned to a neutral position. Re-test for tenderness at the TP."}
+{"id": "article-102952_19", "title": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Technique or Treatment -- Strain-Counterstrain (SCS) Technique for Posterior Cervical C1-C8 (PC1-8) TPs", "content": "With the provider\u00a0at the head of the table, have the patient lay supine on the treatment table. The provider locates the\u00a0TP. The provider establishes a pain scale with the patient at 10 out of 10. The provider\u00a0gently and passively wraps the patient around the\u00a0TP, taking them to a position-of-comfort by\u00a0extending, side-bending, and rotating the head away (ESARA) from the TP\u00a0until the TP pain has reduced to at least a 3 out of 10 (70% tenderness reduction) or better (with the goal of 100% tenderness reduction). The provider reduces\u00a0his/her palpating pressure at the TP and continues to monitor,\u00a0maintaining\u00a0the patient's position for 90 seconds (do not remove contact with the TP until the technique is complete). After 90 seconds has elapsed, the patient's head should be slowly and passively returned to a neutral position. Re-test for tenderness at the TP.", "contents": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Technique or Treatment -- Strain-Counterstrain (SCS) Technique for Posterior Cervical C1-C8 (PC1-8) TPs. With the provider\u00a0at the head of the table, have the patient lay supine on the treatment table. The provider locates the\u00a0TP. The provider establishes a pain scale with the patient at 10 out of 10. The provider\u00a0gently and passively wraps the patient around the\u00a0TP, taking them to a position-of-comfort by\u00a0extending, side-bending, and rotating the head away (ESARA) from the TP\u00a0until the TP pain has reduced to at least a 3 out of 10 (70% tenderness reduction) or better (with the goal of 100% tenderness reduction). The provider reduces\u00a0his/her palpating pressure at the TP and continues to monitor,\u00a0maintaining\u00a0the patient's position for 90 seconds (do not remove contact with the TP until the technique is complete). After 90 seconds has elapsed, the patient's head should be slowly and passively returned to a neutral position. Re-test for tenderness at the TP."}
+{"id": "article-102952_20", "title": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Technique or Treatment", "content": "*The exceptions to treating PC1-C8 TPs with \"ESARA\" are for\u00a0PC1 midline\u00a0and PC3 midline\u00a0TPs, which are treated with cervical flexion only (no side-bending or rotation).", "contents": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Technique or Treatment. *The exceptions to treating PC1-C8 TPs with \"ESARA\" are for\u00a0PC1 midline\u00a0and PC3 midline\u00a0TPs, which are treated with cervical flexion only (no side-bending or rotation)."}
+{"id": "article-102952_21", "title": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Complications", "content": "Significant complications are rarely associated with cervical strain-counterstrain (SCS). Any complications may be associated with the position of the patient during the technique. It is recommended to avoid positions that cause discomfort, dizziness, panic, or neurogenic pain (such as rapid rotation and extension of the upper cervicals). A minor side effect may include pain in the antagonistic muscles. However, this is usually self-limiting and well-tolerated by patients.", "contents": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Complications. Significant complications are rarely associated with cervical strain-counterstrain (SCS). Any complications may be associated with the position of the patient during the technique. It is recommended to avoid positions that cause discomfort, dizziness, panic, or neurogenic pain (such as rapid rotation and extension of the upper cervicals). A minor side effect may include pain in the antagonistic muscles. However, this is usually self-limiting and well-tolerated by patients."}
+{"id": "article-102952_22", "title": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Clinical Significance", "content": "The clinical use of cervical strain-counterstrain (SCS) on patients with\u00a0neck pain is an effective and conservative alternative\u00a0or adjunct to other treatment modalities.", "contents": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Clinical Significance. The clinical use of cervical strain-counterstrain (SCS) on patients with\u00a0neck pain is an effective and conservative alternative\u00a0or adjunct to other treatment modalities."}
+{"id": "article-102952_23", "title": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Enhancing Healthcare Team Outcomes", "content": "A patient with persistent cervical pain may present with a variety of symptoms and complaints. Without direct knowledge of the existence of osteopathic manipulative treatment (OMT), these patients often turn to unnecessary and aggressive management options. While cervical strain-counterstrain (SCS) may be a popular technique utilized among several osteopathic physicians, it is rarely used elsewhere. Therefore,\u00a0osteopaths should educate allopathic physicians and healthcare providers as a whole on the benefits of OMT, so they feel more inclined to refer patients to a specialist when necessary. Through the use of interprofessional communication,\u00a0osteopathic clinicians can prevent unsatisfied outcomes and enhance the care of their patients.", "contents": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Enhancing Healthcare Team Outcomes. A patient with persistent cervical pain may present with a variety of symptoms and complaints. Without direct knowledge of the existence of osteopathic manipulative treatment (OMT), these patients often turn to unnecessary and aggressive management options. While cervical strain-counterstrain (SCS) may be a popular technique utilized among several osteopathic physicians, it is rarely used elsewhere. Therefore,\u00a0osteopaths should educate allopathic physicians and healthcare providers as a whole on the benefits of OMT, so they feel more inclined to refer patients to a specialist when necessary. Through the use of interprofessional communication,\u00a0osteopathic clinicians can prevent unsatisfied outcomes and enhance the care of their patients."}
+{"id": "article-102952_24", "title": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

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+{"id": "article-102953_0", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Continuing Education Activity", "content": "Post-isometric relaxation is the most\u00a0commonly used muscle energy technique (MET) in osteopathic medicine for improving thoracic spine restriction. MET is used by osteopathic physicians as a conservative, nonpharmacological treatment method for somatic dysfunctions of the musculoskeletal system. MET is a form of manual therapy and stretching. The patient actively contracts muscles in a precise direction while the therapist provides counterforce resistance. Isometric contractions relax and lengthen muscles. This activity\u00a0discusses the procedural method for using\u00a0MET with post-isometric relaxation to treat the thoracic spine's somatic dysfunction, the relevant anatomy and physiology, and its indications and contraindications.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Continuing Education Activity. Post-isometric relaxation is the most\u00a0commonly used muscle energy technique (MET) in osteopathic medicine for improving thoracic spine restriction. MET is used by osteopathic physicians as a conservative, nonpharmacological treatment method for somatic dysfunctions of the musculoskeletal system. MET is a form of manual therapy and stretching. The patient actively contracts muscles in a precise direction while the therapist provides counterforce resistance. Isometric contractions relax and lengthen muscles. This activity\u00a0discusses the procedural method for using\u00a0MET with post-isometric relaxation to treat the thoracic spine's somatic dysfunction, the relevant anatomy and physiology, and its indications and contraindications."}
+{"id": "article-102953_1", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Continuing Education Activity", "content": "Objectives: Screen patients effectively to assess their suitability for muscle energy technique with post-isometric relaxation, considering factors such as acute fractures, dislocations, tissue damage, and central muscle spasm. Differentiate among somatic dysfunctions and other underlying disease processes such as infection, fracture, or malignancy that require alternative management approaches. Select the appropriate frequency, duration, and intensity of the post-isometric relaxation\u00a0muscle energy technique sessions based on patient response and treatment goals. Communicate effectively with patients about the rationale, benefits, and potential risks of the muscle energy technique with post-isometric relaxation as part of their overall treatment plan. Access free multiple choice questions on this topic.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Continuing Education Activity. Objectives: Screen patients effectively to assess their suitability for muscle energy technique with post-isometric relaxation, considering factors such as acute fractures, dislocations, tissue damage, and central muscle spasm. Differentiate among somatic dysfunctions and other underlying disease processes such as infection, fracture, or malignancy that require alternative management approaches. Select the appropriate frequency, duration, and intensity of the post-isometric relaxation\u00a0muscle energy technique sessions based on patient response and treatment goals. Communicate effectively with patients about the rationale, benefits, and potential risks of the muscle energy technique with post-isometric relaxation as part of their overall treatment plan. Access free multiple choice questions on this topic."}
+{"id": "article-102953_2", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Introduction", "content": "Muscle energy technique, commonly\u00a0known as\u00a0MET, is a form of manual therapy and stretching used in osteopathy. The patient actively contracts muscles in a precise direction while the therapist provides counterforce resistance. Isometric contractions relax and lengthen muscles.\u00a0The technique is often regarded as direct, as the patient is placed toward the barrier. [1]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Introduction. Muscle energy technique, commonly\u00a0known as\u00a0MET, is a form of manual therapy and stretching used in osteopathy. The patient actively contracts muscles in a precise direction while the therapist provides counterforce resistance. Isometric contractions relax and lengthen muscles.\u00a0The technique is often regarded as direct, as the patient is placed toward the barrier. [1]"}
+{"id": "article-102953_3", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Introduction", "content": "In 1948, Fred Mitchell, Sr, DO, developed the technique after deducing the kinematic motions in the pelvis. From these concepts, he started to treat these somatic dysfunctions using muscle action as an activating force. [2] Osteopathic physicians typically use MET to correct somatic dysfunction that causes pain and discomfort, especially\u00a0when performing therapy on the thoracic spine. [3] [4]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Introduction. In 1948, Fred Mitchell, Sr, DO, developed the technique after deducing the kinematic motions in the pelvis. From these concepts, he started to treat these somatic dysfunctions using muscle action as an activating force. [2] Osteopathic physicians typically use MET to correct somatic dysfunction that causes pain and discomfort, especially\u00a0when performing therapy on the thoracic spine. [3] [4]"}
+{"id": "article-102953_4", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Introduction", "content": "There are\u00a09 physiologic principles to muscle energy: joint mobilization using muscle force, respiratory assistance, oculocephalic reflex, reciprocal inhibition, crossed extensor reflex, isokinetic strengthening, isolytic lengthening, muscle force in one region of the body to achieve movement in another and post-isometric relaxation. Out of these 9, post-isometric relaxation is the most commonly\u00a0performed MET.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Introduction. There are\u00a09 physiologic principles to muscle energy: joint mobilization using muscle force, respiratory assistance, oculocephalic reflex, reciprocal inhibition, crossed extensor reflex, isokinetic strengthening, isolytic lengthening, muscle force in one region of the body to achieve movement in another and post-isometric relaxation. Out of these 9, post-isometric relaxation is the most commonly\u00a0performed MET."}
+{"id": "article-102953_5", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Introduction", "content": "Dr Mitchell, Sr initially hypothesized\u00a0that after an isometric contraction, the muscle is in a refractory state where it may be passively stretched without a reflexive contraction. MET with post-isometric relaxation involves putting increased tension on the muscle fibers by asking the patient to contract against a barrier; this activates the Golgi tendon fibers. Once activated, there is a reflexive inhibition and relaxation of the muscle through the Ia fibers, and the clinician may further passively stretch the muscle due to the refractory state. [2]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Introduction. Dr Mitchell, Sr initially hypothesized\u00a0that after an isometric contraction, the muscle is in a refractory state where it may be passively stretched without a reflexive contraction. MET with post-isometric relaxation involves putting increased tension on the muscle fibers by asking the patient to contract against a barrier; this activates the Golgi tendon fibers. Once activated, there is a reflexive inhibition and relaxation of the muscle through the Ia fibers, and the clinician may further passively stretch the muscle due to the refractory state. [2]"}
+{"id": "article-102953_6", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Anatomy and Physiology", "content": "A comprehensive understanding of muscle physiology is imperative for mastering MET. There are\u00a04 types of muscle contraction: isometric, concentric, eccentric, and isolytic. Isometric contraction is when the muscles contract without having the origin and insertion of the muscle approach each other. Concentric contraction is when the muscles shorten with contraction. Eccentric contraction is when the muscle lengthens with contraction. And finally, isolytic contraction is when an external force lengthens muscle contraction. [5]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Anatomy and Physiology. A comprehensive understanding of muscle physiology is imperative for mastering MET. There are\u00a04 types of muscle contraction: isometric, concentric, eccentric, and isolytic. Isometric contraction is when the muscles contract without having the origin and insertion of the muscle approach each other. Concentric contraction is when the muscles shorten with contraction. Eccentric contraction is when the muscle lengthens with contraction. And finally, isolytic contraction is when an external force lengthens muscle contraction. [5]"}
+{"id": "article-102953_7", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Anatomy and Physiology", "content": "Muscles consist of numerous muscle spindles. Each spindle has approximately 3\u00a0to 12 intrafusal muscle fibers surrounded by a large extrafusal fiber. Each muscle spindle\u00a0has an efferent and an afferent neural component. Motor nerve fibers are the alpha motor neurons innervating the extrafusal fibers and the gamma motor neurons innervating the intrafusal fibers. The afferent (sensory) portions are the Ia and II fibers that innervate muscle spindles and the Ib fingers, which innervate the Golgi tendon organs at the myotendinous junction. [6]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Anatomy and Physiology. Muscles consist of numerous muscle spindles. Each spindle has approximately 3\u00a0to 12 intrafusal muscle fibers surrounded by a large extrafusal fiber. Each muscle spindle\u00a0has an efferent and an afferent neural component. Motor nerve fibers are the alpha motor neurons innervating the extrafusal fibers and the gamma motor neurons innervating the intrafusal fibers. The afferent (sensory) portions are the Ia and II fibers that innervate muscle spindles and the Ib fingers, which innervate the Golgi tendon organs at the myotendinous junction. [6]"}
+{"id": "article-102953_8", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Anatomy and Physiology", "content": "Golgi tendon fibers play a crucial role in MET through a post-isometric relaxation mechanism. The fibers are stimulated when muscles experience heightened tension, initiating a negative feedback loop that inhibits further contraction via the Ia fibers. [2]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Anatomy and Physiology. Golgi tendon fibers play a crucial role in MET through a post-isometric relaxation mechanism. The fibers are stimulated when muscles experience heightened tension, initiating a negative feedback loop that inhibits further contraction via the Ia fibers. [2]"}
+{"id": "article-102953_9", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Anatomy and Physiology", "content": "The thoracic spine consists of 12 spinal vertebrae, and it holds particular significance for osteopathic physicians due to its association with sympathetic nerve fibers. Somatic dysfunctions in this region can result from biomechanical factors, such as restrictions in segments affected by surrounding muscles, or they may even have viscerosomatic origins. While the scope of this review\u00a0does not cover viscerosomatic reflexes, addressing and understanding these issues is crucial for osteopathic care.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Anatomy and Physiology. The thoracic spine consists of 12 spinal vertebrae, and it holds particular significance for osteopathic physicians due to its association with sympathetic nerve fibers. Somatic dysfunctions in this region can result from biomechanical factors, such as restrictions in segments affected by surrounding muscles, or they may even have viscerosomatic origins. While the scope of this review\u00a0does not cover viscerosomatic reflexes, addressing and understanding these issues is crucial for osteopathic care."}
+{"id": "article-102953_10", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Anatomy and Physiology", "content": "Thoracic vertebrae have\u00a0a posterior spinous process,\u00a0an anterior vertebral body, and bilateral transverse processes on each side. These vertebrae\u00a0have facet joints above and below, facilitating articulation with adjacent segments. The superior facet joint in the thoracic segment is oriented in a posterior, upward, and lateral direction. Due to the presence of the ribs, thoracic vertebrae also have a superior and inferior costal facet near the vertebral body and a transverse costal facet on the transverse process.\u00a0The orientation of\u00a0T12's articular facet may face slightly from the\u00a0other thoracic vertebrae due to its articulation with L1. [7]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Anatomy and Physiology. Thoracic vertebrae have\u00a0a posterior spinous process,\u00a0an anterior vertebral body, and bilateral transverse processes on each side. These vertebrae\u00a0have facet joints above and below, facilitating articulation with adjacent segments. The superior facet joint in the thoracic segment is oriented in a posterior, upward, and lateral direction. Due to the presence of the ribs, thoracic vertebrae also have a superior and inferior costal facet near the vertebral body and a transverse costal facet on the transverse process.\u00a0The orientation of\u00a0T12's articular facet may face slightly from the\u00a0other thoracic vertebrae due to its articulation with L1. [7]"}
+{"id": "article-102953_11", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Anatomy and Physiology", "content": "The Rule of Threes, frequently taught in osteopathic education, aids in pinpointing the location of the spinous process concerning the transverse process.\u00a0According to this rule, for T1 through T3, the spinous process aligns with the transverse process. For T4 through T6, the spinous process is positioned midway between the transverse processes of the adjacent segments. From T7 through T10, the spinous process\u00a0is at the level of the next transverse process (the 7th spinous process is\u00a0at the level of T8). The 11th spinous\u00a0process\u00a0is halfway, and the 12th spinous process\u00a0is at the same level as its transverse process. [8] [9] Debates over the accuracy of the Rule of Threes and the consideration of Geelhoed's rule are topics of discussion, but they fall outside the scope of this activity. [9]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Anatomy and Physiology. The Rule of Threes, frequently taught in osteopathic education, aids in pinpointing the location of the spinous process concerning the transverse process.\u00a0According to this rule, for T1 through T3, the spinous process aligns with the transverse process. For T4 through T6, the spinous process is positioned midway between the transverse processes of the adjacent segments. From T7 through T10, the spinous process\u00a0is at the level of the next transverse process (the 7th spinous process is\u00a0at the level of T8). The 11th spinous\u00a0process\u00a0is halfway, and the 12th spinous process\u00a0is at the same level as its transverse process. [8] [9] Debates over the accuracy of the Rule of Threes and the consideration of Geelhoed's rule are topics of discussion, but they fall outside the scope of this activity. [9]"}
+{"id": "article-102953_12", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Anatomy and Physiology", "content": "Somatic dysfunctions are categorized into 2 types. Type 1 dysfunctions involve a group of segments and often result from chronic poor posture. These dysfunctions typically affect the larger, long-supportive muscles of the back, like the erector spinae, and are usually positioned neutrally but with rotation and side bending in opposite directions. On the other hand, Type 2 dysfunctions are often more acutely tender and affect the smaller supportive muscles between segments, such as the rotatores, multifidus, interspinales, and intertransversarii muscles. Type 2 dysfunctions are typically characterized by flexion or extension, side bending, and rotation in the same direction. [10] [11]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Anatomy and Physiology. Somatic dysfunctions are categorized into 2 types. Type 1 dysfunctions involve a group of segments and often result from chronic poor posture. These dysfunctions typically affect the larger, long-supportive muscles of the back, like the erector spinae, and are usually positioned neutrally but with rotation and side bending in opposite directions. On the other hand, Type 2 dysfunctions are often more acutely tender and affect the smaller supportive muscles between segments, such as the rotatores, multifidus, interspinales, and intertransversarii muscles. Type 2 dysfunctions are typically characterized by flexion or extension, side bending, and rotation in the same direction. [10] [11]"}
+{"id": "article-102953_13", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Indications", "content": "MET\u00a0with post-isometric relaxation is indicated in somatic dysfunction as long as there are no contraindications. If a muscle is painful, it may be a better candidate for MET with reciprocal inhibition. MET\u00a0with post-isometric relaxation is indicated for the treatment of somatic dysfunction in the thoracic spine resulting in, but not limited to: Back pain [12] Decreased range of motion [13] Respiratory dysfunction", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Indications. MET\u00a0with post-isometric relaxation is indicated in somatic dysfunction as long as there are no contraindications. If a muscle is painful, it may be a better candidate for MET with reciprocal inhibition. MET\u00a0with post-isometric relaxation is indicated for the treatment of somatic dysfunction in the thoracic spine resulting in, but not limited to: Back pain [12] Decreased range of motion [13] Respiratory dysfunction"}
+{"id": "article-102953_14", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Contraindications", "content": "MET\u00a0with post-isometric relaxation is contraindicated in patients with an acute fracture or dislocation. Those with tissue damage to ligaments, tendons, and muscles may not be the best candidates. It\u00a0is best to wait for vital stability before trying this technique. If muscle spasm is centrally mediated,\u00a0patients will also not respond well to MET. Patients need to be cooperative to follow the instructions required for this technique.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Contraindications. MET\u00a0with post-isometric relaxation is contraindicated in patients with an acute fracture or dislocation. Those with tissue damage to ligaments, tendons, and muscles may not be the best candidates. It\u00a0is best to wait for vital stability before trying this technique. If muscle spasm is centrally mediated,\u00a0patients will also not respond well to MET. Patients need to be cooperative to follow the instructions required for this technique."}
+{"id": "article-102953_15", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Equipment", "content": "MET\u00a0with post-isometric relaxation is a hands-on osteopathic manipulative treatment that necessitates a stable, firm surface, preferably an adjustable height cushioned table for optimal treatment positioning and patient and physician comfort", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Equipment. MET\u00a0with post-isometric relaxation is a hands-on osteopathic manipulative treatment that necessitates a stable, firm surface, preferably an adjustable height cushioned table for optimal treatment positioning and patient and physician comfort"}
+{"id": "article-102953_16", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Personnel", "content": "MET\u00a0with post-isometric relaxation requires a\u00a0qualified provider trained in muscle energy techniques.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Personnel. MET\u00a0with post-isometric relaxation requires a\u00a0qualified provider trained in muscle energy techniques."}
+{"id": "article-102953_17", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Preparation", "content": "After thoroughly discussing the risks, benefits, and alternative treatment options, obtaining informed patient consent is imperative for any procedure, including MET and\u00a0osteopathic manipulative therapy. Before initiating physical contact with the patient, the provider should clearly explain the procedures they will perform. The treatment process commences with a comprehensive static and dynamic evaluation of the segments within the thoracic spine. Clinicians may employ soft tissue techniques as a prelude to direct techniques like MET\u00a0with post-isometric relaxation, particularly when significant muscle texture changes are present. [14]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Preparation. After thoroughly discussing the risks, benefits, and alternative treatment options, obtaining informed patient consent is imperative for any procedure, including MET and\u00a0osteopathic manipulative therapy. Before initiating physical contact with the patient, the provider should clearly explain the procedures they will perform. The treatment process commences with a comprehensive static and dynamic evaluation of the segments within the thoracic spine. Clinicians may employ soft tissue techniques as a prelude to direct techniques like MET\u00a0with post-isometric relaxation, particularly when significant muscle texture changes are present. [14]"}
+{"id": "article-102953_18", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Technique or Treatment", "content": "The targetted segment must be localized and isolated when treating the thoracic spine with MET. In the upper thoracic spine (T1-T4),\u00a0it is common to use the head and neck as a lever.\u00a0The lower thoracic spine segments (T5-T12) can be localized by manipulating the position of the patient's trunk.\u00a0Localizing the dysfunctional segment involves monitoring the posterior transverse process for motion throughout the treatment through palpation. Post-isometric relaxation is the type of MET most commonly used. The patient is placed into the barrier and asked to resist motion toward freedom.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Technique or Treatment. The targetted segment must be localized and isolated when treating the thoracic spine with MET. In the upper thoracic spine (T1-T4),\u00a0it is common to use the head and neck as a lever.\u00a0The lower thoracic spine segments (T5-T12) can be localized by manipulating the position of the patient's trunk.\u00a0Localizing the dysfunctional segment involves monitoring the posterior transverse process for motion throughout the treatment through palpation. Post-isometric relaxation is the type of MET most commonly used. The patient is placed into the barrier and asked to resist motion toward freedom."}
+{"id": "article-102953_19", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Technique or Treatment -- Muscle Energy Technique With Post-Isometric Relaxation", "content": "Example Osteopathic Diagnosis: T3 flexed, rotated right, and sidebent right.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Technique or Treatment -- Muscle Energy Technique With Post-Isometric Relaxation. Example Osteopathic Diagnosis: T3 flexed, rotated right, and sidebent right."}
+{"id": "article-102953_20", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Technique or Treatment -- Muscle Energy Technique With Post-Isometric Relaxation", "content": "Step 1. The treatment can be\u00a0performed with the patient\u00a0either seated or supine. In the seated approach, the patient sits, and the clinician stands behind the patient. As this is an upper thoracic segment, the head will be used as a lever to affect motion on T3. The right hand will monitor the transverse process of T3.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Technique or Treatment -- Muscle Energy Technique With Post-Isometric Relaxation. Step 1. The treatment can be\u00a0performed with the patient\u00a0either seated or supine. In the seated approach, the patient sits, and the clinician stands behind the patient. As this is an upper thoracic segment, the head will be used as a lever to affect motion on T3. The right hand will monitor the transverse process of T3."}
+{"id": "article-102953_21", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Technique or Treatment -- Muscle Energy Technique With Post-Isometric Relaxation", "content": "Step 2. The clinician extends the\u00a0patient's head, side bends, and rotates it to the left until motion can be felt at T3 to engage the barrier. It is essential to position the patient in a way that engages the articular barrier, not just causing fascial tightening.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Technique or Treatment -- Muscle Energy Technique With Post-Isometric Relaxation. Step 2. The clinician extends the\u00a0patient's head, side bends, and rotates it to the left until motion can be felt at T3 to engage the barrier. It is essential to position the patient in a way that engages the articular barrier, not just causing fascial tightening."}
+{"id": "article-102953_22", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Technique or Treatment -- Muscle Energy Technique With Post-Isometric Relaxation", "content": "Step 3. The patient is instructed to gently but continuously attempt to return his head to an upright, neutral position while the clinician applies an equal counterforce. This position is maintained for 3\u00a0to 5 seconds before instructing the patient to relax and remain in place. The patient must stay relaxed for 3\u00a0to 5 seconds before engaging a new barrier. By alternating the contraction and relaxation before engaging a new barrier, the Golgi tendon fibers and muscle spindle fibers are engaged to allow for the lengthening of the agonist muscle and relaxation of the antagonist muscle.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Technique or Treatment -- Muscle Energy Technique With Post-Isometric Relaxation. Step 3. The patient is instructed to gently but continuously attempt to return his head to an upright, neutral position while the clinician applies an equal counterforce. This position is maintained for 3\u00a0to 5 seconds before instructing the patient to relax and remain in place. The patient must stay relaxed for 3\u00a0to 5 seconds before engaging a new barrier. By alternating the contraction and relaxation before engaging a new barrier, the Golgi tendon fibers and muscle spindle fibers are engaged to allow for the lengthening of the agonist muscle and relaxation of the antagonist muscle."}
+{"id": "article-102953_23", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Technique or Treatment -- Muscle Energy Technique With Post-Isometric Relaxation", "content": "Step 4. Repeat the previous step 3 to 5 times\u00a0with a passive stretch into the restrictive barrier with no patient involvement following the final round of treatment. Passively return the patient to a neutral position. Step 6. Reassess for improvement in symmetry of the treated segment by palpating the transverse processes of T3 for the example given.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Technique or Treatment -- Muscle Energy Technique With Post-Isometric Relaxation. Step 4. Repeat the previous step 3 to 5 times\u00a0with a passive stretch into the restrictive barrier with no patient involvement following the final round of treatment. Passively return the patient to a neutral position. Step 6. Reassess for improvement in symmetry of the treated segment by palpating the transverse processes of T3 for the example given."}
+{"id": "article-102953_24", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Technique or Treatment -- Technical Pearls", "content": "When treating the lower thoracic segment, it\u00a0is easier to maneuver the patient around if\u00a0her arms are crossed and the clinician sidebends\u00a0her by pushing down on the ipsilateral shoulder using the\u00a0axilla. When treating type 1 somatic dysfunctions (eg, T3-6 neutral, side bent right, and rotated left), the curve's apex is treated first.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Technique or Treatment -- Technical Pearls. When treating the lower thoracic segment, it\u00a0is easier to maneuver the patient around if\u00a0her arms are crossed and the clinician sidebends\u00a0her by pushing down on the ipsilateral shoulder using the\u00a0axilla. When treating type 1 somatic dysfunctions (eg, T3-6 neutral, side bent right, and rotated left), the curve's apex is treated first."}
+{"id": "article-102953_25", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Technique or Treatment -- Technical Pearls", "content": "T12 is challenging to treat as the facets below and above face in different directions. The thoracic facets of the vertebrae face posteriorly, upwards, and laterally. However, lumbar facet joints (L1) face posteriorly, upward, and medially. When using MET, it is essential to localize precisely.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Technique or Treatment -- Technical Pearls. T12 is challenging to treat as the facets below and above face in different directions. The thoracic facets of the vertebrae face posteriorly, upwards, and laterally. However, lumbar facet joints (L1) face posteriorly, upward, and medially. When using MET, it is essential to localize precisely."}
+{"id": "article-102953_26", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Complications", "content": "Patients undergoing MET\u00a0with post-isometric relaxation treatment should understand they may experience muscle soreness and fatigue after treatment. The clinician may suggest increasing water intake following treatment. Excessive force can result in complications such as tendon avulsion or rib fracture. To mitigate the force in post-isometric relaxation, the patient must be asked to resist just enough to engage the treated segment.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Complications. Patients undergoing MET\u00a0with post-isometric relaxation treatment should understand they may experience muscle soreness and fatigue after treatment. The clinician may suggest increasing water intake following treatment. Excessive force can result in complications such as tendon avulsion or rib fracture. To mitigate the force in post-isometric relaxation, the patient must be asked to resist just enough to engage the treated segment."}
+{"id": "article-102953_27", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Clinical Significance", "content": "Somatic dysfunction of the thoracic spine commonly results in back pain and discomfort, causing patients to seek medical advice.\u00a0Osteopathic techniques, including MET, provide a conservative, nonpharmacological avenue for alleviating pain and correcting musculoskeletal somatic dysfunctions in the thoracic spine, leading to an increased range of motion in affected joints. [3] [15]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Clinical Significance. Somatic dysfunction of the thoracic spine commonly results in back pain and discomfort, causing patients to seek medical advice.\u00a0Osteopathic techniques, including MET, provide a conservative, nonpharmacological avenue for alleviating pain and correcting musculoskeletal somatic dysfunctions in the thoracic spine, leading to an increased range of motion in affected joints. [3] [15]"}
+{"id": "article-102953_28", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Clinical Significance", "content": "MET\u00a0with post-isometric relaxation creates necessary soft tissue relaxation to help with high-velocity, low-amplitude techniques.\u00a0MET can also help resolve hypertonic tissue before myofascial release techniques.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Clinical Significance. MET\u00a0with post-isometric relaxation creates necessary soft tissue relaxation to help with high-velocity, low-amplitude techniques.\u00a0MET can also help resolve hypertonic tissue before myofascial release techniques."}
+{"id": "article-102953_29", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Enhancing Healthcare Team Outcomes", "content": "Understanding of osteopathic medicine has grown as more osteopathic physicians practice in the United States. However, many patients and healthcare workers remain unfamiliar with\u00a0MET\u00a0and\u00a0its role in medicine. The patient's active involvement in the contraction and relaxation phases, along with precise positioning, contributes to successful MET\u00a0with post-isometric relaxation treatment. Understanding the roles of MET\u00a0with post-isometric relaxation and osteopathic manipulative treatment in symptom management is essential for healthcare teams, as they can offer safe and effective relief for patients when administered by skilled providers in appropriate situations.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Enhancing Healthcare Team Outcomes. Understanding of osteopathic medicine has grown as more osteopathic physicians practice in the United States. However, many patients and healthcare workers remain unfamiliar with\u00a0MET\u00a0and\u00a0its role in medicine. The patient's active involvement in the contraction and relaxation phases, along with precise positioning, contributes to successful MET\u00a0with post-isometric relaxation treatment. Understanding the roles of MET\u00a0with post-isometric relaxation and osteopathic manipulative treatment in symptom management is essential for healthcare teams, as they can offer safe and effective relief for patients when administered by skilled providers in appropriate situations."}
+{"id": "article-102953_30", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure With Post-Isometric Relaxation - Thoracic Vertebrae -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

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+{"id": "article-102954_0", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Continuing Education Activity", "content": "Osteopathic manipulative treatment, or OMT for short, is a technique by which osteopathic physicians have used their hands to diagnose and treat numerous health conditions for years. This type of hands-on treatment has helped reduce the number of pain medications patients may need for a musculoskeletal injury. High velocity-low amplitude, or HVLA for short, is a type of manipulation in which the provider provides a rapid (high velocity) therapeutic force of brief duration that travels a short distance (low amplitude) within the anatomic range of motion of a joint and engages a restrictive barrier in one or more planes of motion to elicit the release of restriction. This activity describes the mechanics of thoracic HVLA and highlights the role of the healthcare team in evaluating and treating this condition.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Continuing Education Activity. Osteopathic manipulative treatment, or OMT for short, is a technique by which osteopathic physicians have used their hands to diagnose and treat numerous health conditions for years. This type of hands-on treatment has helped reduce the number of pain medications patients may need for a musculoskeletal injury. High velocity-low amplitude, or HVLA for short, is a type of manipulation in which the provider provides a rapid (high velocity) therapeutic force of brief duration that travels a short distance (low amplitude) within the anatomic range of motion of a joint and engages a restrictive barrier in one or more planes of motion to elicit the release of restriction. This activity describes the mechanics of thoracic HVLA and highlights the role of the healthcare team in evaluating and treating this condition."}
+{"id": "article-102954_1", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Continuing Education Activity", "content": "Objectives: Describe the neurophysiologic mechanisms of HVLA. Identify the indications/contraindications of HVLA treatment. Outline the steps in performing HVLA on the thoracic spine. Summarize the importance of collaboration and communication amongst the interprofessional team to improve outcomes for patients receiving thoracic HVLA. Access free multiple choice questions on this topic.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Continuing Education Activity. Objectives: Describe the neurophysiologic mechanisms of HVLA. Identify the indications/contraindications of HVLA treatment. Outline the steps in performing HVLA on the thoracic spine. Summarize the importance of collaboration and communication amongst the interprofessional team to improve outcomes for patients receiving thoracic HVLA. Access free multiple choice questions on this topic."}
+{"id": "article-102954_2", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Introduction", "content": "Osteopathic manipulative treatment, or OMT for short, is a\u00a0technique where\u00a0osteopathic physicians have\u00a0used their\u00a0hands to diagnose and treat numerous health conditions for years. This type of hands-on treatment has helped reduce the number of pain medications patients may need for a musculoskeletal injury. High velocity-low amplitude, or HVLA for short, is a type of manipulation in which the provider provides a rapid (high velocity) therapeutic force of brief duration that travels a short distance (low amplitude) within the anatomic range of motion of a joint and engages a restrictive barrier in one or more planes of motion to elicit the release of restriction. This article describes the mechanics of thoracic HVLA and highlights the role of the healthcare team in evaluating and treating this condition.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Introduction. Osteopathic manipulative treatment, or OMT for short, is a\u00a0technique where\u00a0osteopathic physicians have\u00a0used their\u00a0hands to diagnose and treat numerous health conditions for years. This type of hands-on treatment has helped reduce the number of pain medications patients may need for a musculoskeletal injury. High velocity-low amplitude, or HVLA for short, is a type of manipulation in which the provider provides a rapid (high velocity) therapeutic force of brief duration that travels a short distance (low amplitude) within the anatomic range of motion of a joint and engages a restrictive barrier in one or more planes of motion to elicit the release of restriction. This article describes the mechanics of thoracic HVLA and highlights the role of the healthcare team in evaluating and treating this condition."}
+{"id": "article-102954_3", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Introduction", "content": "High velocity, low amplitude manipulation is a common treatment used most often when patients are experiencing pain or loss of joint motion. The most commonly taught method of thoracic HVLA is the \"Kirksville Crunch.\" This method is widely known in the osteopathic community and effectively treats most thoracic joint somatic dysfunctions. It is important to learn this technique as well as its alternatives if a patient is unable to be manipulated using one particular method. Learning how to perform effective thoracic HVLA is essential to the practicing osteopathic physician as it will help improve patient satisfaction by providing immediate results. Additionally, treating a musculoskeletal ailment with thoracic HVLA will decrease the number of pain medications prescribed to the patient. [1]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Introduction. High velocity, low amplitude manipulation is a common treatment used most often when patients are experiencing pain or loss of joint motion. The most commonly taught method of thoracic HVLA is the \"Kirksville Crunch.\" This method is widely known in the osteopathic community and effectively treats most thoracic joint somatic dysfunctions. It is important to learn this technique as well as its alternatives if a patient is unable to be manipulated using one particular method. Learning how to perform effective thoracic HVLA is essential to the practicing osteopathic physician as it will help improve patient satisfaction by providing immediate results. Additionally, treating a musculoskeletal ailment with thoracic HVLA will decrease the number of pain medications prescribed to the patient. [1]"}
+{"id": "article-102954_4", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Anatomy and Physiology", "content": "Four major tenets that serve to guide the osteopathic physician are important in understanding the goals of HVLA treatment. They are (1) the body is a unit; a person is a unit combining body, mind, and spirit, (2) the body possesses the capability of self-healing, self-regulation, and maintenance, (3) structure and function are inter-related, (4) rational treatment is based upon an understanding of the other three tenets. When performing any osteopathic manipulation on a patient, it is crucial to keep these tenets in mind. Osteopathic physicians receive specialized training in using manipulation, and it is vitally important to understand the anatomy and physiology behind these maneuvers before performing them on patients. [2]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Anatomy and Physiology. Four major tenets that serve to guide the osteopathic physician are important in understanding the goals of HVLA treatment. They are (1) the body is a unit; a person is a unit combining body, mind, and spirit, (2) the body possesses the capability of self-healing, self-regulation, and maintenance, (3) structure and function are inter-related, (4) rational treatment is based upon an understanding of the other three tenets. When performing any osteopathic manipulation on a patient, it is crucial to keep these tenets in mind. Osteopathic physicians receive specialized training in using manipulation, and it is vitally important to understand the anatomy and physiology behind these maneuvers before performing them on patients. [2]"}
+{"id": "article-102954_5", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Anatomy and Physiology", "content": "High velocity, low amplitude (HVLA) is a treatment modality utilized by many practitioners for the treatment of many different somatic dysfunctions. Thoracic HVLA specifically focuses\u00a0on restoring structure and function to the thoracic spine. The thoracic spine is a unique segment of the spine as each vertebra is attached to a pair of ribs and is responsible for anchoring the rib cage.\u00a0Fryette's Laws can describe somatic dysfunctions of the thoracic spine. Both type I and type II segment somatic dysfunctions can be effectively treated with thoracic HVLA if indicated. Often, one of the transverse processes on an affected thoracic segment is oriented posteriorly, and, when palpated, the patient reports pain in that area. The somatic dysfunction is then elicited by having the patient flex and extend at the affected segment and determining how the posterior transverse process reacts. [3]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Anatomy and Physiology. High velocity, low amplitude (HVLA) is a treatment modality utilized by many practitioners for the treatment of many different somatic dysfunctions. Thoracic HVLA specifically focuses\u00a0on restoring structure and function to the thoracic spine. The thoracic spine is a unique segment of the spine as each vertebra is attached to a pair of ribs and is responsible for anchoring the rib cage.\u00a0Fryette's Laws can describe somatic dysfunctions of the thoracic spine. Both type I and type II segment somatic dysfunctions can be effectively treated with thoracic HVLA if indicated. Often, one of the transverse processes on an affected thoracic segment is oriented posteriorly, and, when palpated, the patient reports pain in that area. The somatic dysfunction is then elicited by having the patient flex and extend at the affected segment and determining how the posterior transverse process reacts. [3]"}
+{"id": "article-102954_6", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Anatomy and Physiology", "content": "From a physiological standpoint, there are some theories\u00a0regarding why HVLA is an effective form of treatment. First, an HVLA thrust appears to stretch a contracted muscle, which, in turn, produces several afferent impulses from the muscle spindles to the central nervous system. The central nervous system then reflexively sends an inhibitory impulse to the muscle spindle to relax the muscle. An alternative theory suggests that instead of the muscle spindle, the Golgi tendon receptors become activated, ultimately relaxing the muscle. [4] [5]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Anatomy and Physiology. From a physiological standpoint, there are some theories\u00a0regarding why HVLA is an effective form of treatment. First, an HVLA thrust appears to stretch a contracted muscle, which, in turn, produces several afferent impulses from the muscle spindles to the central nervous system. The central nervous system then reflexively sends an inhibitory impulse to the muscle spindle to relax the muscle. An alternative theory suggests that instead of the muscle spindle, the Golgi tendon receptors become activated, ultimately relaxing the muscle. [4] [5]"}
+{"id": "article-102954_7", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Indications", "content": "Indications for thoracic HVLA include the following: Palpable somatic dysfunction of a joint in the thoracic spine Firm distinct restrictive barrier Pain [6] Loss of range of motion", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Indications. Indications for thoracic HVLA include the following: Palpable somatic dysfunction of a joint in the thoracic spine Firm distinct restrictive barrier Pain [6] Loss of range of motion"}
+{"id": "article-102954_8", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Contraindications", "content": "There are several absolute and relative contraindications that the practitioner should be aware of before initiating thoracic HVLA treatment on a patient. [7]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Contraindications. There are several absolute and relative contraindications that the practitioner should be aware of before initiating thoracic HVLA treatment on a patient. [7]"}
+{"id": "article-102954_9", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Contraindications -- Absolute Contraindications", "content": "Bony compromise (tumor, infection, trauma, inflammation) Neurological issues (acute myelopathy, spinal cord compression, cauda equina syndrome, nerve root compression) Vascular compromise (vertebrobasilar insufficiency or cervical artery abnormalities, aortic aneurysm, angina pectoris, acute abdominal pain with guarding) Increased risk of harm to the patient (lack of diagnosis, lack of skill/expertise by the clinician, lack of consent from the patient)", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Contraindications -- Absolute Contraindications. Bony compromise (tumor, infection, trauma, inflammation) Neurological issues (acute myelopathy, spinal cord compression, cauda equina syndrome, nerve root compression) Vascular compromise (vertebrobasilar insufficiency or cervical artery abnormalities, aortic aneurysm, angina pectoris, acute abdominal pain with guarding) Increased risk of harm to the patient (lack of diagnosis, lack of skill/expertise by the clinician, lack of consent from the patient)"}
+{"id": "article-102954_10", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Contraindications -- Relative Contraindications", "content": "Hypermobility Serious kyphosis or scoliosis Disc herniation or disc protrusion Systemic infection Serious degenerative joint disease Adverse reaction to previous HVLA manipulation The clinician should perform a thorough history and physical examination before any osteopathic manipulative treatment.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Contraindications -- Relative Contraindications. Hypermobility Serious kyphosis or scoliosis Disc herniation or disc protrusion Systemic infection Serious degenerative joint disease Adverse reaction to previous HVLA manipulation The clinician should perform a thorough history and physical examination before any osteopathic manipulative treatment."}
+{"id": "article-102954_11", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Equipment", "content": "Equipment required for this procedure includes an OMT or a massage table on which the patient can sit or lie down.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Equipment. Equipment required for this procedure includes an OMT or a massage table on which the patient can sit or lie down."}
+{"id": "article-102954_12", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Personnel", "content": "A patient who has given consent and an osteopathic physician who has had formal training in OMT during medical school or post-graduate training are necessary for this procedure.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Personnel. A patient who has given consent and an osteopathic physician who has had formal training in OMT during medical school or post-graduate training are necessary for this procedure."}
+{"id": "article-102954_13", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Preparation", "content": "The physician must obtain informed consent from the patient before proceeding with intervention. A clear discussion with the patient of the risks, benefits, and alternative treatment options should be documented prior to starting treatment. Additionally, a complete osteopathic structural exam of the thoracic spine should occur before beginning the procedure.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Preparation. The physician must obtain informed consent from the patient before proceeding with intervention. A clear discussion with the patient of the risks, benefits, and alternative treatment options should be documented prior to starting treatment. Additionally, a complete osteopathic structural exam of the thoracic spine should occur before beginning the procedure."}
+{"id": "article-102954_14", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Technique or Treatment", "content": "Two main thoracic HVLA techniques are performable on a patient with a thoracic somatic dysfunction. There is the seated method and the supine method (also called Kirksville Crunch). Descriptions of both techniques will follow, but it is ultimately provider preference and overall comfort level, which\u00a0will ultimately\u00a0dictate the choice of the technique. [8]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Technique or Treatment. Two main thoracic HVLA techniques are performable on a patient with a thoracic somatic dysfunction. There is the seated method and the supine method (also called Kirksville Crunch). Descriptions of both techniques will follow, but it is ultimately provider preference and overall comfort level, which\u00a0will ultimately\u00a0dictate the choice of the technique. [8]"}
+{"id": "article-102954_15", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Technique or Treatment", "content": "After diagnosing somatic dysfunction, the physician will position the dysfunctional segment such that all restrictive barriers are engaged. This process occurs by reversing all three planes of motion of the dysfunctional segment. For example, if the thoracic segment T7 has demonstrated the somatic dysfunction ERSr (extended, rotated, and side-bent right), then the segment would be placed in flexion, rotated, and side-bent to the left until motion is felt; this is called the restrictive barrier. A short quick thrust is then applied, and the patient then undergoes reassessment. There are two different variations to performing thoracic HVLA: seated and supine. The steps for performing these various maneuvers appear below.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Technique or Treatment. After diagnosing somatic dysfunction, the physician will position the dysfunctional segment such that all restrictive barriers are engaged. This process occurs by reversing all three planes of motion of the dysfunctional segment. For example, if the thoracic segment T7 has demonstrated the somatic dysfunction ERSr (extended, rotated, and side-bent right), then the segment would be placed in flexion, rotated, and side-bent to the left until motion is felt; this is called the restrictive barrier. A short quick thrust is then applied, and the patient then undergoes reassessment. There are two different variations to performing thoracic HVLA: seated and supine. The steps for performing these various maneuvers appear below."}
+{"id": "article-102954_16", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Technique or Treatment -- Seated Position Technique", "content": "The clinician stands behind the patient with their hands clasped behind their head. The clinician places their epigastric area behind the posterior transverse process of the dysfunctional segment. The clinician reaches under the patient's arms and holds the forearms. The patient is then instructed to take a deep breath, and during exhalation, the clinician pulls the elbows together and extends the trunk. The clinician should then push their abdomen into the posterior transverse process. At maximal exhalation, a short quick thrust is applied by the clinician's abdomen into the patient's posterior transverse process. The patient should then be rechecked after the manipulation.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Technique or Treatment -- Seated Position Technique. The clinician stands behind the patient with their hands clasped behind their head. The clinician places their epigastric area behind the posterior transverse process of the dysfunctional segment. The clinician reaches under the patient's arms and holds the forearms. The patient is then instructed to take a deep breath, and during exhalation, the clinician pulls the elbows together and extends the trunk. The clinician should then push their abdomen into the posterior transverse process. At maximal exhalation, a short quick thrust is applied by the clinician's abdomen into the patient's posterior transverse process. The patient should then be rechecked after the manipulation."}
+{"id": "article-102954_17", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Technique or Treatment -- Supine Position Technique (so-called \"Kirksville Crunch\")", "content": "The clinician stands opposite the side of the thoracic rotation.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Technique or Treatment -- Supine Position Technique (so-called \"Kirksville Crunch\"). The clinician stands opposite the side of the thoracic rotation."}
+{"id": "article-102954_18", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Technique or Treatment -- Supine Position Technique (so-called \"Kirksville Crunch\")", "content": "The patient crosses their arms with elbows together. From the clinician's perspective, the patient's arm opposite where they are standing should be on top; this is referred to as opposite over adjacent. From the patient's perspective, the arm on the side of the thoracic rotation should be on top. For example, if the patient has a somatic dysfunction at T5 that is flexed, rotated, and side-bent to the right, the patient's right arm would be on top of the left arm.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Technique or Treatment -- Supine Position Technique (so-called \"Kirksville Crunch\"). The patient crosses their arms with elbows together. From the clinician's perspective, the patient's arm opposite where they are standing should be on top; this is referred to as opposite over adjacent. From the patient's perspective, the arm on the side of the thoracic rotation should be on top. For example, if the patient has a somatic dysfunction at T5 that is flexed, rotated, and side-bent to the right, the patient's right arm would be on top of the left arm."}
+{"id": "article-102954_19", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Technique or Treatment -- Supine Position Technique (so-called \"Kirksville Crunch\")", "content": "The clinician reaches their caudad arm across the patient and places their thenar eminence behind the posterior transverse process.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Technique or Treatment -- Supine Position Technique (so-called \"Kirksville Crunch\"). The clinician reaches their caudad arm across the patient and places their thenar eminence behind the posterior transverse process."}
+{"id": "article-102954_20", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Technique or Treatment -- Supine Position Technique (so-called \"Kirksville Crunch\")", "content": "The clinician leans their epigastric area into the patient's crossed elbows. The clinician's other hand then lifts the patient's head and trunk until pressure from leaning on the elbows is felt by the hand on the posterior transverse process.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Technique or Treatment -- Supine Position Technique (so-called \"Kirksville Crunch\"). The clinician leans their epigastric area into the patient's crossed elbows. The clinician's other hand then lifts the patient's head and trunk until pressure from leaning on the elbows is felt by the hand on the posterior transverse process."}
+{"id": "article-102954_21", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Technique or Treatment -- Supine Position Technique (so-called \"Kirksville Crunch\")", "content": "The patient is asked to take a deep breath as the clinician leans into the elbows during exhalation.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Technique or Treatment -- Supine Position Technique (so-called \"Kirksville Crunch\"). The patient is asked to take a deep breath as the clinician leans into the elbows during exhalation."}
+{"id": "article-102954_22", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Technique or Treatment -- Supine Position Technique (so-called \"Kirksville Crunch\")", "content": "At maximum exhalation, the clinician applies a short quick thrust from their abdomen onto the patient's elbows to mobilize the joint. The patient should then be rechecked after the manipulation.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Technique or Treatment -- Supine Position Technique (so-called \"Kirksville Crunch\"). At maximum exhalation, the clinician applies a short quick thrust from their abdomen onto the patient's elbows to mobilize the joint. The patient should then be rechecked after the manipulation."}
+{"id": "article-102954_23", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Complications", "content": "Aside from some muscular soreness or possible symptom exacerbation, there are relatively few side effects of HVLA in the thoracic region. There are more serious side effects if performing HVLA in the cervical or lumbar region, but these are outside of the scope of this article. [9]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Complications. Aside from some muscular soreness or possible symptom exacerbation, there are relatively few side effects of HVLA in the thoracic region. There are more serious side effects if performing HVLA in the cervical or lumbar region, but these are outside of the scope of this article. [9]"}
+{"id": "article-102954_24", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Clinical Significance", "content": "Back pain is a very common problem seen in many primary care offices and ERs. Usually, back pain is musculoskeletal, caused by turning, twisting, pulling, or lifting incorrectly. Many times these patients are amenable to some hands-on treatment as opposed to taking medication. Osteopathic physicians have received training in these special hands-on procedures, which can help with back pain. These include counter strain, kneading, and stretching techniques, muscle energy, and HVLA.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Clinical Significance. Back pain is a very common problem seen in many primary care offices and ERs. Usually, back pain is musculoskeletal, caused by turning, twisting, pulling, or lifting incorrectly. Many times these patients are amenable to some hands-on treatment as opposed to taking medication. Osteopathic physicians have received training in these special hands-on procedures, which can help with back pain. These include counter strain, kneading, and stretching techniques, muscle energy, and HVLA."}
+{"id": "article-102954_25", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Clinical Significance", "content": "Many factors account for which procedure the practitioner chooses, but it is most often based on provider comfort and preference, as well as if the patient is willing and able to receive treatment. Thoracic HVLA is an important method of OMT in the osteopathic physician's toolkit as it can serve to treat musculoskeletal ailments while concurrently allowing for a reduction in the number of NSAIDs or other pain medication that a patient may be taking. [1] [10]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Clinical Significance. Many factors account for which procedure the practitioner chooses, but it is most often based on provider comfort and preference, as well as if the patient is willing and able to receive treatment. Thoracic HVLA is an important method of OMT in the osteopathic physician's toolkit as it can serve to treat musculoskeletal ailments while concurrently allowing for a reduction in the number of NSAIDs or other pain medication that a patient may be taking. [1] [10]"}
+{"id": "article-102954_26", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Enhancing Healthcare Team Outcomes", "content": "Osteopathic manipulative treatment is a form of hands-on therapy that, in the appropriate setting, can help to enhance patient-centered care and improve outcomes. HVLA is a specific treatment modality that is more suited for the younger population. Some of the contraindications mentioned previously occur more in the elderly population, thus not allowing them to receive HVLA treatment. It is crucial to weigh the risks and benefits of HVLA treatment in these patients before attempting this type of maneuver. Other, less forceful techniques such as counter strain, kneading and stretching, muscle energy, or articulatory techniques should merit consideration before HVLA. [11]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Enhancing Healthcare Team Outcomes. Osteopathic manipulative treatment is a form of hands-on therapy that, in the appropriate setting, can help to enhance patient-centered care and improve outcomes. HVLA is a specific treatment modality that is more suited for the younger population. Some of the contraindications mentioned previously occur more in the elderly population, thus not allowing them to receive HVLA treatment. It is crucial to weigh the risks and benefits of HVLA treatment in these patients before attempting this type of maneuver. Other, less forceful techniques such as counter strain, kneading and stretching, muscle energy, or articulatory techniques should merit consideration before HVLA. [11]"}
+{"id": "article-102954_27", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Enhancing Healthcare Team Outcomes", "content": "Regardless of treatment modality, osteopathic manipulative treatment serves as a manner\u00a0by which to reduce the number of pain medications a patient is taking. [1] [10] Overall, this can help improve patient outcomes by effectively reducing the number of pills a patient takes per day. Ideally, however, this helps patients stop an NSAID or an opioid medication completely.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Enhancing Healthcare Team Outcomes. Regardless of treatment modality, osteopathic manipulative treatment serves as a manner\u00a0by which to reduce the number of pain medications a patient is taking. [1] [10] Overall, this can help improve patient outcomes by effectively reducing the number of pills a patient takes per day. Ideally, however, this helps patients stop an NSAID or an opioid medication completely."}
+{"id": "article-102954_28", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

statpearls/chunk/article-102956.jsonl

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+{"id": "article-102956_0", "title": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Continuing Education Activity", "content": "This procedure outlines thoracic strain-counterstrain and functional positional release. These two indirect techniques are used for somatic dysfunctions of the thoracic spine. The primary indications for using these techniques are back/neck pain and patient intolerance to direct osteopathic techniques or techniques that require the patient to activate musculature. This activity highlights the role of the osteopathic clinician in evaluating and managing patients with musculoskeletal issues and somatic dysfunctions of the thoracic spine.", "contents": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Continuing Education Activity. This procedure outlines thoracic strain-counterstrain and functional positional release. These two indirect techniques are used for somatic dysfunctions of the thoracic spine. The primary indications for using these techniques are back/neck pain and patient intolerance to direct osteopathic techniques or techniques that require the patient to activate musculature. This activity highlights the role of the osteopathic clinician in evaluating and managing patients with musculoskeletal issues and somatic dysfunctions of the thoracic spine."}
+{"id": "article-102956_1", "title": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Continuing Education Activity", "content": "Objectives: Determine\u00a0the correct procedure for treating somatic dysfunctions of the thoracic spine with strain-counterstrain and functional position release. Assess\u00a0the indications/contraindications for treating somatic dysfunctions of the thoracic spine with strain-counterstrain and functional position release. Identify potential complications of strain-counterstrain and functional positional release on the thoracic spine. Communicate\u00a0the importance of improving care coordination to enhance the delivery of care for patients affected by thoracic segment somatic dysfunctions. Access free multiple choice questions on this topic.", "contents": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Continuing Education Activity. Objectives: Determine\u00a0the correct procedure for treating somatic dysfunctions of the thoracic spine with strain-counterstrain and functional position release. Assess\u00a0the indications/contraindications for treating somatic dysfunctions of the thoracic spine with strain-counterstrain and functional position release. Identify potential complications of strain-counterstrain and functional positional release on the thoracic spine. Communicate\u00a0the importance of improving care coordination to enhance the delivery of care for patients affected by thoracic segment somatic dysfunctions. Access free multiple choice questions on this topic."}
+{"id": "article-102956_2", "title": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Introduction", "content": "Upper back and neck pain caused by somatic dysfunctions of the thoracic spine are extremely common. Common causes include postural changes\u00a0and injuries. [1] [2] A viscerosomatic response can also cause somatic dysfunctions. For example, patients who present with chest pain may have an underlying cardiac issue and, therefore, might have a corresponding somatic dysfunction at the level of T1-T5 of the spine.", "contents": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Introduction. Upper back and neck pain caused by somatic dysfunctions of the thoracic spine are extremely common. Common causes include postural changes\u00a0and injuries. [1] [2] A viscerosomatic response can also cause somatic dysfunctions. For example, patients who present with chest pain may have an underlying cardiac issue and, therefore, might have a corresponding somatic dysfunction at the level of T1-T5 of the spine."}
+{"id": "article-102956_3", "title": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Introduction", "content": "There are a variety of osteopathic manipulative treatments (OMT) for somatic dysfunctions. Indirect osteopathic techniques can frequently treat dysfunctions. Strain-counterstrain (SCS) and Functional Positional Release (FPR) are\u00a0commonly used indirect techniques. These methods require the clinician to passively take the patient into a position of ease or away from the restrictive barrier. SCS involves placing the patient where the target muscle is shortened, which allows the vertebrae to return to its proper position. FPR uses components of SCS and a functional method with the addition of an activating force (compression or torsion). [3] We discuss these\u00a02 osteopathic techniques to treat somatic dysfunctions of the thoracic spine.", "contents": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Introduction. There are a variety of osteopathic manipulative treatments (OMT) for somatic dysfunctions. Indirect osteopathic techniques can frequently treat dysfunctions. Strain-counterstrain (SCS) and Functional Positional Release (FPR) are\u00a0commonly used indirect techniques. These methods require the clinician to passively take the patient into a position of ease or away from the restrictive barrier. SCS involves placing the patient where the target muscle is shortened, which allows the vertebrae to return to its proper position. FPR uses components of SCS and a functional method with the addition of an activating force (compression or torsion). [3] We discuss these\u00a02 osteopathic techniques to treat somatic dysfunctions of the thoracic spine."}
+{"id": "article-102956_4", "title": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Anatomy and Physiology", "content": "There are\u00a012 thoracic vertebrae in the spine, designated as T1-T12. [4] The thoracic vertebrae form a kyphotic curve. [5] It is essential to note the thoracic vertebrae provide attachment to the ribcage. [6] Injuries, specifically of or originating from the ribs, are a common cause of somatic dysfunctions of the thoracic vertebrae due to the articulation between the ribs and thoracic spine. [2] Because of costal facets, the thoracic vertebrae are unique compared to the cervical and lumbar vertebrae. [4]", "contents": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Anatomy and Physiology. There are\u00a012 thoracic vertebrae in the spine, designated as T1-T12. [4] The thoracic vertebrae form a kyphotic curve. [5] It is essential to note the thoracic vertebrae provide attachment to the ribcage. [6] Injuries, specifically of or originating from the ribs, are a common cause of somatic dysfunctions of the thoracic vertebrae due to the articulation between the ribs and thoracic spine. [2] Because of costal facets, the thoracic vertebrae are unique compared to the cervical and lumbar vertebrae. [4]"}
+{"id": "article-102956_5", "title": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Anatomy and Physiology", "content": "Each thoracic vertebra has\u00a06 facets to allow for articulation with the ribs. [4] T1, T11, and T12 are distinct from the other thoracic vertebrae. T1 is the only vertebrae where the entire costal facets provide articulation with rib 1, which has a very flat spinous process. [4] In contrast to the other thoracic vertebrae, T11 and T12 do not have facets on the transverse processes. [4]", "contents": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Anatomy and Physiology. Each thoracic vertebra has\u00a06 facets to allow for articulation with the ribs. [4] T1, T11, and T12 are distinct from the other thoracic vertebrae. T1 is the only vertebrae where the entire costal facets provide articulation with rib 1, which has a very flat spinous process. [4] In contrast to the other thoracic vertebrae, T11 and T12 do not have facets on the transverse processes. [4]"}
+{"id": "article-102956_6", "title": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Anatomy and Physiology", "content": "Lastly, T12 articulates with the lumbar spine at the level of L1. The thoracic vertebrae have several muscular attachments, including erector spinae, interspinales, intertransversarii, latissimus dorsi, multifidus, rhomboid major and minor, rotatores, semispinalis, serratus posterior superior and inferior, splenius capitis and cervicis, and trapezius. [4] The arterial supply of the thoracic spine is primarily from the posterior intercostal arteries, branches from the subclavian artery, and the thoracic aorta. [4] The venous supply is primarily from venous plexuses surrounding the vertebral canal. [4] The nervous supply of the thoracic vertebrae is supplied by the meningeal branches originating from spinal nerves. [4]", "contents": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Anatomy and Physiology. Lastly, T12 articulates with the lumbar spine at the level of L1. The thoracic vertebrae have several muscular attachments, including erector spinae, interspinales, intertransversarii, latissimus dorsi, multifidus, rhomboid major and minor, rotatores, semispinalis, serratus posterior superior and inferior, splenius capitis and cervicis, and trapezius. [4] The arterial supply of the thoracic spine is primarily from the posterior intercostal arteries, branches from the subclavian artery, and the thoracic aorta. [4] The venous supply is primarily from venous plexuses surrounding the vertebral canal. [4] The nervous supply of the thoracic vertebrae is supplied by the meningeal branches originating from spinal nerves. [4]"}
+{"id": "article-102956_7", "title": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Anatomy and Physiology", "content": "SCS and FPR use the body\u2019s intrinsic ability to relax. SCS involves neuromuscular activity between a muscle agonist and antagonist called the Proprioceptive Theory. [7] This theory is based on regulating muscle spindle activity. When lengthening the muscle spindle, there is increased muscle spindle activity and a reflexive muscle contraction, which decreases spindle discharge and reflexive contraction when the muscle shortens. [7] SCS passively shortens the dysfunctional agonist muscle for an extended period, returning the muscle spindle activity to normal. [8] Further studies on similar theories, such as proprioceptive neuromuscular facilitation, demonstrated this mechanism increases the range of motion by improving muscle elasticity. [9]", "contents": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Anatomy and Physiology. SCS and FPR use the body\u2019s intrinsic ability to relax. SCS involves neuromuscular activity between a muscle agonist and antagonist called the Proprioceptive Theory. [7] This theory is based on regulating muscle spindle activity. When lengthening the muscle spindle, there is increased muscle spindle activity and a reflexive muscle contraction, which decreases spindle discharge and reflexive contraction when the muscle shortens. [7] SCS passively shortens the dysfunctional agonist muscle for an extended period, returning the muscle spindle activity to normal. [8] Further studies on similar theories, such as proprioceptive neuromuscular facilitation, demonstrated this mechanism increases the range of motion by improving muscle elasticity. [9]"}
+{"id": "article-102956_8", "title": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Anatomy and Physiology", "content": "FPR is similar to SCS. The physiology behind FPR involves altering increased gamma motor neuron activity that affects the muscle spindle. [10] A reduction in the gamma motor neuron activity forces the lengthening of the extrafusal fibers to their relaxed state. [10]", "contents": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Anatomy and Physiology. FPR is similar to SCS. The physiology behind FPR involves altering increased gamma motor neuron activity that affects the muscle spindle. [10] A reduction in the gamma motor neuron activity forces the lengthening of the extrafusal fibers to their relaxed state. [10]"}
+{"id": "article-102956_9", "title": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Indications", "content": "Indications to perform SCS or FPR on a somatic dysfunction of the thoracic spine include an identified tender point associated with: Back pain Chest pain Neck pain Headache Joint hypo-mobility Fascial restrictions Muscle dysfunction or spasms in the localized area or the thoracic spine. [7]", "contents": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Indications. Indications to perform SCS or FPR on a somatic dysfunction of the thoracic spine include an identified tender point associated with: Back pain Chest pain Neck pain Headache Joint hypo-mobility Fascial restrictions Muscle dysfunction or spasms in the localized area or the thoracic spine. [7]"}
+{"id": "article-102956_10", "title": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Indications", "content": "Indications are also based on the patient\u2019s needs. If the patient is not able to activate their own muscles and needs more assistance from the clinician, both of these passive, indirect techniques are appropriate.", "contents": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Indications. Indications are also based on the patient\u2019s needs. If the patient is not able to activate their own muscles and needs more assistance from the clinician, both of these passive, indirect techniques are appropriate."}
+{"id": "article-102956_11", "title": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Contraindications", "content": "SCS and FPR are contraindicated in any patient who cannot give feedback to the clinician. [7] Contraindications of SCS and FPR include: Acute fracture Shoulder dislocation (specific to thoracic extension somatic dysfunctions)", "contents": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Contraindications. SCS and FPR are contraindicated in any patient who cannot give feedback to the clinician. [7] Contraindications of SCS and FPR include: Acute fracture Shoulder dislocation (specific to thoracic extension somatic dysfunctions)"}
+{"id": "article-102956_12", "title": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Equipment", "content": "Equipment needed for this procedure includes an exam table, OMT table, or massage table for the patient to sit or lay, and a stool for the clinician to sit.", "contents": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Equipment. Equipment needed for this procedure includes an exam table, OMT table, or massage table for the patient to sit or lay, and a stool for the clinician to sit."}
+{"id": "article-102956_13", "title": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Personnel", "content": "The osteopathic clinician is the only person required to perform these techniques correctly.", "contents": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Personnel. The osteopathic clinician is the only person required to perform these techniques correctly."}
+{"id": "article-102956_14", "title": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Preparation", "content": "The clinician should discuss the risks, benefits, and alternative treatment options and obtain informed consent from the patient. Evaluation of the thoracic spine is critical before treatment. Visual assessment, pain scale, muscle strength and range of motion, and identification of tender points (TP) and somatic dysfunction should all occur before initiating treatment.", "contents": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Preparation. The clinician should discuss the risks, benefits, and alternative treatment options and obtain informed consent from the patient. Evaluation of the thoracic spine is critical before treatment. Visual assessment, pain scale, muscle strength and range of motion, and identification of tender points (TP) and somatic dysfunction should all occur before initiating treatment."}
+{"id": "article-102956_15", "title": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Technique or Treatment", "content": "SCS and FPR are indirect techniques. Indirect techniques require the clinician to place the patient at ease, away from the restrictive barrier [11] .", "contents": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Technique or Treatment. SCS and FPR are indirect techniques. Indirect techniques require the clinician to place the patient at ease, away from the restrictive barrier [11] ."}
+{"id": "article-102956_16", "title": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Technique or Treatment", "content": "During SCS, the clinician first must locate a tender point (TP), sometimes called Jones tender points. For the thoracic spine, there are\u00a012 anterior (AT1-12),\u00a012 posterior (PT1-12), and 4\u00a0lateral (LAT5-8) tender points. Each TP corresponds to a thoracic vertebra; AT1 correlates with thoracic vertebrae T1.", "contents": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Technique or Treatment. During SCS, the clinician first must locate a tender point (TP), sometimes called Jones tender points. For the thoracic spine, there are\u00a012 anterior (AT1-12),\u00a012 posterior (PT1-12), and 4\u00a0lateral (LAT5-8) tender points. Each TP corresponds to a thoracic vertebra; AT1 correlates with thoracic vertebrae T1."}
+{"id": "article-102956_17", "title": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Technique or Treatment", "content": "For the anterior TPs 1-8, the patient\u00a0is supine, and the clinician\u00a0is seated at the head of the table. For AT 9-12, the patient will be supine, and the clinician will be standing on the side of the patient where the TP is. AT1 is located at the sternal notch. AT2-8 are all located below the sternal notch in a row down the sternum, ending at the xiphoid process. The clinician will modify the patient's position by flexing the patient's head towards the sternum. AT9 is located superior/laterally from the umbilicus, AT10-11 are located inferior/laterally from the umbilicus, and AT12 is located on the superior portion of the iliac crest.", "contents": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Technique or Treatment. For the anterior TPs 1-8, the patient\u00a0is supine, and the clinician\u00a0is seated at the head of the table. For AT 9-12, the patient will be supine, and the clinician will be standing on the side of the patient where the TP is. AT1 is located at the sternal notch. AT2-8 are all located below the sternal notch in a row down the sternum, ending at the xiphoid process. The clinician will modify the patient's position by flexing the patient's head towards the sternum. AT9 is located superior/laterally from the umbilicus, AT10-11 are located inferior/laterally from the umbilicus, and AT12 is located on the superior portion of the iliac crest."}
+{"id": "article-102956_18", "title": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Technique or Treatment", "content": "The clinician modifies the patient's position by flexing the patient's hips and knees and resting them on the clinician's leg, which should be positioned on the table. The clinician should then cross the patient's leg farther from the clinician over the patient's other leg to induce side bending and rotating away from the TP. The lateral TP's are located at the costal cartilages of the rib of the corresponding vertebrae. The patient is seated, and the clinician\u00a0is behind the patient with their leg on the table. The clinician\u00a0modifies the patient's position by rotating them towards the clinician's leg and away from the TP. The posterior TP's are located at the ends of the transverse processes of the corresponding vertebrae. The patient is prone, and the clinician stands on the TP's opposite side. For the upper TP's, modify by pulling the patient's shoulder back on the same side of the TP. For the lower TP's, modify by pulling the patient's pelvis back on the same side of the TP.", "contents": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Technique or Treatment. The clinician modifies the patient's position by flexing the patient's hips and knees and resting them on the clinician's leg, which should be positioned on the table. The clinician should then cross the patient's leg farther from the clinician over the patient's other leg to induce side bending and rotating away from the TP. The lateral TP's are located at the costal cartilages of the rib of the corresponding vertebrae. The patient is seated, and the clinician\u00a0is behind the patient with their leg on the table. The clinician\u00a0modifies the patient's position by rotating them towards the clinician's leg and away from the TP. The posterior TP's are located at the ends of the transverse processes of the corresponding vertebrae. The patient is prone, and the clinician stands on the TP's opposite side. For the upper TP's, modify by pulling the patient's shoulder back on the same side of the TP. For the lower TP's, modify by pulling the patient's pelvis back on the same side of the TP."}
+{"id": "article-102956_19", "title": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Technique or Treatment", "content": "After locating a TP, the clinician asks the patient how they rate their pain at the tender point on a scale of 1\u00a0to 10. The clinician modifies the patient's position based on the TP location until the patient reports their pain has decreased to a 3 out of 10 or less on the pain scale. Once the pain is reportedly a 3 out of 10 or less, the clinician holds the modified patient position for\u00a090 seconds. After\u00a090 seconds, the clinician passively returns the patient to neutral.", "contents": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Technique or Treatment. After locating a TP, the clinician asks the patient how they rate their pain at the tender point on a scale of 1\u00a0to 10. The clinician modifies the patient's position based on the TP location until the patient reports their pain has decreased to a 3 out of 10 or less on the pain scale. Once the pain is reportedly a 3 out of 10 or less, the clinician holds the modified patient position for\u00a090 seconds. After\u00a090 seconds, the clinician passively returns the patient to neutral."}
+{"id": "article-102956_20", "title": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Technique or Treatment", "content": "Before treating the thoracic spine with FPR, a diagnosis of the spine with Fryette's principles is necessary. Fryette's principle says that a group curve is neutral, rotated, and side bent in different directions (eg, T1-T3NRLSR). It also states that if a single vertebra is dysfunctional, it\u00a0is typically non-neutral (flexed or extended), rotated, and side bent to the same side (eg, T1FRLSL). Since FPR is indirect, place the patient away from the restrictive barrier or into the diagnosis.", "contents": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Technique or Treatment. Before treating the thoracic spine with FPR, a diagnosis of the spine with Fryette's principles is necessary. Fryette's principle says that a group curve is neutral, rotated, and side bent in different directions (eg, T1-T3NRLSR). It also states that if a single vertebra is dysfunctional, it\u00a0is typically non-neutral (flexed or extended), rotated, and side bent to the same side (eg, T1FRLSL). Since FPR is indirect, place the patient away from the restrictive barrier or into the diagnosis."}
+{"id": "article-102956_21", "title": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Technique or Treatment", "content": "The patient is seated, and the clinician is standing behind the patient. Have them sit as straight as possible to straighten the patient's thoracic kyphosis. Ask the patient to cross their arms. The clinician should place their forearm on the opposite shoulder to which the TP is located. The clinician's other hand should be monitoring the thoracic vertebrae of concern. Once the patient and clinician are in the correct position, induce the patient into their diagnosis and add a compressive force with the forearm resting on the patient's shoulder for 3\u00a0to 5 seconds.", "contents": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Technique or Treatment. The patient is seated, and the clinician is standing behind the patient. Have them sit as straight as possible to straighten the patient's thoracic kyphosis. Ask the patient to cross their arms. The clinician should place their forearm on the opposite shoulder to which the TP is located. The clinician's other hand should be monitoring the thoracic vertebrae of concern. Once the patient and clinician are in the correct position, induce the patient into their diagnosis and add a compressive force with the forearm resting on the patient's shoulder for 3\u00a0to 5 seconds."}
+{"id": "article-102956_22", "title": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Complications", "content": "SCS and FPR are safe, noninvasive techniques with no serious complications when performed appropriately. After treatment, patients may experience some minor muscle soreness, headache, and lightheadedness. Clinicians should caution their patients regarding soreness lasting 1 to 5 days after treatment.", "contents": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Complications. SCS and FPR are safe, noninvasive techniques with no serious complications when performed appropriately. After treatment, patients may experience some minor muscle soreness, headache, and lightheadedness. Clinicians should caution their patients regarding soreness lasting 1 to 5 days after treatment."}
+{"id": "article-102956_23", "title": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Clinical Significance", "content": "Neck and upper back pain from somatic dysfunctions of the thoracic spine are very common. However, there are limited non-pharmacologic treatment options. SCS and FPR are options that can provide immediate relief. Also, patients who see osteopathic clinicians will receive a holistic and whole-body approach to care. Clinicians treat the thoracic spine and any associated dysfunctions throughout the kinetic chain, including cervical, lumbar, pelvic, and sacral dysfunctions, leading to a better, longer-lasting treatment.", "contents": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Clinical Significance. Neck and upper back pain from somatic dysfunctions of the thoracic spine are very common. However, there are limited non-pharmacologic treatment options. SCS and FPR are options that can provide immediate relief. Also, patients who see osteopathic clinicians will receive a holistic and whole-body approach to care. Clinicians treat the thoracic spine and any associated dysfunctions throughout the kinetic chain, including cervical, lumbar, pelvic, and sacral dysfunctions, leading to a better, longer-lasting treatment."}
+{"id": "article-102956_24", "title": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Enhancing Healthcare Team Outcomes", "content": "Osteopathic manipulative treatment for somatic dysfunctions of the thoracic spine requires an interprofessional team. Without proper management, acute somatic dysfunctions of the thoracic spine can spiral into severe chronic issues.", "contents": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Enhancing Healthcare Team Outcomes. Osteopathic manipulative treatment for somatic dysfunctions of the thoracic spine requires an interprofessional team. Without proper management, acute somatic dysfunctions of the thoracic spine can spiral into severe chronic issues."}
+{"id": "article-102956_25", "title": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Enhancing Healthcare Team Outcomes", "content": "While the primary facilitator of treatment is the osteopathic clinician, a multidisciplinary and\u00a0holistic\u00a0approach is now preferred\u00a0requiring\u00a0several specialists.\u00a0In an osteopathic clinic, a resident or fellow clinician practicing neuromuscular medicine gathers information about the patient\u2019s medical, social, and family history and provides pertinent information to the\u00a0osteopathic clinician. They also assist the osteopathic clinician during the treatment while communicating effectively with the patient.", "contents": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Enhancing Healthcare Team Outcomes. While the primary facilitator of treatment is the osteopathic clinician, a multidisciplinary and\u00a0holistic\u00a0approach is now preferred\u00a0requiring\u00a0several specialists.\u00a0In an osteopathic clinic, a resident or fellow clinician practicing neuromuscular medicine gathers information about the patient\u2019s medical, social, and family history and provides pertinent information to the\u00a0osteopathic clinician. They also assist the osteopathic clinician during the treatment while communicating effectively with the patient."}
+{"id": "article-102956_26", "title": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Enhancing Healthcare Team Outcomes", "content": "A\u00a0pharmacist helps ensure the patient is on the\u00a0appropriate\u00a0pain medication and dosage. The musculoskeletal physiotherapist is essential in treating thoracic dysfunctions of the spine. They provide the patient with exercises to strengthen the musculature around the spinal dysfunctions, which the osteopathic clinician addressed.", "contents": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Enhancing Healthcare Team Outcomes. A\u00a0pharmacist helps ensure the patient is on the\u00a0appropriate\u00a0pain medication and dosage. The musculoskeletal physiotherapist is essential in treating thoracic dysfunctions of the spine. They provide the patient with exercises to strengthen the musculature around the spinal dysfunctions, which the osteopathic clinician addressed."}
+{"id": "article-102956_27", "title": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Enhancing Healthcare Team Outcomes", "content": "When the surrounding musculature and spinal segments are addressed, the patient has longer-lasting relief and a better outcome. Lastly, a\u00a0psychiatrist\u00a0is a vital component of treating spinal pain according to the biopsychosocial model of care. [12] This model highlights a\u00a0multidisciplinary\u00a0approach to persistent pain because of the intertwined physical and psychological variables\u00a0associated\u00a0with pain. [12] Accordingly, a psychiatrist may address the cognitive and behavioral components of pain while the other team members focus on the\u00a0physical\u00a0aspects of\u00a0pain. The\u00a0emphasis of these studies shows that somatic dysfunctions of the spine and\u00a0its\u00a0associated pain require a holistic and multidisciplinary approach that leads to better patient outcomes. [12]", "contents": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Enhancing Healthcare Team Outcomes. When the surrounding musculature and spinal segments are addressed, the patient has longer-lasting relief and a better outcome. Lastly, a\u00a0psychiatrist\u00a0is a vital component of treating spinal pain according to the biopsychosocial model of care. [12] This model highlights a\u00a0multidisciplinary\u00a0approach to persistent pain because of the intertwined physical and psychological variables\u00a0associated\u00a0with pain. [12] Accordingly, a psychiatrist may address the cognitive and behavioral components of pain while the other team members focus on the\u00a0physical\u00a0aspects of\u00a0pain. The\u00a0emphasis of these studies shows that somatic dysfunctions of the spine and\u00a0its\u00a0associated pain require a holistic and multidisciplinary approach that leads to better patient outcomes. [12]"}
+{"id": "article-102956_28", "title": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Osteopathic Manipulative Treatment: Counterstrain/FPR Procedure - Thoracic Vertebrae -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

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+{"id": "article-102957_0", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Continuing Education Activity", "content": "Low back pain is characterized by both physical discomfort and psychological distress and affects a significant portion of the population. The causes of the condition are often multifactorial and sometimes unknown.\u00a0Traditional treatments, such as opioids, merely mask pain symptoms without addressing the underlying cause of the ailment.\u00a0In response, the muscle energy technique (MET) offers a promising approach to managing low back pain by targeting various components of the spine, including vertebrae, intervertebral discs, ligaments, and associated muscles. Through manipulation and realignment, MET aims to alleviate both acute and chronic low back pain, offering relief and improving patient well-being.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Continuing Education Activity. Low back pain is characterized by both physical discomfort and psychological distress and affects a significant portion of the population. The causes of the condition are often multifactorial and sometimes unknown.\u00a0Traditional treatments, such as opioids, merely mask pain symptoms without addressing the underlying cause of the ailment.\u00a0In response, the muscle energy technique (MET) offers a promising approach to managing low back pain by targeting various components of the spine, including vertebrae, intervertebral discs, ligaments, and associated muscles. Through manipulation and realignment, MET aims to alleviate both acute and chronic low back pain, offering relief and improving patient well-being."}
+{"id": "article-102957_1", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Continuing Education Activity", "content": "MET involves specific physiological principles and techniques, with the most commonly used method being post-isometric relaxation, which is particularly effective in reducing pain and improving circulation.\u00a0Furthermore, the treatment aligns with osteopathic philosophy, which emphasizes considering the whole body when addressing pain and dysfunction.\u00a0This activity highlights the specific physiological principles and techniques involved in MET necessary for clinicians to enhance their ability to effectively manage acute and chronic low back pain, as well as other musculoskeletal issues.\u00a0This activity also\u00a0provides an understanding of how MET aligns with osteopathic philosophy, which emphasizes holistic approaches to healthcare. By integrating these principles into practice, clinicians can offer patients safer and more effective alternatives to traditional treatments, ultimately enhancing patient well-being and quality of life.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Continuing Education Activity. MET involves specific physiological principles and techniques, with the most commonly used method being post-isometric relaxation, which is particularly effective in reducing pain and improving circulation.\u00a0Furthermore, the treatment aligns with osteopathic philosophy, which emphasizes considering the whole body when addressing pain and dysfunction.\u00a0This activity highlights the specific physiological principles and techniques involved in MET necessary for clinicians to enhance their ability to effectively manage acute and chronic low back pain, as well as other musculoskeletal issues.\u00a0This activity also\u00a0provides an understanding of how MET aligns with osteopathic philosophy, which emphasizes holistic approaches to healthcare. By integrating these principles into practice, clinicians can offer patients safer and more effective alternatives to traditional treatments, ultimately enhancing patient well-being and quality of life."}
+{"id": "article-102957_2", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Continuing Education Activity", "content": "Objectives: Identify somatic dysfunctions in the lumbar vertebrae through osteopathic evaluation techniques. Implement muscle energy techniques for treating lumbar dysfunctions effectively and safely by considering patient-specific factors. Apply appropriate muscle energy techniques, such as post-isometric relaxation, based on the patient's presentation, clinical findings, and treatment goals. Collaborate with other healthcare professionals and coordinate with patients to integrate muscle energy techniques into comprehensive patient care plans. Access free multiple choice questions on this topic.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Continuing Education Activity. Objectives: Identify somatic dysfunctions in the lumbar vertebrae through osteopathic evaluation techniques. Implement muscle energy techniques for treating lumbar dysfunctions effectively and safely by considering patient-specific factors. Apply appropriate muscle energy techniques, such as post-isometric relaxation, based on the patient's presentation, clinical findings, and treatment goals. Collaborate with other healthcare professionals and coordinate with patients to integrate muscle energy techniques into comprehensive patient care plans. Access free multiple choice questions on this topic."}
+{"id": "article-102957_3", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Introduction", "content": "Low back pain represents one of the most prevalent ailments in contemporary society. Statistics indicate that around\u00a090% of individuals will encounter acute back pain at some point in their lives, with approximately 10% experiencing chronic low back pain. [1] The multifactorial nature of low back pain often makes its origins complex, with only about 15% of cases attributed to known causes, leaving the remaining 85% with unknown etiologies. [2] This\u00a0condition not only induces physical discomfort but also impacts patients psychologically, contributing to feelings of depression and anxiety. [3] Addressing spinal pain remains a significant challenge for healthcare providers worldwide. However, the muscle energy technique (MET) presents a promising treatment approach. By manipulating various components of the spine, including vertebrae, intervertebral discs, spinal ligaments, and associated muscles, MET offers a means to significantly alleviate both acute and chronic low back pain. [4] [2] [5]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Introduction. Low back pain represents one of the most prevalent ailments in contemporary society. Statistics indicate that around\u00a090% of individuals will encounter acute back pain at some point in their lives, with approximately 10% experiencing chronic low back pain. [1] The multifactorial nature of low back pain often makes its origins complex, with only about 15% of cases attributed to known causes, leaving the remaining 85% with unknown etiologies. [2] This\u00a0condition not only induces physical discomfort but also impacts patients psychologically, contributing to feelings of depression and anxiety. [3] Addressing spinal pain remains a significant challenge for healthcare providers worldwide. However, the muscle energy technique (MET) presents a promising treatment approach. By manipulating various components of the spine, including vertebrae, intervertebral discs, spinal ligaments, and associated muscles, MET offers a means to significantly alleviate both acute and chronic low back pain. [4] [2] [5]"}
+{"id": "article-102957_4", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Introduction", "content": "Dr. Fred Mitchell, Sr. initially developed the MET in the 1950s. This technique is considered a direct, active treatment. In MET, the patient is frequently positioned toward the barrier, and the patient will move to produce an activating force. There are\u00a09 physiological principles to muscle energy\u2014post-isometric relaxation, respiratory assist, joint mobilization using muscle force, oculocephalic reflex, reciprocal inhibition, crossed extensor reflex, isokinetic strengthening, isolytic lengthening, and muscle force in one region of the body to achieve movement in another. Among these, post-isometric isolation is the most commonly utilized method. In this technique, the patient is positioned toward the barrier and instructed to apply an activating force toward freedom. The resulting isometric contraction induces reciprocal inhibition and relaxation of antagonistic muscles, effectively addressing soft tissue restrictive barriers and promoting joint mobilization. This process ultimately leads to pain reduction and improved circulation. [5] [6] [7] [8]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Introduction. Dr. Fred Mitchell, Sr. initially developed the MET in the 1950s. This technique is considered a direct, active treatment. In MET, the patient is frequently positioned toward the barrier, and the patient will move to produce an activating force. There are\u00a09 physiological principles to muscle energy\u2014post-isometric relaxation, respiratory assist, joint mobilization using muscle force, oculocephalic reflex, reciprocal inhibition, crossed extensor reflex, isokinetic strengthening, isolytic lengthening, and muscle force in one region of the body to achieve movement in another. Among these, post-isometric isolation is the most commonly utilized method. In this technique, the patient is positioned toward the barrier and instructed to apply an activating force toward freedom. The resulting isometric contraction induces reciprocal inhibition and relaxation of antagonistic muscles, effectively addressing soft tissue restrictive barriers and promoting joint mobilization. This process ultimately leads to pain reduction and improved circulation. [5] [6] [7] [8]"}
+{"id": "article-102957_5", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Introduction", "content": "MET is an important tool for trained professionals in addressing low back pain, which is particularly crucial due to the marked potential abuse of opioid medications. Opioids do not address the underlying somatic dysfunction causing low back pain and serve only to mask pain. MET reduces pain by addressing the root of the problem, which is the misalignment and inappropriate proprioception of the spine, surrounding musculature, and other associated soft tissues. MET realigns spinal segments and relaxes musculature and associated soft tissues by delicately restoring spinal segments to their anatomical alignment through the body's muscular system. This procedure enhances the flexibility of muscles, fascia, and joints, leading to decreased pain, improved circulation, and enhanced lymphatic drainage in the treated region. [5]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Introduction. MET is an important tool for trained professionals in addressing low back pain, which is particularly crucial due to the marked potential abuse of opioid medications. Opioids do not address the underlying somatic dysfunction causing low back pain and serve only to mask pain. MET reduces pain by addressing the root of the problem, which is the misalignment and inappropriate proprioception of the spine, surrounding musculature, and other associated soft tissues. MET realigns spinal segments and relaxes musculature and associated soft tissues by delicately restoring spinal segments to their anatomical alignment through the body's muscular system. This procedure enhances the flexibility of muscles, fascia, and joints, leading to decreased pain, improved circulation, and enhanced lymphatic drainage in the treated region. [5]"}
+{"id": "article-102957_6", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Introduction", "content": "Misalignment of the lumbar spine and its associated spinal tissues is a recognized contributor to nonspecific low back pain. [9] However, through osteopathic evaluation of the lumbar spine, clinicians can pinpoint specific dysfunctions and effectively alleviate the associated pain.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Introduction. Misalignment of the lumbar spine and its associated spinal tissues is a recognized contributor to nonspecific low back pain. [9] However, through osteopathic evaluation of the lumbar spine, clinicians can pinpoint specific dysfunctions and effectively alleviate the associated pain."}
+{"id": "article-102957_7", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Anatomy and Physiology", "content": "Discussion of the various mechanisms of muscle energy exceeds the scope of this article. Instead, the focus will be on MET with post-isometric relaxation for treating lumbar dysfunctions. This technique entails positioning the patient toward the barrier and resisting the physician as they push toward freedom. This motion triggers the Golgi tendon reflex, facilitating relaxation and potentially articulating the treated segment. [8] [10]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Anatomy and Physiology. Discussion of the various mechanisms of muscle energy exceeds the scope of this article. Instead, the focus will be on MET with post-isometric relaxation for treating lumbar dysfunctions. This technique entails positioning the patient toward the barrier and resisting the physician as they push toward freedom. This motion triggers the Golgi tendon reflex, facilitating relaxation and potentially articulating the treated segment. [8] [10]"}
+{"id": "article-102957_8", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Anatomy and Physiology", "content": "Understanding the functional anatomy of the lumbar region is important.\u00a0The lumbar spine is made up of 5 vertebrae that form a gentle lordotic curve above the sacrum. Compared to other vertebral segments, the lumbar region is larger in size, which gives it stability while still allowing for movement. It is important to note that the main function of the lumbar spine is to facilitate movements of the trunk. [11] [12]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Anatomy and Physiology. Understanding the functional anatomy of the lumbar region is important.\u00a0The lumbar spine is made up of 5 vertebrae that form a gentle lordotic curve above the sacrum. Compared to other vertebral segments, the lumbar region is larger in size, which gives it stability while still allowing for movement. It is important to note that the main function of the lumbar spine is to facilitate movements of the trunk. [11] [12]"}
+{"id": "article-102957_9", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Anatomy and Physiology", "content": "The vertebral body is larger than the other spinal vertebrae, and unlike the other vertebrae, the lumbar vertebrae do not have any costal facets nor a transfer foramina. In between each vertebra are intervertebral discs that dissipate heavy loads. Each disc is composed of a compressible nucleus pulposus surrounded by layers of an annulus of collagen fibers. The posterior aspect of the discs is thinner than the anterior. This aspect carries a greater risk of disc rupture and herniation. [13] The vertebral nerve on the posterior longitudinal ligament becomes irritated during the\u00a0initial stages of a disc rupture, which causes lower back pain.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Anatomy and Physiology. The vertebral body is larger than the other spinal vertebrae, and unlike the other vertebrae, the lumbar vertebrae do not have any costal facets nor a transfer foramina. In between each vertebra are intervertebral discs that dissipate heavy loads. Each disc is composed of a compressible nucleus pulposus surrounded by layers of an annulus of collagen fibers. The posterior aspect of the discs is thinner than the anterior. This aspect carries a greater risk of disc rupture and herniation. [13] The vertebral nerve on the posterior longitudinal ligament becomes irritated during the\u00a0initial stages of a disc rupture, which causes lower back pain."}
+{"id": "article-102957_10", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Anatomy and Physiology", "content": "The pedicles and the transverse and articular processes are important posterior elements of the lumbar spine. Positioned on the superior third of the posterior surface of the vertebral body, the pedicle connects the posterior elements to the vertebral body. Each pedicle extends laterally to form the transverse process, which can be located directly lateral to its respective spinous process during a physical examination. Additionally, the segment features both superior and inferior articular processes, with the inferior process facing caudally and laterally from the pedicle, while the superior process faces medially.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Anatomy and Physiology. The pedicles and the transverse and articular processes are important posterior elements of the lumbar spine. Positioned on the superior third of the posterior surface of the vertebral body, the pedicle connects the posterior elements to the vertebral body. Each pedicle extends laterally to form the transverse process, which can be located directly lateral to its respective spinous process during a physical examination. Additionally, the segment features both superior and inferior articular processes, with the inferior process facing caudally and laterally from the pedicle, while the superior process faces medially."}
+{"id": "article-102957_11", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Anatomy and Physiology", "content": "The lumbar facet joints are thought to be a source of low back pain. The facet is innervated by the dorsal rami above and below the joint. [14] Pain\u00a0at the facet may be referred to the lower extremities. Finally, the lamina will start from the pedicle, travel caudally and medially, and meet other lamina at midline.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Anatomy and Physiology. The lumbar facet joints are thought to be a source of low back pain. The facet is innervated by the dorsal rami above and below the joint. [14] Pain\u00a0at the facet may be referred to the lower extremities. Finally, the lamina will start from the pedicle, travel caudally and medially, and meet other lamina at midline."}
+{"id": "article-102957_12", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Anatomy and Physiology", "content": "Ligamentous structures provide stability to the lumbar vertebra. The ligamentum flavum attaches each pedicle and lamina to the next and makes up the posterolateral boundary to the neural foramen. Hypertrophy of the ligamentum flavum can cause potential nerve root compression and can commonly be injured with excessive spinal flexion. The interspinous ligament allows the thoracolumbar fascia and multifidus to be anchored to the facet joint capsule, which also acts as a central support system for the lumbar spine. The anterior longitudinal ligament runs along the anterior surface of the vertebral body. The posterior longitudinal ligament runs on the posterior aspect of the vertebral body. As this ligament is half\u00a0its original width at the level of L5, it is much weaker in the lumbar spine than in superior segments of the spine. [15] The iliolumbar ligament is attached to the transverse process of L4 and L5 and extends to the anterior edge of the iliac crest. Notably, it may be one of the first ligaments to become tender to palpation during lumbosacral strain. [16]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Anatomy and Physiology. Ligamentous structures provide stability to the lumbar vertebra. The ligamentum flavum attaches each pedicle and lamina to the next and makes up the posterolateral boundary to the neural foramen. Hypertrophy of the ligamentum flavum can cause potential nerve root compression and can commonly be injured with excessive spinal flexion. The interspinous ligament allows the thoracolumbar fascia and multifidus to be anchored to the facet joint capsule, which also acts as a central support system for the lumbar spine. The anterior longitudinal ligament runs along the anterior surface of the vertebral body. The posterior longitudinal ligament runs on the posterior aspect of the vertebral body. As this ligament is half\u00a0its original width at the level of L5, it is much weaker in the lumbar spine than in superior segments of the spine. [15] The iliolumbar ligament is attached to the transverse process of L4 and L5 and extends to the anterior edge of the iliac crest. Notably, it may be one of the first ligaments to become tender to palpation during lumbosacral strain. [16]"}
+{"id": "article-102957_13", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Anatomy and Physiology", "content": "Understanding the muscular anatomy is crucial in lumbar spine treatment, as these muscles play a vital role in correcting somatic dysfunctions. Notably, the first 3 lumbar vertebrae are associated with the diaphragm; the left crura of the diaphragm attaches to L1 and L2, while the right crura connects from L1 to L3. Additionally, the lumbar vertebrae contribute to the origin of the erector spinae muscles. The psoas muscle, a primary hip flexor, attaches from L1 to L4 and joins the iliacus muscle to insert at the lesser trochanter of the femur. Asymmetric tension in the psoas muscles often contributes to back pain. [17] Moreover, the multifidus muscle plays a crucial role in supporting the lumbar spine during various activities, including standing, sitting, walking, trunk motion, and lifting. Dysfunction in these muscles is another common cause of low back pain.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Anatomy and Physiology. Understanding the muscular anatomy is crucial in lumbar spine treatment, as these muscles play a vital role in correcting somatic dysfunctions. Notably, the first 3 lumbar vertebrae are associated with the diaphragm; the left crura of the diaphragm attaches to L1 and L2, while the right crura connects from L1 to L3. Additionally, the lumbar vertebrae contribute to the origin of the erector spinae muscles. The psoas muscle, a primary hip flexor, attaches from L1 to L4 and joins the iliacus muscle to insert at the lesser trochanter of the femur. Asymmetric tension in the psoas muscles often contributes to back pain. [17] Moreover, the multifidus muscle plays a crucial role in supporting the lumbar spine during various activities, including standing, sitting, walking, trunk motion, and lifting. Dysfunction in these muscles is another common cause of low back pain."}
+{"id": "article-102957_14", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Indications", "content": "Indications for MET of the lumbar vertebrae include acute or chronic low back pain, lumbar muscle spasm, decreased range of motion, or lumbar spine stiffness. [2] [9] Through viscerosomatic reflexes, MET of the lumbar vertebrae is also indicated for prostate, descending colon, sigmoid colon, rectum, and lower extremities pathologies. Overall, MET is a safe procedure with a low risk of injury when it is performed correctly.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Indications. Indications for MET of the lumbar vertebrae include acute or chronic low back pain, lumbar muscle spasm, decreased range of motion, or lumbar spine stiffness. [2] [9] Through viscerosomatic reflexes, MET of the lumbar vertebrae is also indicated for prostate, descending colon, sigmoid colon, rectum, and lower extremities pathologies. Overall, MET is a safe procedure with a low risk of injury when it is performed correctly."}
+{"id": "article-102957_15", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Contraindications", "content": "Contraindications for MET of the lumbar spine include recent surgery\u00a0at the lumbar region, significant injury of the lumbar spine including lumbar spinal fracture or acute cord compression, cauda equina syndrome, lumbar spinal malignancy, metastasis of primary malignancy to the lumbar spine, osteomyelitis of the lumbar spine, and severe osteoporosis. Additionally, there is a relative contraindication to performing MET on intensive care unit patients with low vitality. The addition of excessive muscle force may further exacerbate this population's compromised condition. For patients with lower vitality levels, using MET through alternative modalities, such as reciprocal inhibition, is advisable. Furthermore, MET is contraindicated for individuals unable to follow verbal directions. [18] [19]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Contraindications. Contraindications for MET of the lumbar spine include recent surgery\u00a0at the lumbar region, significant injury of the lumbar spine including lumbar spinal fracture or acute cord compression, cauda equina syndrome, lumbar spinal malignancy, metastasis of primary malignancy to the lumbar spine, osteomyelitis of the lumbar spine, and severe osteoporosis. Additionally, there is a relative contraindication to performing MET on intensive care unit patients with low vitality. The addition of excessive muscle force may further exacerbate this population's compromised condition. For patients with lower vitality levels, using MET through alternative modalities, such as reciprocal inhibition, is advisable. Furthermore, MET is contraindicated for individuals unable to follow verbal directions. [18] [19]"}
+{"id": "article-102957_16", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Equipment", "content": "The equipment utilized for MET includes a padded treatment table or a comfortable surface for the patient to sit or lie on, positioned at an appropriate height for the clinician.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Equipment. The equipment utilized for MET includes a padded treatment table or a comfortable surface for the patient to sit or lie on, positioned at an appropriate height for the clinician."}
+{"id": "article-102957_17", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Personnel", "content": "Healthcare professionals trained in osteopathic manipulative medicine.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Personnel. Healthcare professionals trained in osteopathic manipulative medicine."}
+{"id": "article-102957_18", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Preparation", "content": "Before beginning treatment, clinicians recognize that a precise diagnosis is essential for success. Lumbar somatic dysfunctions can be categorized into type 1 (neutral group dysfunctions) or type 2 (non-neutral dysfunction) based on Fryette's law of spinal mechanics. [8] A straightforward method of determining the diagnosis involves comparing the position of the transverse process bilaterally. The direction of rotation is indicated by the side with the posterior transverse process.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Preparation. Before beginning treatment, clinicians recognize that a precise diagnosis is essential for success. Lumbar somatic dysfunctions can be categorized into type 1 (neutral group dysfunctions) or type 2 (non-neutral dysfunction) based on Fryette's law of spinal mechanics. [8] A straightforward method of determining the diagnosis involves comparing the position of the transverse process bilaterally. The direction of rotation is indicated by the side with the posterior transverse process."}
+{"id": "article-102957_19", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Preparation", "content": "Clinicians instruct the patient to flex forward and extend backward until the segment level to observe any changes in the position of the transverse process. If the transverse process becomes more level in flexion or extension, it indicates a flexed or extended somatic dysfunction (type 2). Conversely, if the segments remain unleveled, it is considered a neutral dysfunction (type 1). Typically, in type 1 (neutral) dysfunction, a group of segments are sidebent and rotated in opposite directions. For instance, neutral rotated right and side bent right (N RrSl); in type 2 (non-neutral dysfunction), the segments are side-bent and rotated in the same direction.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Preparation. Clinicians instruct the patient to flex forward and extend backward until the segment level to observe any changes in the position of the transverse process. If the transverse process becomes more level in flexion or extension, it indicates a flexed or extended somatic dysfunction (type 2). Conversely, if the segments remain unleveled, it is considered a neutral dysfunction (type 1). Typically, in type 1 (neutral) dysfunction, a group of segments are sidebent and rotated in opposite directions. For instance, neutral rotated right and side bent right (N RrSl); in type 2 (non-neutral dysfunction), the segments are side-bent and rotated in the same direction."}
+{"id": "article-102957_20", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Technique or Treatment", "content": "MET applied to the lumbar spine can decrease low back pain intensity. [20] Various approaches exist for treating the lumbar spine with MET. Below is a simple approach for performing it in a seated position. Alternatively, methods may involve lying down in lateral recumbent positions and engaging either the side bending or rotational component as the activating force. Despite differences in technique, the overall treatment principles remain consistent during post-isometric relaxation: position the patient toward the barrier and instruct them to push against the clinician's resistance toward freedom. [8] The following steps describe the treatment for a neutral, side bent left and rotated right diagnosis (NSlRr, type 1): Step 1: The patient is instructed to sit straddling a treatment table near the end so that their back faces the physician, who may stand beside or behind them. The patient then crosses their arms across their chest.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Technique or Treatment. MET applied to the lumbar spine can decrease low back pain intensity. [20] Various approaches exist for treating the lumbar spine with MET. Below is a simple approach for performing it in a seated position. Alternatively, methods may involve lying down in lateral recumbent positions and engaging either the side bending or rotational component as the activating force. Despite differences in technique, the overall treatment principles remain consistent during post-isometric relaxation: position the patient toward the barrier and instruct them to push against the clinician's resistance toward freedom. [8] The following steps describe the treatment for a neutral, side bent left and rotated right diagnosis (NSlRr, type 1): Step 1: The patient is instructed to sit straddling a treatment table near the end so that their back faces the physician, who may stand beside or behind them. The patient then crosses their arms across their chest."}
+{"id": "article-102957_21", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Technique or Treatment", "content": "Step 2: The physician positions themselves behind the patient and places their left axilla on their left shoulder. The physician's left hand makes contact with the patient's right shoulder, while the left arm is crossed anteriorly to the patient's chest. Step 3: Using\u00a0their right hand, the physician palpates the dysfunctional lumbar segment and maintains this position throughout the treatment to assess the restrictive barrier and monitor tissue release in the lumbar spine.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Technique or Treatment. Step 2: The physician positions themselves behind the patient and places their left axilla on their left shoulder. The physician's left hand makes contact with the patient's right shoulder, while the left arm is crossed anteriorly to the patient's chest. Step 3: Using\u00a0their right hand, the physician palpates the dysfunctional lumbar segment and maintains this position throughout the treatment to assess the restrictive barrier and monitor tissue release in the lumbar spine."}
+{"id": "article-102957_22", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Technique or Treatment", "content": "Step 4: The physician initiates right-side bending by applying downward pressure to the patient's right shoulder. Subsequently, the patient is rotated to the left, down to the level of the lumbar spine segment, by the physician pulling the patient's right shoulder anteriorly until a restrictive barrier is felt. This positioning places the patient's lumbar segment in a rotated left and side-bent right position, contrary to the patient's lumbar spine diagnosis. As a result, the treated segment is positioned at its restrictive barrier, allowing for correction of segmental restriction.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Technique or Treatment. Step 4: The physician initiates right-side bending by applying downward pressure to the patient's right shoulder. Subsequently, the patient is rotated to the left, down to the level of the lumbar spine segment, by the physician pulling the patient's right shoulder anteriorly until a restrictive barrier is felt. This positioning places the patient's lumbar segment in a rotated left and side-bent right position, contrary to the patient's lumbar spine diagnosis. As a result, the treated segment is positioned at its restrictive barrier, allowing for correction of segmental restriction."}
+{"id": "article-102957_23", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Technique or Treatment", "content": "Step 5: While maintaining the restrictive barrier, the physician instructs the patient to \"attempt to sit in a neutral position,\" \"turn their body to the right against the thumb placed on their back,\" or \"push their left shoulder toward the ceiling.\" These instructions aim to engage specific muscle groups and apply a gentle counterforce against the physician. Essentially, the patient rotates right and side-bends left against the isometric resistance provided by the physician, maintaining the treatment position. The patient is advised to exert approximately 30% of their force during this step, and the physician asks them to hold the contraction for 3 to 5 seconds. Step 6: The physician repositions the patient to the new restrictive barrier, as done before in Step 4, and prompts them to attempt sitting in a neutral position again, as described in Step 5. Step 7: Steps 4 through 6 are repeated between 3\u00a0and\u00a05 times.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Technique or Treatment. Step 5: While maintaining the restrictive barrier, the physician instructs the patient to \"attempt to sit in a neutral position,\" \"turn their body to the right against the thumb placed on their back,\" or \"push their left shoulder toward the ceiling.\" These instructions aim to engage specific muscle groups and apply a gentle counterforce against the physician. Essentially, the patient rotates right and side-bends left against the isometric resistance provided by the physician, maintaining the treatment position. The patient is advised to exert approximately 30% of their force during this step, and the physician asks them to hold the contraction for 3 to 5 seconds. Step 6: The physician repositions the patient to the new restrictive barrier, as done before in Step 4, and prompts them to attempt sitting in a neutral position again, as described in Step 5. Step 7: Steps 4 through 6 are repeated between 3\u00a0and\u00a05 times."}
+{"id": "article-102957_24", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Technique or Treatment", "content": "Step 8: Finally, the physician reassesses the dysfunctional lumbar segment for improvement. The following steps describe the treatment for a flexed, side-bent left, and rotated left diagnosis (FSlRl). Step 1: The patient is positioned to sit straddling a treatment table near its edge, with their back facing the physician, who may stand beside or behind them. The patient crosses their arms across their chest. Step 2: Positioned behind the patient, the physician places their right axilla on the patient's right shoulder. They then make contact with the patient's left shoulder using their right hand, resulting in their right arm crossing anteriorly to the patient's chest. Step 3: Using\u00a0their left hand, the physician palpates the dysfunctional lumbar segment and maintains this position throughout the treatment to assess the restrictive barrier and monitor tissue release in the lumbar spine.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Technique or Treatment. Step 8: Finally, the physician reassesses the dysfunctional lumbar segment for improvement. The following steps describe the treatment for a flexed, side-bent left, and rotated left diagnosis (FSlRl). Step 1: The patient is positioned to sit straddling a treatment table near its edge, with their back facing the physician, who may stand beside or behind them. The patient crosses their arms across their chest. Step 2: Positioned behind the patient, the physician places their right axilla on the patient's right shoulder. They then make contact with the patient's left shoulder using their right hand, resulting in their right arm crossing anteriorly to the patient's chest. Step 3: Using\u00a0their left hand, the physician palpates the dysfunctional lumbar segment and maintains this position throughout the treatment to assess the restrictive barrier and monitor tissue release in the lumbar spine."}
+{"id": "article-102957_25", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Technique or Treatment", "content": "Step 4: The physician initiates right-side bending by applying downward pressure to the patient's right shoulder through contact with the physician's axilla. Subsequently, the physician rotates the patient to the right down to the level of the lumbar spine segment by pulling the patient's left shoulder anteriorly until a restrictive barrier is palpated. The physician then leans the patient backward slightly to extend the lumbar spine until a restrictive barrier is palpated at the segment, engaging all 3 planes of motion to their restrictive barriers. This positioning places the patient's lumbar segment in a rotated right, side-bent right, and extended position opposite to the patient's lumbar spine diagnosis. Consequently, the treated segment is positioned at its restrictive barrier, allowing for correction of segmental restriction.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Technique or Treatment. Step 4: The physician initiates right-side bending by applying downward pressure to the patient's right shoulder through contact with the physician's axilla. Subsequently, the physician rotates the patient to the right down to the level of the lumbar spine segment by pulling the patient's left shoulder anteriorly until a restrictive barrier is palpated. The physician then leans the patient backward slightly to extend the lumbar spine until a restrictive barrier is palpated at the segment, engaging all 3 planes of motion to their restrictive barriers. This positioning places the patient's lumbar segment in a rotated right, side-bent right, and extended position opposite to the patient's lumbar spine diagnosis. Consequently, the treated segment is positioned at its restrictive barrier, allowing for correction of segmental restriction."}
+{"id": "article-102957_26", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Technique or Treatment", "content": "Step 5: While\u00a0maintaining the restrictive barrier, the physician instructs the patient to \"attempt to sit in a neutral position,\" \"turn their body to the left against the thumb placed on their back,\" or \"push their right shoulder toward the ceiling.\" These instructions aim to engage specific muscle groups and apply a gentle counterforce against the physician. Essentially, the patient's side bends left, rotates left, and flexes the lumbar spine against the physician's isometric resistance created by maintaining the patient's treatment position. The patient should exert approximately 30% of their force during this step, and the physician instructs them to hold the contraction for 3 to 5 seconds. Step 6: The physician will reposition the patient to the new restrictive barrier, as done before in Step 4, and ask the patient to attempt to sit in a neutral position again, as described in Step 5. Step 7: Steps 4 through 6 are repeated between 3\u00a0and 5 times.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Technique or Treatment. Step 5: While\u00a0maintaining the restrictive barrier, the physician instructs the patient to \"attempt to sit in a neutral position,\" \"turn their body to the left against the thumb placed on their back,\" or \"push their right shoulder toward the ceiling.\" These instructions aim to engage specific muscle groups and apply a gentle counterforce against the physician. Essentially, the patient's side bends left, rotates left, and flexes the lumbar spine against the physician's isometric resistance created by maintaining the patient's treatment position. The patient should exert approximately 30% of their force during this step, and the physician instructs them to hold the contraction for 3 to 5 seconds. Step 6: The physician will reposition the patient to the new restrictive barrier, as done before in Step 4, and ask the patient to attempt to sit in a neutral position again, as described in Step 5. Step 7: Steps 4 through 6 are repeated between 3\u00a0and 5 times."}
+{"id": "article-102957_27", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Technique or Treatment", "content": "Step 8: Finally, the physician reassesses the dysfunctional lumbar segment for improvement. [2]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Technique or Treatment. Step 8: Finally, the physician reassesses the dysfunctional lumbar segment for improvement. [2]"}
+{"id": "article-102957_28", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Technique or Treatment", "content": "A crucial clinical consideration during seated MET is to position the patient in a way that places the segment being treated at the apex of the side-bending/flexion/extension curve being formed. This positioning ensures that the other segments are \"locked\" in place, facilitating specific changes in the lesion being corrected.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Technique or Treatment. A crucial clinical consideration during seated MET is to position the patient in a way that places the segment being treated at the apex of the side-bending/flexion/extension curve being formed. This positioning ensures that the other segments are \"locked\" in place, facilitating specific changes in the lesion being corrected."}
+{"id": "article-102957_29", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Complications", "content": "The complication rate associated with MET is minimal when the appropriate type of MET is selected. Common complaints may include self-limiting soreness that resolves within a few days. Occasionally, patients may experience being \"overcorrected\" or \"over-treated,\" resulting in reversing their initial lumbar diagnosis. Notably, monitoring the dysfunctional segment throughout the procedure and reevaluating it upon completion is crucial.\u00a0Excessive force is a common cause of complications, as it may prevent precise treatment by engaging larger muscle groups. Reports indicate that tendon avulsion is a potential complication resulting from excessive force. [8]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Complications. The complication rate associated with MET is minimal when the appropriate type of MET is selected. Common complaints may include self-limiting soreness that resolves within a few days. Occasionally, patients may experience being \"overcorrected\" or \"over-treated,\" resulting in reversing their initial lumbar diagnosis. Notably, monitoring the dysfunctional segment throughout the procedure and reevaluating it upon completion is crucial.\u00a0Excessive force is a common cause of complications, as it may prevent precise treatment by engaging larger muscle groups. Reports indicate that tendon avulsion is a potential complication resulting from excessive force. [8]"}
+{"id": "article-102957_30", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Clinical Significance", "content": "Various\u00a0treatments for low back pain include massage, physical therapy, exercise programs, spinal injections, transcutaneous electric nerve stimulation (TENS), patches, creams, medications, and counseling. Unfortunately, many of these treatments have inconclusive efficacy. Further research on managing low back pain is needed due to its high prevalence in patients, its large healthcare costs, and the conflicting efficacy of treatments. [4] However, some studies have shown that MET decreases back pain. [20] [21] [4] Misalignment of the lumbar spine or loss of lumbar joint function\u00a0are common causes for non-specific low back pain, and MET works to address the root of the problem. [9]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Clinical Significance. Various\u00a0treatments for low back pain include massage, physical therapy, exercise programs, spinal injections, transcutaneous electric nerve stimulation (TENS), patches, creams, medications, and counseling. Unfortunately, many of these treatments have inconclusive efficacy. Further research on managing low back pain is needed due to its high prevalence in patients, its large healthcare costs, and the conflicting efficacy of treatments. [4] However, some studies have shown that MET decreases back pain. [20] [21] [4] Misalignment of the lumbar spine or loss of lumbar joint function\u00a0are common causes for non-specific low back pain, and MET works to address the root of the problem. [9]"}
+{"id": "article-102957_31", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Clinical Significance", "content": "A pilot study performed in 2003 showed that MET significantly improved acute low back pain in which the patients underwent 4 contractions\u00a0of MET held for 5 seconds each for a total of 8 treatments. They were compared to a control group that received a sham treatment. The Oswestry Disability Index (ODI) was recorded before and after MET. ODI statistically significantly improved, with a decrease in ODI by 83% in the MET group versus 65% in the control group. [22] A systematic review of 26 studies of symptomatic and asymptomatic patients found that MET effectively treats acute and chronic low back pain. This review also found that MET treats other musculoskeletal pain, such as chronic neck and epicondylitis. [5]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Clinical Significance. A pilot study performed in 2003 showed that MET significantly improved acute low back pain in which the patients underwent 4 contractions\u00a0of MET held for 5 seconds each for a total of 8 treatments. They were compared to a control group that received a sham treatment. The Oswestry Disability Index (ODI) was recorded before and after MET. ODI statistically significantly improved, with a decrease in ODI by 83% in the MET group versus 65% in the control group. [22] A systematic review of 26 studies of symptomatic and asymptomatic patients found that MET effectively treats acute and chronic low back pain. This review also found that MET treats other musculoskeletal pain, such as chronic neck and epicondylitis. [5]"}
+{"id": "article-102957_32", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Clinical Significance", "content": "Aligned with osteopathic philosophy, clinicians recognize that low back pain may not originate solely from the lumbar region. Clinicians should assess whether low back pain arises from somatic dysfunction elsewhere in the body, potentially manifesting as a compensatory reaction. [23] For example, osteopathic dysfunction in the sacrum or the innominates can cause pain in the lower back. Trigger points in the quadriceps or gluteal muscles can also\u00a0cause pain in the lumbar spine. [24] Pain from the superior cluneal nerve can be confused with lumbar back pain. [25] Furthermore, it is not uncommon to consider that a patient experiencing a sprain in the lower extremity may develop compensatory changes in the knees and hips during ambulation, potentially resulting in lumbar pain due to inappropriate gait patterns. [26] Hence, low back pain may not exclusively stem from lumbar spine dysfunction. When assessing a patient with low back pain, a comprehensive approach involving a detailed trauma history and examination of the entire body is crucial.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Clinical Significance. Aligned with osteopathic philosophy, clinicians recognize that low back pain may not originate solely from the lumbar region. Clinicians should assess whether low back pain arises from somatic dysfunction elsewhere in the body, potentially manifesting as a compensatory reaction. [23] For example, osteopathic dysfunction in the sacrum or the innominates can cause pain in the lower back. Trigger points in the quadriceps or gluteal muscles can also\u00a0cause pain in the lumbar spine. [24] Pain from the superior cluneal nerve can be confused with lumbar back pain. [25] Furthermore, it is not uncommon to consider that a patient experiencing a sprain in the lower extremity may develop compensatory changes in the knees and hips during ambulation, potentially resulting in lumbar pain due to inappropriate gait patterns. [26] Hence, low back pain may not exclusively stem from lumbar spine dysfunction. When assessing a patient with low back pain, a comprehensive approach involving a detailed trauma history and examination of the entire body is crucial."}
+{"id": "article-102957_33", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Clinical Significance", "content": "In summary, MET represents a gentle and effective approach to managing low back pain, with a minimal risk of harm to patients during the procedure. Nonetheless, further research is warranted to delve deeper into the mechanisms of action associated with MET.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Clinical Significance. In summary, MET represents a gentle and effective approach to managing low back pain, with a minimal risk of harm to patients during the procedure. Nonetheless, further research is warranted to delve deeper into the mechanisms of action associated with MET."}
+{"id": "article-102957_34", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Enhancing Healthcare Team Outcomes", "content": "The interprofessional healthcare team involved in the practice of MET and osteopathic manipulative medicine includes healthcare professionals trained in these modalities, patients, and nursing staff. Physicians must ensure patients are fully informed about the treatment process during MET procedures. Physicians should be aware of the patient's experience, inquire about any worsening or new pain, and promptly terminate the procedure if the patient becomes uncomfortable. Effective communication between the physician and patient is essential throughout the treatment.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Enhancing Healthcare Team Outcomes. The interprofessional healthcare team involved in the practice of MET and osteopathic manipulative medicine includes healthcare professionals trained in these modalities, patients, and nursing staff. Physicians must ensure patients are fully informed about the treatment process during MET procedures. Physicians should be aware of the patient's experience, inquire about any worsening or new pain, and promptly terminate the procedure if the patient becomes uncomfortable. Effective communication between the physician and patient is essential throughout the treatment."}
+{"id": "article-102957_35", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

statpearls/chunk/article-102958.jsonl

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+{"id": "article-102958_0", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Continuing Education Activity", "content": "Lumbar spine high-velocity low-amplitude (HVLA) thrusting techniques are a form of manual medicine used by osteopathic providers. As the name implies, this technique involves high-velocity thrusting techniques under controlled pressure applied in order to correct a specific osteopathic diagnosis discovered previously on an osteopathic physical exam. This activity outlines lumbar high-velocity low-amplitude (HVLA) osteopathic techniques of the lumbar spine and explains the role of the osteopathic practitioner in evaluating and treating patients who are undergoing lumbar HVLA. The views expressed are those of the author(s) and do not reflect the official policy of the Department of the Army, Department of Defense or the U.S. Government.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Continuing Education Activity. Lumbar spine high-velocity low-amplitude (HVLA) thrusting techniques are a form of manual medicine used by osteopathic providers. As the name implies, this technique involves high-velocity thrusting techniques under controlled pressure applied in order to correct a specific osteopathic diagnosis discovered previously on an osteopathic physical exam. This activity outlines lumbar high-velocity low-amplitude (HVLA) osteopathic techniques of the lumbar spine and explains the role of the osteopathic practitioner in evaluating and treating patients who are undergoing lumbar HVLA. The views expressed are those of the author(s) and do not reflect the official policy of the Department of the Army, Department of Defense or the U.S. Government."}
+{"id": "article-102958_1", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Continuing Education Activity", "content": "Objectives: Outline the indications and contraindications for high-velocity low-amplitude of the lumbar spine to improve patient selection for this technique. Summarize the process of developing and osteopathic diagnosis of the lumbar spine to improve technique selection for a given patient. Review the available techniques for high-velocity low-amplitude (HVLA) techniques for the lumbar spine to improve treatment satisfaction and patient outcomes in patients selected for treatment with HVLA. Identify potential pitfalls and challenges associated with high-velocity low-amplitude of the lumbar spine in order to avoid potential complications and improve outcomes for patients receiving these techniques. Access free multiple choice questions on this topic.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Continuing Education Activity. Objectives: Outline the indications and contraindications for high-velocity low-amplitude of the lumbar spine to improve patient selection for this technique. Summarize the process of developing and osteopathic diagnosis of the lumbar spine to improve technique selection for a given patient. Review the available techniques for high-velocity low-amplitude (HVLA) techniques for the lumbar spine to improve treatment satisfaction and patient outcomes in patients selected for treatment with HVLA. Identify potential pitfalls and challenges associated with high-velocity low-amplitude of the lumbar spine in order to avoid potential complications and improve outcomes for patients receiving these techniques. Access free multiple choice questions on this topic."}
+{"id": "article-102958_2", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Introduction", "content": "Lumbar spine high-velocity low-amplitude (HVLA) thrusting techniques are a form of manual medicine used by osteopathic providers. As the name implies, this technique involves high-velocity thrusting techniques under controlled pressure applied to correct a specific osteopathic diagnosis discovered previously on\u00a0an osteopathic physical exam.\u00a0HVLA techniques are frequently used in osteopathic manipulative medicine as an adjunct to other treatment modalities for low back pain, among other conditions.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Introduction. Lumbar spine high-velocity low-amplitude (HVLA) thrusting techniques are a form of manual medicine used by osteopathic providers. As the name implies, this technique involves high-velocity thrusting techniques under controlled pressure applied to correct a specific osteopathic diagnosis discovered previously on\u00a0an osteopathic physical exam.\u00a0HVLA techniques are frequently used in osteopathic manipulative medicine as an adjunct to other treatment modalities for low back pain, among other conditions."}
+{"id": "article-102958_3", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Introduction", "content": "This article reviews the background anatomy and physiology behind these techniques as well as discusses the technical aspects of their application. This discussion includes patient screening for contraindications and discussion of alternate techniques to attempt prior to HVLA application. The technical aspects addressed include obtaining a proper osteopathic diagnosis for the vertebral segment in question as well as\u00a0outlining the set-up and application of the thrusting techniques themselves. Also, common pitfalls and a discussion on improving healthcare team implementation of these techniques are both addressed.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Introduction. This article reviews the background anatomy and physiology behind these techniques as well as discusses the technical aspects of their application. This discussion includes patient screening for contraindications and discussion of alternate techniques to attempt prior to HVLA application. The technical aspects addressed include obtaining a proper osteopathic diagnosis for the vertebral segment in question as well as\u00a0outlining the set-up and application of the thrusting techniques themselves. Also, common pitfalls and a discussion on improving healthcare team implementation of these techniques are both addressed."}
+{"id": "article-102958_4", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Anatomy and Physiology", "content": "Anatomical consideration of these manipulative techniques deserves attention before addressing the technical specifics.\u00a0The lumbar spine includes five vertebral segments and their corresponding nerve roots that exit below the corresponding vertebra. For example, the L3 never root exits through the foramen between L3 and L4. [1]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Anatomy and Physiology. Anatomical consideration of these manipulative techniques deserves attention before addressing the technical specifics.\u00a0The lumbar spine includes five vertebral segments and their corresponding nerve roots that exit below the corresponding vertebra. For example, the L3 never root exits through the foramen between L3 and L4. [1]"}
+{"id": "article-102958_5", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Anatomy and Physiology", "content": "This anatomy is relevant when targeting a particular adjustment to a specific patient complaint. If a patient reports pain that radiates down a specified dermatome, one could conceivably tailor therapy toward that region based on the innervation\u00a0and corresponding spinal segments. Likewise, osteopathic physicians are trained to target somatic dysfunctions that could be contributing to other ailments based on those dermatomes.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Anatomy and Physiology. This anatomy is relevant when targeting a particular adjustment to a specific patient complaint. If a patient reports pain that radiates down a specified dermatome, one could conceivably tailor therapy toward that region based on the innervation\u00a0and corresponding spinal segments. Likewise, osteopathic physicians are trained to target somatic dysfunctions that could be contributing to other ailments based on those dermatomes."}
+{"id": "article-102958_6", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Anatomy and Physiology", "content": "The inherent mechanics native to the lumbar spine also warrant attention. The lumbar spine contributes a large percentage of side-bending, rotation, and flexion ability of the axial skeleton. As such, the options for manipulation are more varied than other, more restricted regions of the spine. This articulation is made possible by several synovial joints that compose much of the surface of the lumbar vertebrae. King among these articulations is the intervertebral disc, which is a fibrocartilaginous structure that sits between vertebrae.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Anatomy and Physiology. The inherent mechanics native to the lumbar spine also warrant attention. The lumbar spine contributes a large percentage of side-bending, rotation, and flexion ability of the axial skeleton. As such, the options for manipulation are more varied than other, more restricted regions of the spine. This articulation is made possible by several synovial joints that compose much of the surface of the lumbar vertebrae. King among these articulations is the intervertebral disc, which is a fibrocartilaginous structure that sits between vertebrae."}
+{"id": "article-102958_7", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Anatomy and Physiology", "content": "Other, smaller articulations include the zygapophyseal joints (facet joints). These synovial joints sit two on the superior surface, and two on each inferior surface of the vertebrae. The superior facets are oriented with the articulating surface posterior and medial and interface with the corresponding articular surface of the adjoining vertebrae. This arrangement leads to the majority of the vertebral motion to be in flexion and extension compared to rotation or side-bending. [2] [1] This relative limitation of side-bending allows manipulation of the vertebrae in lumbar HVLA.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Anatomy and Physiology. Other, smaller articulations include the zygapophyseal joints (facet joints). These synovial joints sit two on the superior surface, and two on each inferior surface of the vertebrae. The superior facets are oriented with the articulating surface posterior and medial and interface with the corresponding articular surface of the adjoining vertebrae. This arrangement leads to the majority of the vertebral motion to be in flexion and extension compared to rotation or side-bending. [2] [1] This relative limitation of side-bending allows manipulation of the vertebrae in lumbar HVLA."}
+{"id": "article-102958_8", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Indications", "content": "Proper patient selection is critical to avoid injury and ensure the efficacy of the treatment. Critical aspects to keep in mind when considering the use of lumbar HVLA are the indications and goals of treatment. HVLA is typically applied to treat acute or chronic low back pain when making a specific lumbar diagnosis. Lumbar osteopathic diagnosis follows many of the same principals as the diagnosis of other parts of the spine (Fryette's laws).", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Indications. Proper patient selection is critical to avoid injury and ensure the efficacy of the treatment. Critical aspects to keep in mind when considering the use of lumbar HVLA are the indications and goals of treatment. HVLA is typically applied to treat acute or chronic low back pain when making a specific lumbar diagnosis. Lumbar osteopathic diagnosis follows many of the same principals as the diagnosis of other parts of the spine (Fryette's laws)."}
+{"id": "article-102958_9", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Indications", "content": "The most fundamental way to diagnose the lumbar spine involves direct palpation to assess the posterior aspect of the transverse processes. After the provider determines the facet orientation in a neutral position, the spinal level in question may be placed into flexion and extension via direct manipulation of the spine or, more fundamentally, by patient positioning. The flexion/extension portion of the diagnosis is determined by which movement results in greater neutralization of the spinal segment. [3] [4]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Indications. The most fundamental way to diagnose the lumbar spine involves direct palpation to assess the posterior aspect of the transverse processes. After the provider determines the facet orientation in a neutral position, the spinal level in question may be placed into flexion and extension via direct manipulation of the spine or, more fundamentally, by patient positioning. The flexion/extension portion of the diagnosis is determined by which movement results in greater neutralization of the spinal segment. [3] [4]"}
+{"id": "article-102958_10", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Indications", "content": "This method describes the most classic means of diagnosing a type 2 dysfunction or dysfunction at one specific level. Type 1 dysfunctions involve multiple spinal segments that side-bent and rotated in opposite directions, generally involving three or more segments. These methods of diagnosis are subject to inter-evaluator bias, though training can improve consensus between providers. [5]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Indications. This method describes the most classic means of diagnosing a type 2 dysfunction or dysfunction at one specific level. Type 1 dysfunctions involve multiple spinal segments that side-bent and rotated in opposite directions, generally involving three or more segments. These methods of diagnosis are subject to inter-evaluator bias, though training can improve consensus between providers. [5]"}
+{"id": "article-102958_11", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Contraindications", "content": "In addition to proper diagnosis, it is important to consider the contra-indications, both relative and absolute. It is helpful to think of relative contra-indications as those that will not result in severe debility/disability if the manipulation occurs. Relative contraindications (to HVLA in general) include acute whiplash, pregnancy, post-surgical, herniated disc, anticoagulation use/hemophilia, tense or malingering patient, female patients who smoke or use oral contraceptive pills (increased risk of thrombus), atherosclerosis, or vertebral artery ischemia.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Contraindications. In addition to proper diagnosis, it is important to consider the contra-indications, both relative and absolute. It is helpful to think of relative contra-indications as those that will not result in severe debility/disability if the manipulation occurs. Relative contraindications (to HVLA in general) include acute whiplash, pregnancy, post-surgical, herniated disc, anticoagulation use/hemophilia, tense or malingering patient, female patients who smoke or use oral contraceptive pills (increased risk of thrombus), atherosclerosis, or vertebral artery ischemia."}
+{"id": "article-102958_12", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Contraindications", "content": "Relative contra-indications would necessitate a discussion with the patient about the possible risks and benefits before the treatment application to inform them of specific risks associated with each condition. Absolute contraindications include osteoporosis, osteomyelitis, fractures in the area of thrusting, boney metastasis, severe rheumatoid arthritis (especially true in cervical HVLA), cauda equina/conus medularis syndrome (or symptoms of numbness/weakness suggestive of these diagnoses), fused spinal joints, osteomyelitis, joint instability, Down\u00a0syndrome (also especially true in cervical spine manipulation), and patient refusal. Typically, the presence of an absolute contraindication excludes HVLA, as the risks would heavily outweigh any benefit. [6] [4]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Contraindications. Relative contra-indications would necessitate a discussion with the patient about the possible risks and benefits before the treatment application to inform them of specific risks associated with each condition. Absolute contraindications include osteoporosis, osteomyelitis, fractures in the area of thrusting, boney metastasis, severe rheumatoid arthritis (especially true in cervical HVLA), cauda equina/conus medularis syndrome (or symptoms of numbness/weakness suggestive of these diagnoses), fused spinal joints, osteomyelitis, joint instability, Down\u00a0syndrome (also especially true in cervical spine manipulation), and patient refusal. Typically, the presence of an absolute contraindication excludes HVLA, as the risks would heavily outweigh any benefit. [6] [4]"}
+{"id": "article-102958_13", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Equipment", "content": "Minimal equipment is necessary for lumbar HVLA. A treatment table designed for osteopathic manipulation is helpful, but a standard treatment table is still appropriate for use. The benefits of the osteopathic treatment tables include the ability to adjust the height of the table for the practitioner's preference and a larger area for the patient to lay flat. The typical orientation and location of articulation points on a standard office chair or treatment table may create points of discomfort for patients and limit options with respect to patient positioning.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Equipment. Minimal equipment is necessary for lumbar HVLA. A treatment table designed for osteopathic manipulation is helpful, but a standard treatment table is still appropriate for use. The benefits of the osteopathic treatment tables include the ability to adjust the height of the table for the practitioner's preference and a larger area for the patient to lay flat. The typical orientation and location of articulation points on a standard office chair or treatment table may create points of discomfort for patients and limit options with respect to patient positioning."}
+{"id": "article-102958_14", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Preparation", "content": "The performance of the technique begins with the positioning of the patient. The patient should be placed in a position of comfort with the patient lying down on one side. Depending on practitioner comfort, the posterior spinous process may be positioned close to or far from the table (the patient either laying on the side with the spinous process posterior or anterior given the diagnosed rotation).", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Preparation. The performance of the technique begins with the positioning of the patient. The patient should be placed in a position of comfort with the patient lying down on one side. Depending on practitioner comfort, the posterior spinous process may be positioned close to or far from the table (the patient either laying on the side with the spinous process posterior or anterior given the diagnosed rotation)."}
+{"id": "article-102958_15", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Preparation", "content": "The goal will be to rotate the patient against the pathologic rotation of the diagnosis (also known as the restrictive barrier), and so the practitioner can push or pull on the patient\u2019s pelvis and thorax for the desired rotation (practitioner preference as above). For example, a patient is evaluated and found to have L3 Flexed Rotated and Sidebent (L3 FRS right) right (the L3 vertebra has rotated to the right relative to L4). The goal is to manually rotate the L3 vertebra to the left to correct the dysfunction as HVLA is a direct technique (acts in a direction to counteract the dysfunction). [7]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Preparation. The goal will be to rotate the patient against the pathologic rotation of the diagnosis (also known as the restrictive barrier), and so the practitioner can push or pull on the patient\u2019s pelvis and thorax for the desired rotation (practitioner preference as above). For example, a patient is evaluated and found to have L3 Flexed Rotated and Sidebent (L3 FRS right) right (the L3 vertebra has rotated to the right relative to L4). The goal is to manually rotate the L3 vertebra to the left to correct the dysfunction as HVLA is a direct technique (acts in a direction to counteract the dysfunction). [7]"}
+{"id": "article-102958_16", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Technique or Treatment", "content": "For a planned thrust where the practitioner is pulling on the patient's pelvis and pushing the thorax, the posterior transverse process is oriented down (closer to the table) with the patient in a lateral lying position. It may be helpful to imagine manipulation of the patient's upper body as manipulation of the superior vertebra (the vertebra diagnosed with dysfunction) and the patient's bottom half as manipulating the lower vertebra, with additional positioning to assist in directing forces to the area of concern.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Technique or Treatment. For a planned thrust where the practitioner is pulling on the patient's pelvis and pushing the thorax, the posterior transverse process is oriented down (closer to the table) with the patient in a lateral lying position. It may be helpful to imagine manipulation of the patient's upper body as manipulation of the superior vertebra (the vertebra diagnosed with dysfunction) and the patient's bottom half as manipulating the lower vertebra, with additional positioning to assist in directing forces to the area of concern."}
+{"id": "article-102958_17", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Technique or Treatment", "content": "Additional positioning continues with the practitioner taking hold of the patient's legs with their more\u00a0inferiorly directed arm, while their other arm palpates the spinous process of the dysfunctional vertebral segment. While palpating for movement, adjust the flexion of the patient's hips with the goal being to detect initial flexion in the dysfunctional vertebral segment (or just below). This step helps to direct the eventual thrust forces to the segment in question. Once the desired flexion in the lumbar spine is achieved, the practitioner instructs the patient to straighten the leg closer to the table and hook the foot of the higher leg (with the leg still bent) over the posterior knee (in the popliteal fossa) of the straightened leg that is in contact with the table.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Technique or Treatment. Additional positioning continues with the practitioner taking hold of the patient's legs with their more\u00a0inferiorly directed arm, while their other arm palpates the spinous process of the dysfunctional vertebral segment. While palpating for movement, adjust the flexion of the patient's hips with the goal being to detect initial flexion in the dysfunctional vertebral segment (or just below). This step helps to direct the eventual thrust forces to the segment in question. Once the desired flexion in the lumbar spine is achieved, the practitioner instructs the patient to straighten the leg closer to the table and hook the foot of the higher leg (with the leg still bent) over the posterior knee (in the popliteal fossa) of the straightened leg that is in contact with the table."}
+{"id": "article-102958_18", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Technique or Treatment", "content": "The end result should create a sort of hinge effect of the top leg over the straight bottom leg with the patient still on their side. Keeping the patient in the established positioning, the practitioner can take their superiorly oriented hand and place it on the patient's lateral rib cage (away from the table). The inferior arm now can come to the patient's hip as the patient is guided in a gentle twisting motion such that the patient's shoulder blades should both nearly touch the table and the patient's hips are rotated toward the practitioner (this motion should create a twisting motion to counter the dysfunctional segment). Continuing this motion, one should reach a limit of the rotation of the spine based on the new dysfunctional limit of rotation, colloquially known as \"locking out the segment.\" \"Locking out\" demonstrates utilizing Fryette's\u00a0principles to isolate the desired joint and to minimize movement\u00a0in\u00a0other joints that may hinder the manipulation. This position should occur before the physiologic limit of rotation, given the dysfunction's presence further limits spinal motion (the aim of the treatment is to improve this range of motion).", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Technique or Treatment. The end result should create a sort of hinge effect of the top leg over the straight bottom leg with the patient still on their side. Keeping the patient in the established positioning, the practitioner can take their superiorly oriented hand and place it on the patient's lateral rib cage (away from the table). The inferior arm now can come to the patient's hip as the patient is guided in a gentle twisting motion such that the patient's shoulder blades should both nearly touch the table and the patient's hips are rotated toward the practitioner (this motion should create a twisting motion to counter the dysfunctional segment). Continuing this motion, one should reach a limit of the rotation of the spine based on the new dysfunctional limit of rotation, colloquially known as \"locking out the segment.\" \"Locking out\" demonstrates utilizing Fryette's\u00a0principles to isolate the desired joint and to minimize movement\u00a0in\u00a0other joints that may hinder the manipulation. This position should occur before the physiologic limit of rotation, given the dysfunction's presence further limits spinal motion (the aim of the treatment is to improve this range of motion)."}
+{"id": "article-102958_19", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Technique or Treatment", "content": "Once the segment is in this limited position, the patient is instructed to take a deep breath in and release. The goal of the practitioner is the thrust through this barrier of motion in a controlled manner when the patient is totally relaxed (at the end of expiration is a common method). The thrust is directed primarily with the hand/arm on the patient's hips toward the table, perpendicular to the axis of rotation. The thrust should be quick and only with sufficient force to move the segments without causing injury to the patient. Following the thrust, the patient may be returned to a neutral rotation and re-examined. Assessing for the degree of change in the segments following the adjustment is a crucial aspect of the treatment as it guides whether the technique should be repeated. [7] [8]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Technique or Treatment. Once the segment is in this limited position, the patient is instructed to take a deep breath in and release. The goal of the practitioner is the thrust through this barrier of motion in a controlled manner when the patient is totally relaxed (at the end of expiration is a common method). The thrust is directed primarily with the hand/arm on the patient's hips toward the table, perpendicular to the axis of rotation. The thrust should be quick and only with sufficient force to move the segments without causing injury to the patient. Following the thrust, the patient may be returned to a neutral rotation and re-examined. Assessing for the degree of change in the segments following the adjustment is a crucial aspect of the treatment as it guides whether the technique should be repeated. [7] [8]"}
+{"id": "article-102958_20", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Technique or Treatment", "content": "Performing the thrust with the opposite transverse process orientation is another option. The primary difference will be to push the hips of the patient away while the patient's upper body rotates toward the examiner (opposite of the above setup). Regardless of the choice of treatment options, the patient should still be re-assessed following completion of the adjustment.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Technique or Treatment. Performing the thrust with the opposite transverse process orientation is another option. The primary difference will be to push the hips of the patient away while the patient's upper body rotates toward the examiner (opposite of the above setup). Regardless of the choice of treatment options, the patient should still be re-assessed following completion of the adjustment."}
+{"id": "article-102958_21", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Technique or Treatment", "content": "It should be noted that the patient's torso can be further manipulated in either of these techniques to create elements of side-bending as well. These elements should counteract the direction of the dysfunction. Based on the dysfunction, the practitioner can direct the arm of the patient cephalad or caudad while initiating the locking step to induce side bending. For example, in a patient with the diagnosis of L4 flexed, rotated, and side-bent right, the side-bending component of the dysfunction is to the right; this would mean that while positioning the patient in the transverse process side down technique above (where the posterior transverse process is towards the table), the patient's table side arm can be directed cephalad (relative to the patient orientation) to induce leftward side-bending prior to the thrust.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Technique or Treatment. It should be noted that the patient's torso can be further manipulated in either of these techniques to create elements of side-bending as well. These elements should counteract the direction of the dysfunction. Based on the dysfunction, the practitioner can direct the arm of the patient cephalad or caudad while initiating the locking step to induce side bending. For example, in a patient with the diagnosis of L4 flexed, rotated, and side-bent right, the side-bending component of the dysfunction is to the right; this would mean that while positioning the patient in the transverse process side down technique above (where the posterior transverse process is towards the table), the patient's table side arm can be directed cephalad (relative to the patient orientation) to induce leftward side-bending prior to the thrust."}
+{"id": "article-102958_22", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Complications", "content": "Complications of the lumbar spine HVLA are very rare, but naturally, the chances of occurrence increase with the above contraindications. These complications can include fractures of lumbar vertebrae, soft tissue strains, and other soft tissue injuries. In rare cases, the patient's subjective pain may be made worse following an HVLA adjustment. These complications once again speak to the importance of practitioner-patient communication as well as the importance of proper setup, isolation of the dysfunction, and reevaluation after an attempted HVLA adjustment.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Complications. Complications of the lumbar spine HVLA are very rare, but naturally, the chances of occurrence increase with the above contraindications. These complications can include fractures of lumbar vertebrae, soft tissue strains, and other soft tissue injuries. In rare cases, the patient's subjective pain may be made worse following an HVLA adjustment. These complications once again speak to the importance of practitioner-patient communication as well as the importance of proper setup, isolation of the dysfunction, and reevaluation after an attempted HVLA adjustment."}
+{"id": "article-102958_23", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Clinical Significance", "content": "Lumbar spine HVLA represents a possible adjunctive therapy for lower back pain, as previously discussed. These techniques have shown measurable effects on the surrounding neurological structures of the spine. [9] [10] Such measurable results lend credibility to the technique efficacy when properly applied. As outlined above, the proper application includes careful patient selection and diagnosis before the HVLA procedure. Following, the procedure patient evaluation through subjective means is typically the method of eliciting feedback on treatment success or failure. This subjective aspect is a principal criticism of osteopathic manipulation at large. Despite this limitation, there have been numerous studies outlining improvements of symptoms and patient satisfaction following osteopathic manipulative techniques. [11]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Clinical Significance. Lumbar spine HVLA represents a possible adjunctive therapy for lower back pain, as previously discussed. These techniques have shown measurable effects on the surrounding neurological structures of the spine. [9] [10] Such measurable results lend credibility to the technique efficacy when properly applied. As outlined above, the proper application includes careful patient selection and diagnosis before the HVLA procedure. Following, the procedure patient evaluation through subjective means is typically the method of eliciting feedback on treatment success or failure. This subjective aspect is a principal criticism of osteopathic manipulation at large. Despite this limitation, there have been numerous studies outlining improvements of symptoms and patient satisfaction following osteopathic manipulative techniques. [11]"}
+{"id": "article-102958_24", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Enhancing Healthcare Team Outcomes", "content": "The practical application of osteopathic manipulative treatment, in particular, high-velocity low-amplitude, into a patient treatment regimen can pose several challenges to a provider. The first such obstacle can be finding a provider proficient in the desired technique. While osteopathic physicians are a growing population of the modern health care team, not all providers retain proficiency in a wide range of osteopathic techniques. This situation is increasingly true as osteopathic providers continue to branch out into various specialties.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Enhancing Healthcare Team Outcomes. The practical application of osteopathic manipulative treatment, in particular, high-velocity low-amplitude, into a patient treatment regimen can pose several challenges to a provider. The first such obstacle can be finding a provider proficient in the desired technique. While osteopathic physicians are a growing population of the modern health care team, not all providers retain proficiency in a wide range of osteopathic techniques. This situation is increasingly true as osteopathic providers continue to branch out into various specialties."}
+{"id": "article-102958_25", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Enhancing Healthcare Team Outcomes", "content": "Even for providers who themselves feel comfortable providing osteopathic treatment to their patients, finding time in a standard visit to perform manipulation can be challenging. [12] [Level 5] One approach adopted by several facilities has been to have a dedicated clinic for osteopathic and other manual medicine techniques. In this way, the visit can be geared specifically toward discussing treatment options and performing techniques with patients.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Enhancing Healthcare Team Outcomes. Even for providers who themselves feel comfortable providing osteopathic treatment to their patients, finding time in a standard visit to perform manipulation can be challenging. [12] [Level 5] One approach adopted by several facilities has been to have a dedicated clinic for osteopathic and other manual medicine techniques. In this way, the visit can be geared specifically toward discussing treatment options and performing techniques with patients."}
+{"id": "article-102958_26", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Enhancing Healthcare Team Outcomes", "content": "This approach greatly increases the time available to the provider performing the technique, rather than rushing to fit it into an otherwise narrow time window of a regular visit. Along these lines, the provider should become aware of specialty clinics that specialize in the implementation of OMT if the provider suspects a patient may benefit from such a visit. [13] [Level 5]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Enhancing Healthcare Team Outcomes. This approach greatly increases the time available to the provider performing the technique, rather than rushing to fit it into an otherwise narrow time window of a regular visit. Along these lines, the provider should become aware of specialty clinics that specialize in the implementation of OMT if the provider suspects a patient may benefit from such a visit. [13] [Level 5]"}
+{"id": "article-102958_27", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Lumbar Vertebrae -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

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+{"id": "article-102960_0", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Continuing Education Activity", "content": "Lumbar somatic dysfunctions appear when any of the lumbar vertebrae are moved from neutral. These positions include being rotated, side bent, flexed, and extended. Lumbar somatic dysfunctions are common in persons with chronic back pain. This activity outlines the evaluation of lumbar somatic dysfunctions and treatment with counterstrain and facilitated positional release and reviews the role of the interprofessional team in improving care for patients with this condition.", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Continuing Education Activity. Lumbar somatic dysfunctions appear when any of the lumbar vertebrae are moved from neutral. These positions include being rotated, side bent, flexed, and extended. Lumbar somatic dysfunctions are common in persons with chronic back pain. This activity outlines the evaluation of lumbar somatic dysfunctions and treatment with counterstrain and facilitated positional release and reviews the role of the interprofessional team in improving care for patients with this condition."}
+{"id": "article-102960_1", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Continuing Education Activity", "content": "Objectives: Identify the indications for performing lumbar counterstrain or facilitated positional release. Outline the typical presentation of a patient with a lumbar somatic dysfunction. Describe the steps of performing lumbar counterstrain or facilitated positional release. Explain the importance of collaboration and communication amongst the interprofessional team to improve outcomes for patients affected by lumbar somatic dysfunctions. Access free multiple choice questions on this topic.", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Continuing Education Activity. Objectives: Identify the indications for performing lumbar counterstrain or facilitated positional release. Outline the typical presentation of a patient with a lumbar somatic dysfunction. Describe the steps of performing lumbar counterstrain or facilitated positional release. Explain the importance of collaboration and communication amongst the interprofessional team to improve outcomes for patients affected by lumbar somatic dysfunctions. Access free multiple choice questions on this topic."}
+{"id": "article-102960_2", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Introduction", "content": "The lumbar spine is involved in a myriad of duties, including weight-bearing, providing a sound structure that allows for locomotion, and upholding the spinal neural structures. With constant motion and close proximity to a network of nerves, the lumbar spine is a common source of low back pain. Low back pain is common in the adult population. Some estimates show that 84% of the adults in the United States will experience low back pain at some point in their life. [1] [2] [3] A metanalysis has found that Osteopathic Manipulative Treatment (OMT) can significantly reduce lower back pain. [4]", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Introduction. The lumbar spine is involved in a myriad of duties, including weight-bearing, providing a sound structure that allows for locomotion, and upholding the spinal neural structures. With constant motion and close proximity to a network of nerves, the lumbar spine is a common source of low back pain. Low back pain is common in the adult population. Some estimates show that 84% of the adults in the United States will experience low back pain at some point in their life. [1] [2] [3] A metanalysis has found that Osteopathic Manipulative Treatment (OMT) can significantly reduce lower back pain. [4]"}
+{"id": "article-102960_3", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Introduction", "content": "There are a variety of Osteopathic Manipulative Treatments (OMT) aimed at reducing lower back pain, two of which include counterstrain (CS) and facilitated positional release (FPR) techniques. Both of these techniques are considered to be indirect techniques, meaning they take the patient away from the restrictive barrier. The basis of the CS technique is\u00a0identifying the\u00a0inappropriately hypertonic, or shortened muscle belly, which causes an excessive amount of\u00a0discomfort during activation or palpation. CS aims to relieve the muscle\u2019s tension indirectly. To achieve this, the muscle is placed in a position of ease for a sustained period. [5] FPR is a similar indirect technique\u00a0that places the somatic dysfunction\u00a0in a neutral position and adds an activating compressive or\u00a0rotational force. [6]", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Introduction. There are a variety of Osteopathic Manipulative Treatments (OMT) aimed at reducing lower back pain, two of which include counterstrain (CS) and facilitated positional release (FPR) techniques. Both of these techniques are considered to be indirect techniques, meaning they take the patient away from the restrictive barrier. The basis of the CS technique is\u00a0identifying the\u00a0inappropriately hypertonic, or shortened muscle belly, which causes an excessive amount of\u00a0discomfort during activation or palpation. CS aims to relieve the muscle\u2019s tension indirectly. To achieve this, the muscle is placed in a position of ease for a sustained period. [5] FPR is a similar indirect technique\u00a0that places the somatic dysfunction\u00a0in a neutral position and adds an activating compressive or\u00a0rotational force. [6]"}
+{"id": "article-102960_4", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Introduction", "content": "While focusing treatment on the lumbar musculature, it is important to evaluate and treat the adjacent axial skeleton and spinal segments. A full osteopathic treatment should consist of evaluating\u00a0the surrounding structures such as the thoracic spine, sacrum, and the pelvis for alleviating and preventing further lumbar somatic dysfunction and associated back pain. [7] [8] This educational paper aims to educate on these two osteopathic treatment modalities for lumbar somatic dysfunctions: counterstrain and facilitated positional release.", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Introduction. While focusing treatment on the lumbar musculature, it is important to evaluate and treat the adjacent axial skeleton and spinal segments. A full osteopathic treatment should consist of evaluating\u00a0the surrounding structures such as the thoracic spine, sacrum, and the pelvis for alleviating and preventing further lumbar somatic dysfunction and associated back pain. [7] [8] This educational paper aims to educate on these two osteopathic treatment modalities for lumbar somatic dysfunctions: counterstrain and facilitated positional release."}
+{"id": "article-102960_5", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Anatomy and Physiology", "content": "Thirty-three vertebrae make up the entirety of the spine. Each vertebra is shaped differently and can group into cervical, thoracic, lumbar, sacral, and coccygeal.", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Anatomy and Physiology. Thirty-three vertebrae make up the entirety of the spine. Each vertebra is shaped differently and can group into cervical, thoracic, lumbar, sacral, and coccygeal."}
+{"id": "article-102960_6", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Anatomy and Physiology", "content": "The lumbar spine consists of fine boney vertebrae that follow a similar shape.\u00a0Between each vertebra, there is a fibrocartilage intervertebral disk that provides cushioning. The anterior surface of the bone is the body. Most of the weight of the spinal column is placed here. Since the lumbar vertebrae are towards the caudal end of the spine, they carry most of the most bodyweight and are thus thicker than the cervical and thoracic vertebrae.", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Anatomy and Physiology. The lumbar spine consists of fine boney vertebrae that follow a similar shape.\u00a0Between each vertebra, there is a fibrocartilage intervertebral disk that provides cushioning. The anterior surface of the bone is the body. Most of the weight of the spinal column is placed here. Since the lumbar vertebrae are towards the caudal end of the spine, they carry most of the most bodyweight and are thus thicker than the cervical and thoracic vertebrae."}
+{"id": "article-102960_7", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Anatomy and Physiology", "content": "The vertebra arch forms the posterior surface of the vertebrae. The arch consists of a left and right-sided pedicel and lamina. The arch creates a circular opening in which the spinal cord runs through down the length of the back. Many structures project off of the arch.", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Anatomy and Physiology. The vertebra arch forms the posterior surface of the vertebrae. The arch consists of a left and right-sided pedicel and lamina. The arch creates a circular opening in which the spinal cord runs through down the length of the back. Many structures project off of the arch."}
+{"id": "article-102960_8", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Anatomy and Physiology", "content": "Two transverse processes project off the vertebral arch laterally, one to the left and one to the right. There is a thick and rounded spinous process that projects off the arch posteriorly in the midline. Four articular processes arise from the arch; two superiorly on the left and right sides and two inferiorly on the left and right sides. Each of the articular processes connects with articular processes from the vertebra above and below it; this allows for the major motion of the lumbar vertebrae to be flexion and extension.", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Anatomy and Physiology. Two transverse processes project off the vertebral arch laterally, one to the left and one to the right. There is a thick and rounded spinous process that projects off the arch posteriorly in the midline. Four articular processes arise from the arch; two superiorly on the left and right sides and two inferiorly on the left and right sides. Each of the articular processes connects with articular processes from the vertebra above and below it; this allows for the major motion of the lumbar vertebrae to be flexion and extension."}
+{"id": "article-102960_9", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Anatomy and Physiology", "content": "Since there is a significant amount of movement that can exist in the lumbar spine, individual lumbar segments can move out of place. Each segment can become improperly aligned by being either rotated, side bent, flexed, or extended. With many muscular attachments and nerves surrounding the bones, there is potential for the out of place vertebral segments to cause pain. [9] [10]", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Anatomy and Physiology. Since there is a significant amount of movement that can exist in the lumbar spine, individual lumbar segments can move out of place. Each segment can become improperly aligned by being either rotated, side bent, flexed, or extended. With many muscular attachments and nerves surrounding the bones, there is potential for the out of place vertebral segments to cause pain. [9] [10]"}
+{"id": "article-102960_10", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Anatomy and Physiology", "content": "One of the major functions of the spinal vertebrae is to house the spinal cord. Some nerves run through the spinal cord and exit out the intervertebral foramen. In the lumbar spine, five pairs of nerves emerge from the cord and carry both motor and sensory neurons. These nerves correspond to a vertebra and exit below their corresponding segment. These then provide innervation to structures surrounding the spine. It is important to note the pain pattern the patient describes. Knowing where each nerve root exits and what the nerve innervates will allow the practitioner to target the treatment to the appropriate spinal segment. [9] [11]", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Anatomy and Physiology. One of the major functions of the spinal vertebrae is to house the spinal cord. Some nerves run through the spinal cord and exit out the intervertebral foramen. In the lumbar spine, five pairs of nerves emerge from the cord and carry both motor and sensory neurons. These nerves correspond to a vertebra and exit below their corresponding segment. These then provide innervation to structures surrounding the spine. It is important to note the pain pattern the patient describes. Knowing where each nerve root exits and what the nerve innervates will allow the practitioner to target the treatment to the appropriate spinal segment. [9] [11]"}
+{"id": "article-102960_11", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Anatomy and Physiology", "content": "To perform a\u00a0CS or FPR technique, one must find a somatic dysfunction or an area of exquisite tenderness in a muscle, tendon, or ligament. The practitioner then places the patient\u2019s body in a position where the tenderness significantly decreases. In a CS technique, the practitioner holds the position for 90 seconds. To complete an FPR maneuver, the practitioner adds a facilitating force of compression or rotation for three seconds. There are many theories of how\u00a0CS and FPR manipulation work, but the most common theory is that the tender point exists because of the overstretching of myofascial tissue resulting in a neuromuscular imbalance. [12] This activity causes an increase in the gamma gain of a muscle spindle. The muscle spindle then sends a signal to the central nervous system, which is perceived as pain. Placing the patient\u2019s body in a position to decrease the pain in the tender point decreases the reflex arc and resets the muscle spindle signal. [13] [14]", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Anatomy and Physiology. To perform a\u00a0CS or FPR technique, one must find a somatic dysfunction or an area of exquisite tenderness in a muscle, tendon, or ligament. The practitioner then places the patient\u2019s body in a position where the tenderness significantly decreases. In a CS technique, the practitioner holds the position for 90 seconds. To complete an FPR maneuver, the practitioner adds a facilitating force of compression or rotation for three seconds. There are many theories of how\u00a0CS and FPR manipulation work, but the most common theory is that the tender point exists because of the overstretching of myofascial tissue resulting in a neuromuscular imbalance. [12] This activity causes an increase in the gamma gain of a muscle spindle. The muscle spindle then sends a signal to the central nervous system, which is perceived as pain. Placing the patient\u2019s body in a position to decrease the pain in the tender point decreases the reflex arc and resets the muscle spindle signal. [13] [14]"}
+{"id": "article-102960_12", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Indications", "content": "The indications to perform OMT on a lumbar segment includes the presence of somatic dysfunction in the lumbar segments. OMT consists of two basic categories: direct and indirect techniques. Indirect techniques like CS and FPR put the muscle and or spinal segment in their position of ease. Thus, these techniques are gentler and can be used on almost all patients, including children and the elderly. [15] [16] In patients with acute somatic dysfunctions, as would be seen soon after a car accident or fall, indirect techniques are often preferred.", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Indications. The indications to perform OMT on a lumbar segment includes the presence of somatic dysfunction in the lumbar segments. OMT consists of two basic categories: direct and indirect techniques. Indirect techniques like CS and FPR put the muscle and or spinal segment in their position of ease. Thus, these techniques are gentler and can be used on almost all patients, including children and the elderly. [15] [16] In patients with acute somatic dysfunctions, as would be seen soon after a car accident or fall, indirect techniques are often preferred."}
+{"id": "article-102960_13", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Contraindications", "content": "Absolute contraindications Absence of somatic dysfunction The patient cannot or does not give consent for the treatment Local acute fracture in the treatment area [17] Relative contraindications Placing the patient in the treatment position would exacerbate a vascular or neurological condition Severe spondylosis with local fusion and no motion at the level treated Severe hip osteoporosis Previous hip dislocation The patient is unable to give feedback [12]", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Contraindications. Absolute contraindications Absence of somatic dysfunction The patient cannot or does not give consent for the treatment Local acute fracture in the treatment area [17] Relative contraindications Placing the patient in the treatment position would exacerbate a vascular or neurological condition Severe spondylosis with local fusion and no motion at the level treated Severe hip osteoporosis Previous hip dislocation The patient is unable to give feedback [12]"}
+{"id": "article-102960_14", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Equipment", "content": "Equipment needed for this procedure includes an OMT table for the patient to sit or lie on and a stool for the practitioner to sit.", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Equipment. Equipment needed for this procedure includes an OMT table for the patient to sit or lie on and a stool for the practitioner to sit."}
+{"id": "article-102960_15", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Personnel", "content": "CS and FPR only require one practitioner to perform the techniques, so the only personnel needed is the practitioner.", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Personnel. CS and FPR only require one practitioner to perform the techniques, so the only personnel needed is the practitioner."}
+{"id": "article-102960_16", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Preparation", "content": "Before treatment, the practitioner should discuss with the patient all of the risks and benefits of the procedure as well as any alternative treatments. The practitioner should also obtain the patient's consent.", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Preparation. Before treatment, the practitioner should discuss with the patient all of the risks and benefits of the procedure as well as any alternative treatments. The practitioner should also obtain the patient's consent."}
+{"id": "article-102960_17", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Preparation", "content": "Once the procedure is explained, and the patient has given consent, then proceed to evaluate\u00a0the lumbar spine. A thorough evaluation will consist of establishing a pain scale, a visual assessment, muscle strength testing, as well as a range of motion testing for the lumbar spine. These will be critical to be able to compare\u00a0the progress made after treatment. An osteopathic evaluation should be completed to find any somatic dysfunctions and or tender points.", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Preparation. Once the procedure is explained, and the patient has given consent, then proceed to evaluate\u00a0the lumbar spine. A thorough evaluation will consist of establishing a pain scale, a visual assessment, muscle strength testing, as well as a range of motion testing for the lumbar spine. These will be critical to be able to compare\u00a0the progress made after treatment. An osteopathic evaluation should be completed to find any somatic dysfunctions and or tender points."}
+{"id": "article-102960_18", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Technique or Treatment -- Lumbar Counterstrain", "content": "The lumbar spine has five anterior tender points and five posterior tender points. The tender points are named for the lumbar vertebra with which they correspond.", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Technique or Treatment -- Lumbar Counterstrain. The lumbar spine has five anterior tender points and five posterior tender points. The tender points are named for the lumbar vertebra with which they correspond."}
+{"id": "article-102960_19", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Technique or Treatment -- Lumbar Counterstrain", "content": "Counterstrain is an indirect technique in which the\u00a0practitioner places the patient away from the restrictive barrier. The basic procedure for all counterstrain techniques starts with the practitioner finding a tender point in a muscle, ligament, or tendon. The practitioner then presses on the tender point with one finger with just enough pressure to blanch the practitioner's diagnosis finger. The practitioner establishes a pain scale, letting the patient know that the tender point's pain is considered 100%. Without moving the monitoring finger, the practitioner moves the patient to find a position where the tender point pain is reduced by 70% or more. This may require fine-tuning the position until the patient feels at least 70% relief. Once that position is found, it is held for 90 seconds while continuing to monitor the tender point. After 90 seconds has passed, the practitioner slowly and passively brings the patient back to neutral and then reassesses the tender point.", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Technique or Treatment -- Lumbar Counterstrain. Counterstrain is an indirect technique in which the\u00a0practitioner places the patient away from the restrictive barrier. The basic procedure for all counterstrain techniques starts with the practitioner finding a tender point in a muscle, ligament, or tendon. The practitioner then presses on the tender point with one finger with just enough pressure to blanch the practitioner's diagnosis finger. The practitioner establishes a pain scale, letting the patient know that the tender point's pain is considered 100%. Without moving the monitoring finger, the practitioner moves the patient to find a position where the tender point pain is reduced by 70% or more. This may require fine-tuning the position until the patient feels at least 70% relief. Once that position is found, it is held for 90 seconds while continuing to monitor the tender point. After 90 seconds has passed, the practitioner slowly and passively brings the patient back to neutral and then reassesses the tender point."}
+{"id": "article-102960_20", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Technique or Treatment -- Lumbar Counterstrain", "content": "L1 Anterior Tender Point", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Technique or Treatment -- Lumbar Counterstrain. L1 Anterior Tender Point"}
+{"id": "article-102960_21", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Technique or Treatment -- Lumbar Counterstrain", "content": "The patient begins by lying supine on the table. Determine if a tender point exists by pressing medial to the anterior superior iliac spines. If the area is tender, stand next to the table on the side of the tender point. Keep light pressure on the tender point with one finger and bring the patient's knees and hips into about 90 degrees of flexion. If desired, the\u00a0practitioner may bring their leg up to the table and rest the patient's legs on their knee. Hold the position for 90 seconds, then bring the patient's legs back to neutral and reassess the tender point. L2 Anterior Tender Point", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Technique or Treatment -- Lumbar Counterstrain. The patient begins by lying supine on the table. Determine if a tender point exists by pressing medial to the anterior superior iliac spines. If the area is tender, stand next to the table on the side of the tender point. Keep light pressure on the tender point with one finger and bring the patient's knees and hips into about 90 degrees of flexion. If desired, the\u00a0practitioner may bring their leg up to the table and rest the patient's legs on their knee. Hold the position for 90 seconds, then bring the patient's legs back to neutral and reassess the tender point. L2 Anterior Tender Point"}
+{"id": "article-102960_22", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Technique or Treatment -- Lumbar Counterstrain", "content": "The patient begins by lying supine on the table. Determine if a tender point exists by pressing medial to the anterior inferior iliac spines. If the area is tender, stand on the opposite side of the table of the tender point. Keep light pressure on the tender point with one finger, with the other hand, bring the patient's hips and knees into about 90 degrees of flexion and rotate the hips 60 degrees away from the tender point. Hold the position for 90 seconds, then bring the patient's legs back to neutral and reassess the tender point. L3 Anterior Tender Point", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Technique or Treatment -- Lumbar Counterstrain. The patient begins by lying supine on the table. Determine if a tender point exists by pressing medial to the anterior inferior iliac spines. If the area is tender, stand on the opposite side of the table of the tender point. Keep light pressure on the tender point with one finger, with the other hand, bring the patient's hips and knees into about 90 degrees of flexion and rotate the hips 60 degrees away from the tender point. Hold the position for 90 seconds, then bring the patient's legs back to neutral and reassess the tender point. L3 Anterior Tender Point"}
+{"id": "article-102960_23", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Technique or Treatment -- Lumbar Counterstrain", "content": "The patient begins by lying supine on the table. Determine if a tender point exists by pressing laterally to the anterior inferior iliac spines. If the area is tender, stand next to the table on the side of the tender point. Keep light pressure on the tender point with one finger, with the other hand, bring the patient's knees and hips into about 90 degrees of flexion and slightly rotate the legs toward the tender point. If desired, the practitioner may bring their leg up to the table to rest the patient's legs on their knee. Side bend the patient's spine away from the tender point. Hold the position for 90 seconds, then bring the patient's legs back to neutral and reassess the tender point. L4 Anterior Tender Point", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Technique or Treatment -- Lumbar Counterstrain. The patient begins by lying supine on the table. Determine if a tender point exists by pressing laterally to the anterior inferior iliac spines. If the area is tender, stand next to the table on the side of the tender point. Keep light pressure on the tender point with one finger, with the other hand, bring the patient's knees and hips into about 90 degrees of flexion and slightly rotate the legs toward the tender point. If desired, the practitioner may bring their leg up to the table to rest the patient's legs on their knee. Side bend the patient's spine away from the tender point. Hold the position for 90 seconds, then bring the patient's legs back to neutral and reassess the tender point. L4 Anterior Tender Point"}
+{"id": "article-102960_24", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Technique or Treatment -- Lumbar Counterstrain", "content": "The patient begins by lying supine on the table. Determine if a tender point exists by pressing below the anterior inferior iliac spines. If the area is tender, stand next to the table on the side of the tender point. Keep light pressure on the tender point with one finger, use the other hand to bring the patient's knees and hips into about 90 degrees of flexion and slightly rotate toward the tender point. If desired, the practitioner may bring their leg up to the table to rest the patient's legs on their knee. Side bend the patient's spine away from the tender point. Hold the position for 90 seconds, then bring the patient's legs back to neutral and reassess the tender point. L5 Anterior Tender Point", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Technique or Treatment -- Lumbar Counterstrain. The patient begins by lying supine on the table. Determine if a tender point exists by pressing below the anterior inferior iliac spines. If the area is tender, stand next to the table on the side of the tender point. Keep light pressure on the tender point with one finger, use the other hand to bring the patient's knees and hips into about 90 degrees of flexion and slightly rotate toward the tender point. If desired, the practitioner may bring their leg up to the table to rest the patient's legs on their knee. Side bend the patient's spine away from the tender point. Hold the position for 90 seconds, then bring the patient's legs back to neutral and reassess the tender point. L5 Anterior Tender Point"}
+{"id": "article-102960_25", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Technique or Treatment -- Lumbar Counterstrain", "content": "The patient begins by lying supine on the table. Determine if a tender point exists by pressing on\u00a0the respective the pubic ramus, just lateral to the symphysis. If the area is tender, stand next to the table on the side of the tender point. Keep light pressure on the tender point with one finger, use the other hand to bring the patient's knees and hips into about 90 degrees of flexion. Bring the patient's far ankle to cross over the nearer ankle and spread the knees slightly apart. Hold the position for 90 seconds, then bring the patient's legs back to neutral and reassess the tender point. L1-5 Posterior Tender Point", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Technique or Treatment -- Lumbar Counterstrain. The patient begins by lying supine on the table. Determine if a tender point exists by pressing on\u00a0the respective the pubic ramus, just lateral to the symphysis. If the area is tender, stand next to the table on the side of the tender point. Keep light pressure on the tender point with one finger, use the other hand to bring the patient's knees and hips into about 90 degrees of flexion. Bring the patient's far ankle to cross over the nearer ankle and spread the knees slightly apart. Hold the position for 90 seconds, then bring the patient's legs back to neutral and reassess the tender point. L1-5 Posterior Tender Point"}
+{"id": "article-102960_26", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Technique or Treatment -- Lumbar Counterstrain", "content": "The patient begins by lying prone on the table. The posterior tender points for L1-5 can be located on the spinous process, transverse process, or in between the two on the corresponding lumbar segment. Locate a tender point and stand on the side of the table opposite of the tender point. Lift the leg on the side of the tender point. If the tender point is midline extension may be enough if the tender point if further out toward the transverse process, pull the leg into adduction. Hold the position for 90 seconds, then bring the patient's leg back to neutral and reassess the tender point. L3,4,5 Upper Pole Tender Points", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Technique or Treatment -- Lumbar Counterstrain. The patient begins by lying prone on the table. The posterior tender points for L1-5 can be located on the spinous process, transverse process, or in between the two on the corresponding lumbar segment. Locate a tender point and stand on the side of the table opposite of the tender point. Lift the leg on the side of the tender point. If the tender point is midline extension may be enough if the tender point if further out toward the transverse process, pull the leg into adduction. Hold the position for 90 seconds, then bring the patient's leg back to neutral and reassess the tender point. L3,4,5 Upper Pole Tender Points"}
+{"id": "article-102960_27", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Technique or Treatment -- Lumbar Counterstrain", "content": "The patient begins by lying prone on the table. The L3, L4, L5 upper pole tender points can be located 2/3 linear distance from the posterior inferior iliac spine (PSIS) to the tensor fascia latae, the posterior edge of the tensor facia latae, and superior and medial to the PSIS, respectively. Locate a tender point and stands on the side of the table opposite the tender point. Lift the patient's leg on the side of the tender point and pull the leg into adduction. Hold the position for 90 seconds, then bring the patient's leg back to neutral and reassess the tender point. Lower Pole L5 Tender Point", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Technique or Treatment -- Lumbar Counterstrain. The patient begins by lying prone on the table. The L3, L4, L5 upper pole tender points can be located 2/3 linear distance from the posterior inferior iliac spine (PSIS) to the tensor fascia latae, the posterior edge of the tensor facia latae, and superior and medial to the PSIS, respectively. Locate a tender point and stands on the side of the table opposite the tender point. Lift the patient's leg on the side of the tender point and pull the leg into adduction. Hold the position for 90 seconds, then bring the patient's leg back to neutral and reassess the tender point. Lower Pole L5 Tender Point"}
+{"id": "article-102960_28", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Technique or Treatment -- Lumbar Counterstrain", "content": "The patient begins by lying prone on the table. The lower pole tender point for L5 can be located inferior to the PSIS. Locate a tender point and sit on a stool on the side of the table of the tender point. Drop the patient's leg off the table and bring the knee and hip into about 90 degrees of flexion. Adduct the thigh by bringing the knee in towards the table. Hold the position for 90 seconds, then bring the patient's leg back to neutral and reassess the tender point.", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Technique or Treatment -- Lumbar Counterstrain. The patient begins by lying prone on the table. The lower pole tender point for L5 can be located inferior to the PSIS. Locate a tender point and sit on a stool on the side of the table of the tender point. Drop the patient's leg off the table and bring the knee and hip into about 90 degrees of flexion. Adduct the thigh by bringing the knee in towards the table. Hold the position for 90 seconds, then bring the patient's leg back to neutral and reassess the tender point."}
+{"id": "article-102960_29", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Technique or Treatment -- Lumbar Facilitated Positional Release", "content": "FPR is also an indirect technique where the practitioner places the patient away from the restrictive barrier. The basic procedure for all FPR techniques is to find a somatic dysfunction, monitor the dysfunction with one finger, then place the patient's body into a position of ease. This will hyper-shorten the muscle or exaggerate the dysfunctional vertebra and allow the muscle spindle to decrease its output. Lastly, a facilitating force is applied by adding compression, torsion, or a\u00a0union of both for three seconds. The facilitating force is released, and the patient is returned to neutral, and the monitoring finger can let go to reassess the somatic dysfunction. Low Back Superficial Muscle Hypertonicity", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Technique or Treatment -- Lumbar Facilitated Positional Release. FPR is also an indirect technique where the practitioner places the patient away from the restrictive barrier. The basic procedure for all FPR techniques is to find a somatic dysfunction, monitor the dysfunction with one finger, then place the patient's body into a position of ease. This will hyper-shorten the muscle or exaggerate the dysfunctional vertebra and allow the muscle spindle to decrease its output. Lastly, a facilitating force is applied by adding compression, torsion, or a\u00a0union of both for three seconds. The facilitating force is released, and the patient is returned to neutral, and the monitoring finger can let go to reassess the somatic dysfunction. Low Back Superficial Muscle Hypertonicity"}
+{"id": "article-102960_30", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Technique or Treatment -- Lumbar Facilitated Positional Release", "content": "The patient begins by lying prone on the table. Straighten the lumbar lordotic curve by placing a pillow under the patient's abdomen. Locate an area of lower back superficial muscle hypertonicity and stand on the side of the hypertonic muscle. Monitor the hypertonic muscle with one finger. Move the patient's legs toward the side of the table of the hypertonicity until motion is felt under the monitoring finger. This will induce lumbar side bending toward the side of the hypertonicity. Cross the patient's farther leg over the closer leg to induce more of a side bend. Hold the patient's farther thigh and rotate it externally while extending the thigh. Keep moving until motion\u00a0can be felt with the monitoring finger. Hold the position for three seconds. Bring the patient's leg back to neutral and reassess the hypertonic muscle. Lumbar Segment Extension Dysfunction", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Technique or Treatment -- Lumbar Facilitated Positional Release. The patient begins by lying prone on the table. Straighten the lumbar lordotic curve by placing a pillow under the patient's abdomen. Locate an area of lower back superficial muscle hypertonicity and stand on the side of the hypertonic muscle. Monitor the hypertonic muscle with one finger. Move the patient's legs toward the side of the table of the hypertonicity until motion is felt under the monitoring finger. This will induce lumbar side bending toward the side of the hypertonicity. Cross the patient's farther leg over the closer leg to induce more of a side bend. Hold the patient's farther thigh and rotate it externally while extending the thigh. Keep moving until motion\u00a0can be felt with the monitoring finger. Hold the position for three seconds. Bring the patient's leg back to neutral and reassess the hypertonic muscle. Lumbar Segment Extension Dysfunction"}
+{"id": "article-102960_31", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Technique or Treatment -- Lumbar Facilitated Positional Release", "content": "Assess the patient's lumbar spinal segments for an extension dysfunction. Once an extension dysfunction is found, the patient begins by lying prone on the table. Straighten the lumbar lordotic curve by placing a pillow under the patient's abdomen. Place a second pillow under the thigh in which the spinal segment is rotated, and side bent towards (e.g., for an L3 Extended SLRL segment place a second pillow under the patient's left thigh). Stand on the side of the table towards which the spinal segment is rotated and side bent. Monitor the most posterior transverse process of the dysfunctional vertebra with one finger. Bring the patient's closest leg into abduction and internal rotation until motion\u00a0can be felt at the monitoring finger. Internal rotation is achievable by grasping above the patient's ankle to rotate the leg. Then press the leg down toward the floor until motion can be felt at the monitoring finger. Hold the position for three seconds. Bring the patient's leg back to neutral and reassess.", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Technique or Treatment -- Lumbar Facilitated Positional Release. Assess the patient's lumbar spinal segments for an extension dysfunction. Once an extension dysfunction is found, the patient begins by lying prone on the table. Straighten the lumbar lordotic curve by placing a pillow under the patient's abdomen. Place a second pillow under the thigh in which the spinal segment is rotated, and side bent towards (e.g., for an L3 Extended SLRL segment place a second pillow under the patient's left thigh). Stand on the side of the table towards which the spinal segment is rotated and side bent. Monitor the most posterior transverse process of the dysfunctional vertebra with one finger. Bring the patient's closest leg into abduction and internal rotation until motion\u00a0can be felt at the monitoring finger. Internal rotation is achievable by grasping above the patient's ankle to rotate the leg. Then press the leg down toward the floor until motion can be felt at the monitoring finger. Hold the position for three seconds. Bring the patient's leg back to neutral and reassess."}
+{"id": "article-102960_32", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Technique or Treatment -- Lumbar Facilitated Positional Release", "content": "Lumbar Segment Flexion Dysfunction", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Technique or Treatment -- Lumbar Facilitated Positional Release. Lumbar Segment Flexion Dysfunction"}
+{"id": "article-102960_33", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Technique or Treatment -- Lumbar Facilitated Positional Release", "content": "Assess the patient's lumbar spinal segments for a flexion dysfunction. Once a flexion dysfunction is found, the patient begins by lying prone on the table. Straighten the lumbar lordotic curve by placing a pillow under the patient's abdomen. Sit on a stool on the side of the table in which the spinal segment is rotated, and side bent towards (e.g., for an L3FSLRL dysfunction sit on the left side). Monitor the most posterior transverse process of the dysfunctional vertebra with one finger. Bring the patient's closest leg off the table. Holding the patient's knee, bring the patient's knee and hip into flexion until motion can be felt at the monitoring finger. Then press the patient's knee into adduction and internal rotation of the hip until motion can be felt at the monitoring finger. Hold the position for 3 seconds. Bring the patient's leg back to neutral and reassess.", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Technique or Treatment -- Lumbar Facilitated Positional Release. Assess the patient's lumbar spinal segments for a flexion dysfunction. Once a flexion dysfunction is found, the patient begins by lying prone on the table. Straighten the lumbar lordotic curve by placing a pillow under the patient's abdomen. Sit on a stool on the side of the table in which the spinal segment is rotated, and side bent towards (e.g., for an L3FSLRL dysfunction sit on the left side). Monitor the most posterior transverse process of the dysfunctional vertebra with one finger. Bring the patient's closest leg off the table. Holding the patient's knee, bring the patient's knee and hip into flexion until motion can be felt at the monitoring finger. Then press the patient's knee into adduction and internal rotation of the hip until motion can be felt at the monitoring finger. Hold the position for 3 seconds. Bring the patient's leg back to neutral and reassess."}
+{"id": "article-102960_34", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Complications", "content": "CS and FPR are two of the most gentle osteopathic techniques. Practitioners\u00a0should warn their patients of possible soreness and stiffness to the area, which is not uncommon considering the dysfunction. It is also important to discuss reasonable outcomes after the treatment\u00a0and the\u00a0need for possible repeat applications due to the nature of their dysfunction.", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Complications. CS and FPR are two of the most gentle osteopathic techniques. Practitioners\u00a0should warn their patients of possible soreness and stiffness to the area, which is not uncommon considering the dysfunction. It is also important to discuss reasonable outcomes after the treatment\u00a0and the\u00a0need for possible repeat applications due to the nature of their dysfunction."}
+{"id": "article-102960_35", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Clinical Significance", "content": "Low back pain is a common reason for an individual to see a healthcare provider. Some estimates say there is up to a 70% prevalence of low back pain in affluent countries. [18] [19] Treating back pain can also become expensive with some diagnosis requiring things such as imaging, costly procedures, medications, and physical rehabilitation. Besides being potentially financially draining, lower back pain can have negative psychological effects and is associated with a depressed mood and emotional distress. [20] Treating a patient with OMT not only provides immediate care and possible relief from pain but also can reduce the cost of care for a patient that is trying to avoid surgery or other costly procedures. [21]", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Clinical Significance. Low back pain is a common reason for an individual to see a healthcare provider. Some estimates say there is up to a 70% prevalence of low back pain in affluent countries. [18] [19] Treating back pain can also become expensive with some diagnosis requiring things such as imaging, costly procedures, medications, and physical rehabilitation. Besides being potentially financially draining, lower back pain can have negative psychological effects and is associated with a depressed mood and emotional distress. [20] Treating a patient with OMT not only provides immediate care and possible relief from pain but also can reduce the cost of care for a patient that is trying to avoid surgery or other costly procedures. [21]"}
+{"id": "article-102960_36", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Enhancing Healthcare Team Outcomes", "content": "Lower back pain can stem from a multitude of causes and create a significant\u00a0cost on the patient, and healthcare, as a whole. These can include but are not limited to spinal fracture, tumor, herniated disk, stenosis, rheumatoid arthritis, and somatic dysfunctions. [19] While the practitioner may initially be the one to diagnose a patient with lower back pain, there is a team of professionals needed to consult, further treat, and keep in contact with the patient. When a patient presents with back pain, it is important to obtain the vital signs which may be performed by a nurse. Imaging may be required; in this case, a radiologist will be essential to come to a diagnosis. [22]", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Enhancing Healthcare Team Outcomes. Lower back pain can stem from a multitude of causes and create a significant\u00a0cost on the patient, and healthcare, as a whole. These can include but are not limited to spinal fracture, tumor, herniated disk, stenosis, rheumatoid arthritis, and somatic dysfunctions. [19] While the practitioner may initially be the one to diagnose a patient with lower back pain, there is a team of professionals needed to consult, further treat, and keep in contact with the patient. When a patient presents with back pain, it is important to obtain the vital signs which may be performed by a nurse. Imaging may be required; in this case, a radiologist will be essential to come to a diagnosis. [22]"}
+{"id": "article-102960_37", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Enhancing Healthcare Team Outcomes", "content": "Once a diagnosis has been reached, the care for the patient needs to continue. Analgesics, antibiotics, or other medications may be necessary.\u00a0A pharmacist will be necessary to dispense and confirm that the patient is on the correct medications. If bracing or other assistive devices are needed, a nurse will be the one to educate the patient on the proper way to use the equipment. A physical and or occupational therapist may be necessary to help the patient recover mobility, strength, and coordination.", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Enhancing Healthcare Team Outcomes. Once a diagnosis has been reached, the care for the patient needs to continue. Analgesics, antibiotics, or other medications may be necessary.\u00a0A pharmacist will be necessary to dispense and confirm that the patient is on the correct medications. If bracing or other assistive devices are needed, a nurse will be the one to educate the patient on the proper way to use the equipment. A physical and or occupational therapist may be necessary to help the patient recover mobility, strength, and coordination."}
+{"id": "article-102960_38", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Enhancing Healthcare Team Outcomes", "content": "Besides working to regain physical function, chronic back pain can have a negative psychological effect on the patient. [23] [24] A psychologist may be recruited to treat any further compounding or secondary conditions due to the lifestyle caused by the dysfunction. Working as an interprofessional team will ensure that the patient's goals, expectations, and health are properly\u00a0optimized,\u00a0thereby reducing the morbidity and mortality. [25] [Level 5]", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Enhancing Healthcare Team Outcomes. Besides working to regain physical function, chronic back pain can have a negative psychological effect on the patient. [23] [24] A psychologist may be recruited to treat any further compounding or secondary conditions due to the lifestyle caused by the dysfunction. Working as an interprofessional team will ensure that the patient's goals, expectations, and health are properly\u00a0optimized,\u00a0thereby reducing the morbidity and mortality. [25] [Level 5]"}
+{"id": "article-102960_39", "title": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Osteopathic Manipulative Treatment: Counterstrain and Facilitated Positional Release (FPR) Procedure - Lumbar Vertebrae -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

statpearls/chunk/article-102961.jsonl

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+{"id": "article-102961_0", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Continuing Education Activity", "content": "Muscle energy and counterstrain technique are two of the modalities used in a larger group of treatments known as osteopathic manipulative treatments (OMT). Often, before more advanced therapies or medications, more conservative measures can be taken to help treat disease processes. This activity reviews the evaluation and treatment of the piriformis muscle and highlights the role of the interprofessional team in evaluating and treating this condition.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Continuing Education Activity. Muscle energy and counterstrain technique are two of the modalities used in a larger group of treatments known as osteopathic manipulative treatments (OMT). Often, before more advanced therapies or medications, more conservative measures can be taken to help treat disease processes. This activity reviews the evaluation and treatment of the piriformis muscle and highlights the role of the interprofessional team in evaluating and treating this condition."}
+{"id": "article-102961_1", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Continuing Education Activity", "content": "Objectives: Identify the indications for muscle energy and counterstrain. Describe the technique in which to treat the piriformis muscle using muscle energy. Outline the technique in which to treat the piriformis muscle using counterstrain. Summarize how to evaluate the piriformis muscle prior to treating it using osteopathic manipulative treatment. Access free multiple choice questions on this topic.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Continuing Education Activity. Objectives: Identify the indications for muscle energy and counterstrain. Describe the technique in which to treat the piriformis muscle using muscle energy. Outline the technique in which to treat the piriformis muscle using counterstrain. Summarize how to evaluate the piriformis muscle prior to treating it using osteopathic manipulative treatment. Access free multiple choice questions on this topic."}
+{"id": "article-102961_2", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Introduction", "content": "Osteopathic manipulative treatment (OMT) is a group of techniques developed using manual manipulation to treat somatic dysfunction. Its goal is to improve the range of motion of muscles/joints, enhance neuromuscular function, decrease overall pain, and improve biochemical balance. [1] Two particular techniques often used in osteopathic practice are muscle energy technique (MET) and counterstrain technique. Muscle energy is an active and direct technique that engages the patient\u2019s restrictive barrier. The patient contracts the muscle of interest while the physician introduces a counterforce. [2] The counterforce can either be isometric or isotonic, and isotonic forces can be concentric or eccentric. Counterstrain technique is a passive and indirect technique that involves identifying a tender point or trigger point and using myofascial planes to maneuver the patient into a position that relieves pain. [3]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Introduction. Osteopathic manipulative treatment (OMT) is a group of techniques developed using manual manipulation to treat somatic dysfunction. Its goal is to improve the range of motion of muscles/joints, enhance neuromuscular function, decrease overall pain, and improve biochemical balance. [1] Two particular techniques often used in osteopathic practice are muscle energy technique (MET) and counterstrain technique. Muscle energy is an active and direct technique that engages the patient\u2019s restrictive barrier. The patient contracts the muscle of interest while the physician introduces a counterforce. [2] The counterforce can either be isometric or isotonic, and isotonic forces can be concentric or eccentric. Counterstrain technique is a passive and indirect technique that involves identifying a tender point or trigger point and using myofascial planes to maneuver the patient into a position that relieves pain. [3]"}
+{"id": "article-102961_3", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Introduction -- Piriformis Muscle/Syndrome", "content": "Often, hypertrophy, irritation, or overuse of the piriformis muscle can lead to piriformis syndrome. Pain resulting from hypertrophy and overuse is an often overlooked cause of back or buttock pain. Additionally, due to the location of the muscle within the pelvis, it can mimic sciatic pain with radiation to the lower extremities. [4] The piriformis muscle can cause sciatic nerve entrapment syndrome.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Introduction -- Piriformis Muscle/Syndrome. Often, hypertrophy, irritation, or overuse of the piriformis muscle can lead to piriformis syndrome. Pain resulting from hypertrophy and overuse is an often overlooked cause of back or buttock pain. Additionally, due to the location of the muscle within the pelvis, it can mimic sciatic pain with radiation to the lower extremities. [4] The piriformis muscle can cause sciatic nerve entrapment syndrome."}
+{"id": "article-102961_4", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Anatomy and Physiology", "content": "The piriformis muscle is a flat and pyramid or pear-shaped muscle that is part of a larger group of muscles responsible for external or lateral rotation of the hip; gemellus superior, obturator internus, gemellus inferior, quadratus femoris, and obturator externus muscles. [5]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Anatomy and Physiology. The piriformis muscle is a flat and pyramid or pear-shaped muscle that is part of a larger group of muscles responsible for external or lateral rotation of the hip; gemellus superior, obturator internus, gemellus inferior, quadratus femoris, and obturator externus muscles. [5]"}
+{"id": "article-102961_5", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Anatomy and Physiology", "content": "The piriformis muscle proximally attaches to the anterior and lateral surfaces of the sacrum and sacrotuberous ligament, exiting the pelvis through the greater sciatic foramen, and distally attaches to the greater trochanter of the femur. Dependent on if the hip is extended or flexed, the piriformis will externally rotate or abduct the hip, respectively. [6] The muscle is innervated by the nerve to the piriformis muscle supplied by S1-S2. Due to the position on the piriformis muscle within the pelvis, many nerves course above, below, and sometimes even through the muscle. [7] In particular, the sciatic nerve has a close passage relationship (above, through, or below).", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Anatomy and Physiology. The piriformis muscle proximally attaches to the anterior and lateral surfaces of the sacrum and sacrotuberous ligament, exiting the pelvis through the greater sciatic foramen, and distally attaches to the greater trochanter of the femur. Dependent on if the hip is extended or flexed, the piriformis will externally rotate or abduct the hip, respectively. [6] The muscle is innervated by the nerve to the piriformis muscle supplied by S1-S2. Due to the position on the piriformis muscle within the pelvis, many nerves course above, below, and sometimes even through the muscle. [7] In particular, the sciatic nerve has a close passage relationship (above, through, or below)."}
+{"id": "article-102961_6", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Anatomy and Physiology", "content": "Muscle energy techniques (METs) were born from the American Fred Mitchell in 1974. These techniques are a manipulative diagnosis and treatment methodology in which the patient's muscles are the active, intrinsic part. Everything is performed with precise and controlled positions, with directions that follow certain axes and against a specific resistance, more or less intense, by the operator. There are nerve reflexes that regulate the posturo-dynamic system: the neuromuscular unit that first controls this system is the reflex arc. This concept works according to a closed circuit: the nerve impulse originating from the muscle penetrates the posterior horn of the gray matter of the spinal cord and transmits the impulse, through a synaptic contact, to the motor neurons of the anterior horn, causing a contractile response. The monosynaptic reflex is referred to as the myotatic reflex. The receptor that coordinates this mechanism is the neuromuscular spindle, which is particularly sensitive to the stretching stimulus.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Anatomy and Physiology. Muscle energy techniques (METs) were born from the American Fred Mitchell in 1974. These techniques are a manipulative diagnosis and treatment methodology in which the patient's muscles are the active, intrinsic part. Everything is performed with precise and controlled positions, with directions that follow certain axes and against a specific resistance, more or less intense, by the operator. There are nerve reflexes that regulate the posturo-dynamic system: the neuromuscular unit that first controls this system is the reflex arc. This concept works according to a closed circuit: the nerve impulse originating from the muscle penetrates the posterior horn of the gray matter of the spinal cord and transmits the impulse, through a synaptic contact, to the motor neurons of the anterior horn, causing a contractile response. The monosynaptic reflex is referred to as the myotatic reflex. The receptor that coordinates this mechanism is the neuromuscular spindle, which is particularly sensitive to the stretching stimulus."}
+{"id": "article-102961_7", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Anatomy and Physiology", "content": "The most important receptor part is at the spindle poles and is the portion most directed towards the points of insertion of the striated muscle, which is closely related to the connective system of the muscle itself. The spindle is in parallel with the muscle fibers that surround it. In the excitation of the spindle, a dynamic component is distinguished, which occurs during the elongation of the spindle (signaled to the nerve centers through the discharge of the primary fibers; predominantly phasic signaling), and a static component, given by the new length that the muscle reaches (signaled by the discharge of secondary fibers, mainly tonic signaling). In the direct myotatic reflex, in addition to the stimulation of the agonist by more or less mild strains, there is also the automatic release of the antagonist.\u00a0From this last notion comes the concept of MET techniques, as it is possible to gain a greater articular excursion thanks to the co-traction / release balance of the musculature that involves a given joint. Furthermore, METs help the musculature with a dysfunctional tonicity condition decrease its tone and recover a more physiological muscle length. [3] [8] [9]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Anatomy and Physiology. The most important receptor part is at the spindle poles and is the portion most directed towards the points of insertion of the striated muscle, which is closely related to the connective system of the muscle itself. The spindle is in parallel with the muscle fibers that surround it. In the excitation of the spindle, a dynamic component is distinguished, which occurs during the elongation of the spindle (signaled to the nerve centers through the discharge of the primary fibers; predominantly phasic signaling), and a static component, given by the new length that the muscle reaches (signaled by the discharge of secondary fibers, mainly tonic signaling). In the direct myotatic reflex, in addition to the stimulation of the agonist by more or less mild strains, there is also the automatic release of the antagonist.\u00a0From this last notion comes the concept of MET techniques, as it is possible to gain a greater articular excursion thanks to the co-traction / release balance of the musculature that involves a given joint. Furthermore, METs help the musculature with a dysfunctional tonicity condition decrease its tone and recover a more physiological muscle length. [3] [8] [9]"}
+{"id": "article-102961_8", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Anatomy and Physiology", "content": "The strain counterstrain technique, formerly called \"spontaneous release from positioning,\" was devised in the 1950s by the American osteopathic physician Dr. Lawrence H. Jones, who developed this innovative approach to treating musculoskeletal disorders. The key concept of the technique is to find a comfortable position for each ailment that the patients accused: the doctor spent over twenty years of study to develop and create the definitive strain and counterstrain technique with its \"tender points\" (TP) anterior and posterior to the body, its ninety seconds of repositioning and the right sequence of diagnosis and treatment. The TPs, tense points, are small areas of tension in the tissues of the whole body, which, once localized, orient the diagnosis and guide the operator in his evaluation and treatment strategy.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Anatomy and Physiology. The strain counterstrain technique, formerly called \"spontaneous release from positioning,\" was devised in the 1950s by the American osteopathic physician Dr. Lawrence H. Jones, who developed this innovative approach to treating musculoskeletal disorders. The key concept of the technique is to find a comfortable position for each ailment that the patients accused: the doctor spent over twenty years of study to develop and create the definitive strain and counterstrain technique with its \"tender points\" (TP) anterior and posterior to the body, its ninety seconds of repositioning and the right sequence of diagnosis and treatment. The TPs, tense points, are small areas of tension in the tissues of the whole body, which, once localized, orient the diagnosis and guide the operator in his evaluation and treatment strategy."}
+{"id": "article-102961_9", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Anatomy and Physiology", "content": "The ideal position in which there is at least a two-thirds reduction in tension in the (TP) indicates correct body positioning. When Dr. Lawrence Jones died, there were approximately 180 TPs and related techniques. To date, his successors have developed and improved the technique covering over 200 TPs. TPs are not like trigger points because TPs have a different location. Therefore, the strain counterstrain technique is an osteopathic manual approach, which consists of a procedure of passive repositioning of the body towards a position of greater comfort. The technique consists of a gentle over-stretch directed in the opposite direction to the erroneous stretch message. This passive position relieves the patient of pain and restores the dysfunctional area, reducing and stopping the inappropriate proprioceptive activity that maintains the somatic dysfunction in the affected area. One theory to explain the benefits of this approach is the reduction of nociceptive afferents, which improves muscle efferences and prevents non-physiological muscle reflexes.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Anatomy and Physiology. The ideal position in which there is at least a two-thirds reduction in tension in the (TP) indicates correct body positioning. When Dr. Lawrence Jones died, there were approximately 180 TPs and related techniques. To date, his successors have developed and improved the technique covering over 200 TPs. TPs are not like trigger points because TPs have a different location. Therefore, the strain counterstrain technique is an osteopathic manual approach, which consists of a procedure of passive repositioning of the body towards a position of greater comfort. The technique consists of a gentle over-stretch directed in the opposite direction to the erroneous stretch message. This passive position relieves the patient of pain and restores the dysfunctional area, reducing and stopping the inappropriate proprioceptive activity that maintains the somatic dysfunction in the affected area. One theory to explain the benefits of this approach is the reduction of nociceptive afferents, which improves muscle efferences and prevents non-physiological muscle reflexes."}
+{"id": "article-102961_10", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Indications", "content": "Somatic dysfunction Shortened/spastic muscle Low back pain with or without resulting neuropathy Pelvic imbalance Limited ROM of muscle and/or extremity/joint Localized edema Trigger points Pain", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Indications. Somatic dysfunction Shortened/spastic muscle Low back pain with or without resulting neuropathy Pelvic imbalance Limited ROM of muscle and/or extremity/joint Localized edema Trigger points Pain"}
+{"id": "article-102961_11", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Contraindications", "content": "Fracture Torn ligament and/or tendon Joint instability Recent surgery Absence of somatic dysfunction and/or symptoms Patient refusal or nonconsenting/uncooperative patient Active infection/open wounds Neuropathic pain Pain caused by infections", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Contraindications. Fracture Torn ligament and/or tendon Joint instability Recent surgery Absence of somatic dysfunction and/or symptoms Patient refusal or nonconsenting/uncooperative patient Active infection/open wounds Neuropathic pain Pain caused by infections"}
+{"id": "article-102961_12", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Equipment", "content": "Preferably an osteopathic manipulative treatment (OMT) table, but an exam table or massage table is also acceptable as long as it is maneuverable to accommodate for positioning of patient and physician. Stool Pillow for patient comfort", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Equipment. Preferably an osteopathic manipulative treatment (OMT) table, but an exam table or massage table is also acceptable as long as it is maneuverable to accommodate for positioning of patient and physician. Stool Pillow for patient comfort"}
+{"id": "article-102961_13", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Personnel", "content": "A clinician trained in osteopathic medicine A patient that has consented to the procedure and has no contraindications for treatment", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Personnel. A clinician trained in osteopathic medicine A patient that has consented to the procedure and has no contraindications for treatment"}
+{"id": "article-102961_14", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Preparation", "content": "It is important to evaluate the piriformis muscle before engaging in treatment for two reasons, first to address and note the severity of the dysfunction prior to treatment, and second, to assess improvement of the dysfunction after treatment. Evaluation of the piriformis muscle can occur in one of three ways depending on which technique an osteopathic physician is using to treat Supine Grab the ankles above the medial malleolus bilaterally (apply gentle traction to ensure that any rotation is coming from the hip and not the knees) and internally rotate to compare both sides The extremity that does not internally rotate can potentially have a spasm within the piriformis muscle. Prone Bend knees at 90 degrees and have the patient drop their legs laterally The extremity that laterally drops the least can potentially have a spasm within the piriformis muscle. Tender-point/trigger-point Find the point of tenderness at the body of the piriformis muscle.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Preparation. It is important to evaluate the piriformis muscle before engaging in treatment for two reasons, first to address and note the severity of the dysfunction prior to treatment, and second, to assess improvement of the dysfunction after treatment. Evaluation of the piriformis muscle can occur in one of three ways depending on which technique an osteopathic physician is using to treat Supine Grab the ankles above the medial malleolus bilaterally (apply gentle traction to ensure that any rotation is coming from the hip and not the knees) and internally rotate to compare both sides The extremity that does not internally rotate can potentially have a spasm within the piriformis muscle. Prone Bend knees at 90 degrees and have the patient drop their legs laterally The extremity that laterally drops the least can potentially have a spasm within the piriformis muscle. Tender-point/trigger-point Find the point of tenderness at the body of the piriformis muscle."}
+{"id": "article-102961_15", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Technique or Treatment -- Counterstrain", "content": "Lay the patient in the prone position and have the practitioner\u00a0sit on the same side as the affected piriformis muscle Locate the tender point at the body of the piriformis muscle Classically this can be found 2\u00a0to 3 inches medial and slightly cephalad to the greater trochanter, or; Bisect the distance between the PSIS and ILA of the ipsilateral side, then bisect the distance between this point and the ipsilateral greater trochanter Have the practitioner suspend the patient's lower extremity off the edge of the table, flex the hip (approximately 135 degrees) while also abducting and externally rotating as needed until tenderness is relieved Hold the position for 90 seconds and slowly return the patient to a neutral position Reassess patient for tenderness", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Technique or Treatment -- Counterstrain. Lay the patient in the prone position and have the practitioner\u00a0sit on the same side as the affected piriformis muscle Locate the tender point at the body of the piriformis muscle Classically this can be found 2\u00a0to 3 inches medial and slightly cephalad to the greater trochanter, or; Bisect the distance between the PSIS and ILA of the ipsilateral side, then bisect the distance between this point and the ipsilateral greater trochanter Have the practitioner suspend the patient's lower extremity off the edge of the table, flex the hip (approximately 135 degrees) while also abducting and externally rotating as needed until tenderness is relieved Hold the position for 90 seconds and slowly return the patient to a neutral position Reassess patient for tenderness"}
+{"id": "article-102961_16", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Technique or Treatment -- Muscle Energy", "content": "Lay the patient in the supine position and have the practitioner\u00a0stand on the same side as the affected piriformis muscle Bend the knee of the affected side and place the foot of that side on the lateral aspect of the opposite knee Have the practitioner push knee medially until meeting the restrictive barrier Have the patient push against the practitioner's\u00a0resistance for 3\u00a0to 5 seconds, allow for a period of isometric relaxation, then engage a new barrier; repeat three times. [10] Return the patient to a neutral position and reassess using supine or prone piriformis testing.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Technique or Treatment -- Muscle Energy. Lay the patient in the supine position and have the practitioner\u00a0stand on the same side as the affected piriformis muscle Bend the knee of the affected side and place the foot of that side on the lateral aspect of the opposite knee Have the practitioner push knee medially until meeting the restrictive barrier Have the patient push against the practitioner's\u00a0resistance for 3\u00a0to 5 seconds, allow for a period of isometric relaxation, then engage a new barrier; repeat three times. [10] Return the patient to a neutral position and reassess using supine or prone piriformis testing."}
+{"id": "article-102961_17", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Complications", "content": "While OMT is generally very safe, common side effects of non-high-velocity techniques are fatigue, headache, or localized and radiating pains, but typically resolve within 24 hours after treatment. [11]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Complications. While OMT is generally very safe, common side effects of non-high-velocity techniques are fatigue, headache, or localized and radiating pains, but typically resolve within 24 hours after treatment. [11]"}
+{"id": "article-102961_18", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Clinical Significance", "content": "Although muscle relaxants, NSAIDs, and steroid injections are possible options to treat the piriformis muscle, the use of counterstrain and muscle energy on patients is an effective and conservative alternative\u00a0or adjunct to other treatment modalities.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Clinical Significance. Although muscle relaxants, NSAIDs, and steroid injections are possible options to treat the piriformis muscle, the use of counterstrain and muscle energy on patients is an effective and conservative alternative\u00a0or adjunct to other treatment modalities."}
+{"id": "article-102961_19", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Clinical Significance", "content": "The manual approach must be repeated with other osteopathic sessions because if the problem derives from a chronic condition, it is necessary to have sufficient time to change the texture of the tissue and the related neurological reflexes. Additional sessions will depend on the patient's physiological response and the cause of the dysfunction.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Clinical Significance. The manual approach must be repeated with other osteopathic sessions because if the problem derives from a chronic condition, it is necessary to have sufficient time to change the texture of the tissue and the related neurological reflexes. Additional sessions will depend on the patient's physiological response and the cause of the dysfunction."}
+{"id": "article-102961_20", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Enhancing Healthcare Team Outcomes", "content": "While osteopathic medicine has existed for over 130 years, many healthcare professionals still poorly understand it. This lack of understanding is partly due to differences in training during residency and medical school education and lack of practice in the inpatient and outpatient settings. Modalities such as muscle energy and counterstrain technique, when appropriate, can help enhance outcomes of patients and their symptoms. It is crucial for the interdisciplinary teams treating patients to understand the role of OMT in treatments and that OMT can serve as an adjunct therapy to existing therapies in place.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Enhancing Healthcare Team Outcomes. While osteopathic medicine has existed for over 130 years, many healthcare professionals still poorly understand it. This lack of understanding is partly due to differences in training during residency and medical school education and lack of practice in the inpatient and outpatient settings. Modalities such as muscle energy and counterstrain technique, when appropriate, can help enhance outcomes of patients and their symptoms. It is crucial for the interdisciplinary teams treating patients to understand the role of OMT in treatments and that OMT can serve as an adjunct therapy to existing therapies in place."}
+{"id": "article-102961_21", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Piriformis Muscle -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

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+{"id": "article-102963_0", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Continuing Education Activity", "content": "Psoas syndrome is a disorder of the iliopsoas muscle leading to back pain, groin pain, snapping hip, buttock up, or difficulty standing. Psoas dysfunctions are common in athletes but can also impact the general population due to their frequent activation as a hip flexor during walking and everyday activities. This activity reviews the muscle energy treatment of the iliopsoas muscle and highlights the role of the interprofessional team in evaluating and treating this condition.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Continuing Education Activity. Psoas syndrome is a disorder of the iliopsoas muscle leading to back pain, groin pain, snapping hip, buttock up, or difficulty standing. Psoas dysfunctions are common in athletes but can also impact the general population due to their frequent activation as a hip flexor during walking and everyday activities. This activity reviews the muscle energy treatment of the iliopsoas muscle and highlights the role of the interprofessional team in evaluating and treating this condition."}
+{"id": "article-102963_1", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Continuing Education Activity", "content": "Objectives: Review the classic presentation and physical exam findings of psoas syndrome. Describe the anatomy of the iliopsoas muscle related to psoas syndrome and mechanisms underlying muscle energy and counterstrain treatments. Describe the muscle energy treatments of the iliopsoas muscle from both the supine and prone positions. Review the contraindications to muscle energy and counterstrain treatment of the iliopsoas muscle. Access free multiple choice questions on this topic.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Continuing Education Activity. Objectives: Review the classic presentation and physical exam findings of psoas syndrome. Describe the anatomy of the iliopsoas muscle related to psoas syndrome and mechanisms underlying muscle energy and counterstrain treatments. Describe the muscle energy treatments of the iliopsoas muscle from both the supine and prone positions. Review the contraindications to muscle energy and counterstrain treatment of the iliopsoas muscle. Access free multiple choice questions on this topic."}
+{"id": "article-102963_2", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Introduction", "content": "Psoas syndrome\u00a0results from dysfunction of the\u00a0iliopsoas muscle and causes a constellation of symptoms, including low back pain, groin pain, pelvic pain, or buttock pain. The primary action of the iliopsoas muscle is hip flexion. Therefore, back pain may occur with\u00a0standing, walking, or changing position from sitting to standing. [1] The associated buttock pain is often on the contralateral side and can radiate down to the knee. When the iliopsoas tendon passes over a bony prominence, it can cause rubbing at these points that produce a \u201cpop\u201d or \u201csnap,\u201d\u00a0leading to a condition called Coxa Saltans or snapping hip. [2] However, psoas syndrome can occur independently of snapping hip.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Introduction. Psoas syndrome\u00a0results from dysfunction of the\u00a0iliopsoas muscle and causes a constellation of symptoms, including low back pain, groin pain, pelvic pain, or buttock pain. The primary action of the iliopsoas muscle is hip flexion. Therefore, back pain may occur with\u00a0standing, walking, or changing position from sitting to standing. [1] The associated buttock pain is often on the contralateral side and can radiate down to the knee. When the iliopsoas tendon passes over a bony prominence, it can cause rubbing at these points that produce a \u201cpop\u201d or \u201csnap,\u201d\u00a0leading to a condition called Coxa Saltans or snapping hip. [2] However, psoas syndrome can occur independently of snapping hip."}
+{"id": "article-102963_3", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Introduction", "content": "Psoas syndrome is commonly seen in athletes, especially jumpers, dancers, and runners, and is among the most common causes of groin pain in this group. [3] However, psoas syndrome can occur in non-athletes due to overuse, given its function as a hip flexor and external rotator of the leg. Treatment typically consists of conservative measures such as\u00a0activity modification, physical therapy, manual therapy, NSAIDs, and corticosteroid injections. If conservative measures do not relieve symptoms, surgical iliopsoas release can be a consideration. [4]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Introduction. Psoas syndrome is commonly seen in athletes, especially jumpers, dancers, and runners, and is among the most common causes of groin pain in this group. [3] However, psoas syndrome can occur in non-athletes due to overuse, given its function as a hip flexor and external rotator of the leg. Treatment typically consists of conservative measures such as\u00a0activity modification, physical therapy, manual therapy, NSAIDs, and corticosteroid injections. If conservative measures do not relieve symptoms, surgical iliopsoas release can be a consideration. [4]"}
+{"id": "article-102963_4", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Introduction", "content": "This procedure review focuses on the use of osteopathic manipulative treatment (OMT) to treat iliopsoas dysfunction. The two specific osteopathic manipulative treatment modalities for the iliopsoas that will be discussed are muscle energy treatment (MET) and counterstrain (CS).", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Introduction. This procedure review focuses on the use of osteopathic manipulative treatment (OMT) to treat iliopsoas dysfunction. The two specific osteopathic manipulative treatment modalities for the iliopsoas that will be discussed are muscle energy treatment (MET) and counterstrain (CS)."}
+{"id": "article-102963_5", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Introduction", "content": "MET is a direct technique where the\u00a0muscle or joint\u00a0is taken into a restrictive barrier and asked to provide an isometric muscle contraction against the provider. [5] Following the isometric contraction, the muscle is relaxed, and the provider takes the dysfunction further into the restrictive barrier. The most common MET protocol, and the one described here, uses three to five repetitions of\u00a0isometric contraction followed by relaxation.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Introduction. MET is a direct technique where the\u00a0muscle or joint\u00a0is taken into a restrictive barrier and asked to provide an isometric muscle contraction against the provider. [5] Following the isometric contraction, the muscle is relaxed, and the provider takes the dysfunction further into the restrictive barrier. The most common MET protocol, and the one described here, uses three to five repetitions of\u00a0isometric contraction followed by relaxation."}
+{"id": "article-102963_6", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Introduction", "content": "CS is an indirect technique where a tenderpoint is localized and\u00a0moved into a position of ease for 90 seconds while monitoring for the reduction of pain and change in the texture of the tenderpoint. The muscle or joint returns to a neutral position, and the tenderpoint is released, resulting in a decrease in hypersensitivity and proprioceptive activity. [6]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Introduction. CS is an indirect technique where a tenderpoint is localized and\u00a0moved into a position of ease for 90 seconds while monitoring for the reduction of pain and change in the texture of the tenderpoint. The muscle or joint returns to a neutral position, and the tenderpoint is released, resulting in a decrease in hypersensitivity and proprioceptive activity. [6]"}
+{"id": "article-102963_7", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Anatomy and Physiology", "content": "The anatomy of the iliopsoas is critical in understanding its role in psoas syndrome and the proper technique of MET and CS treatment of iliopsoas dysfunction. The iliopsoas divides into two parts: 1) the psoas (major and minor) muscle and 2) the iliacus muscle. The psoas major originates at the T12 through L5 vertebrae and inserts on the lesser trochanter of the femur. The psoas minor originates at the T12 to L1 vertebrae and inserts at the iliopubic eminence. The iliacus muscle originates within the iliac fossa/sacral ala and inserts at the lesser trochanter of the femur. [7]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Anatomy and Physiology. The anatomy of the iliopsoas is critical in understanding its role in psoas syndrome and the proper technique of MET and CS treatment of iliopsoas dysfunction. The iliopsoas divides into two parts: 1) the psoas (major and minor) muscle and 2) the iliacus muscle. The psoas major originates at the T12 through L5 vertebrae and inserts on the lesser trochanter of the femur. The psoas minor originates at the T12 to L1 vertebrae and inserts at the iliopubic eminence. The iliacus muscle originates within the iliac fossa/sacral ala and inserts at the lesser trochanter of the femur. [7]"}
+{"id": "article-102963_8", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Anatomy and Physiology", "content": "The psoas major and minor muscles receive innervation of the L1-3 branches of the lumbar plexus, while the iliacus receives innervation from the femoral nerve. [7] The psoas and the iliacus muscle fibers pass deep to the inguinal ligament and merge to insert on the less trochanter of the femur. The iliopsoas is primarily responsible for hip flexion but also aids in external rotation of the leg and may also act as a stabilizer of the spine during hip flexion.\u00a0A study done by Hu et al. found that the contralateral psoas muscle was activated with hip flexion and is likely involved in spine stabilization. [8] OMT is used to treat iliopsoas somatic dysfunctions to decrease pain, improve range of motion, and restore neuromusculoskeletal function.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Anatomy and Physiology. The psoas major and minor muscles receive innervation of the L1-3 branches of the lumbar plexus, while the iliacus receives innervation from the femoral nerve. [7] The psoas and the iliacus muscle fibers pass deep to the inguinal ligament and merge to insert on the less trochanter of the femur. The iliopsoas is primarily responsible for hip flexion but also aids in external rotation of the leg and may also act as a stabilizer of the spine during hip flexion.\u00a0A study done by Hu et al. found that the contralateral psoas muscle was activated with hip flexion and is likely involved in spine stabilization. [8] OMT is used to treat iliopsoas somatic dysfunctions to decrease pain, improve range of motion, and restore neuromusculoskeletal function."}
+{"id": "article-102963_9", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Anatomy and Physiology", "content": "There are several proposed mechanisms for MET, but the two commonly accepted principles are 1) post-isometric relaxation and 2) reciprocal inhibition. Both principles take advantage of the\u00a0proprioceptive mechanisms within muscle fibers and joints, including the alpha motor neuron and Golgi tendon organ. Post-isometric relaxation is based on the theory that the muscle enters a refractory period following isometric contraction. During this refractory period, there is reduced muscle tone, which allows the muscle to be taken further into the restrictive barrier.\u00a0Reciprocal inhibition hypothesizes that there is a period of antagonist muscle relaxation following the contraction of the agonist muscle, which allows the muscle to be taken further into the restrictive barrier. [5]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Anatomy and Physiology. There are several proposed mechanisms for MET, but the two commonly accepted principles are 1) post-isometric relaxation and 2) reciprocal inhibition. Both principles take advantage of the\u00a0proprioceptive mechanisms within muscle fibers and joints, including the alpha motor neuron and Golgi tendon organ. Post-isometric relaxation is based on the theory that the muscle enters a refractory period following isometric contraction. During this refractory period, there is reduced muscle tone, which allows the muscle to be taken further into the restrictive barrier.\u00a0Reciprocal inhibition hypothesizes that there is a period of antagonist muscle relaxation following the contraction of the agonist muscle, which allows the muscle to be taken further into the restrictive barrier. [5]"}
+{"id": "article-102963_10", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Anatomy and Physiology", "content": "CS tenderpoints form due to injury or dysfunction of the muscle resulting in altered proprioception and hyperactivity of the affected muscle. During CS, the muscle becomes passively shortened to reset the Golgi tendon and return the muscle to its proper length and alignment. [6]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Anatomy and Physiology. CS tenderpoints form due to injury or dysfunction of the muscle resulting in altered proprioception and hyperactivity of the affected muscle. During CS, the muscle becomes passively shortened to reset the Golgi tendon and return the muscle to its proper length and alignment. [6]"}
+{"id": "article-102963_11", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Indications", "content": "Before initiating OMT, a somatic dysfunction should be present. Somatic dysfunction is a change in joint or muscle function or architecture. Somatic dysfunction describes tissue texture changes, asymmetry, restriction of motion, and tenderness. Examples of possible somatic dysfunctions of the iliopsoas include\u00a0hypertonic tissue texture, restriction in hip extension, and tenderness of the iliopsoas. Patients who would benefit from MET or CS treatments may also present with symptoms of psoas syndrome, as described above.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Indications. Before initiating OMT, a somatic dysfunction should be present. Somatic dysfunction is a change in joint or muscle function or architecture. Somatic dysfunction describes tissue texture changes, asymmetry, restriction of motion, and tenderness. Examples of possible somatic dysfunctions of the iliopsoas include\u00a0hypertonic tissue texture, restriction in hip extension, and tenderness of the iliopsoas. Patients who would benefit from MET or CS treatments may also present with symptoms of psoas syndrome, as described above."}
+{"id": "article-102963_12", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Indications", "content": "The choice of MET or CS as a treatment modality depends on the patient\u2019s status and physician preference. CS is a passive treatment that involves monitoring the psoas, shortening the muscle into a position of ease, and holding this position for an extended period. CS\u00a0is appropriate for a patient in extreme discomfort or someone unable to produce a coordinated muscle contraction.\u00a0MET is an active treatment that requires the patient to provide a voluntary isometric muscle contraction against the physician, followed by muscle relaxation during which the physician will take the dysfunction further into the restrictive barrier.\u00a0During both techniques, the patient must be able to provide feedback to the physician.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Indications. The choice of MET or CS as a treatment modality depends on the patient\u2019s status and physician preference. CS is a passive treatment that involves monitoring the psoas, shortening the muscle into a position of ease, and holding this position for an extended period. CS\u00a0is appropriate for a patient in extreme discomfort or someone unable to produce a coordinated muscle contraction.\u00a0MET is an active treatment that requires the patient to provide a voluntary isometric muscle contraction against the physician, followed by muscle relaxation during which the physician will take the dysfunction further into the restrictive barrier.\u00a0During both techniques, the patient must be able to provide feedback to the physician."}
+{"id": "article-102963_13", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Contraindications", "content": "Contraindications to MET include: Fracture in the affected area Unstable pelvis or hip joint Recent surgery, or low energy [9] Inability\u00a0to provide isometric contraction of the affected area Inability\u00a0to follow directions Contraindications to CS include: Inability to voluntarily relax Inability to provide feedback to the physician Fracture in the affected area Torn ligament or tendon in the affected area [9]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Contraindications. Contraindications to MET include: Fracture in the affected area Unstable pelvis or hip joint Recent surgery, or low energy [9] Inability\u00a0to provide isometric contraction of the affected area Inability\u00a0to follow directions Contraindications to CS include: Inability to voluntarily relax Inability to provide feedback to the physician Fracture in the affected area Torn ligament or tendon in the affected area [9]"}
+{"id": "article-102963_14", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Equipment", "content": "The only required equipment for this procedure is a firm OMT or massage table.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Equipment. The only required equipment for this procedure is a firm OMT or massage table."}
+{"id": "article-102963_15", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Personnel", "content": "A clinician trained in OMT is required.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Personnel. A clinician trained in OMT is required."}
+{"id": "article-102963_16", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Preparation", "content": "The clinician should discuss the risks, benefits, and alternative treatment options to OMT with the patient before performing OMT and obtain consent from the patient to proceed with OMT.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Preparation. The clinician should discuss the risks, benefits, and alternative treatment options to OMT with the patient before performing OMT and obtain consent from the patient to proceed with OMT."}
+{"id": "article-102963_17", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Preparation", "content": "After obtaining informed consent, the physician should establish the pain scale, assess the\u00a0range of motion and strength of the affected muscle, and perform any appropriate neurologic testing. Also, an osteopathic structural exam of the lumbar spine, pelvis, and hip should be performed. Special considerations for the iliopsoas include the Thomas test to assess the flexibility of the iliopsoas muscle.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Preparation. After obtaining informed consent, the physician should establish the pain scale, assess the\u00a0range of motion and strength of the affected muscle, and perform any appropriate neurologic testing. Also, an osteopathic structural exam of the lumbar spine, pelvis, and hip should be performed. Special considerations for the iliopsoas include the Thomas test to assess the flexibility of the iliopsoas muscle."}
+{"id": "article-102963_18", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Technique or Treatment -- Muscle Energy Technique with the Patient in the Prone Position", "content": "Physician position: Standing on the contralateral side of the dysfunction Patient position: Lying prone Technique: Place the cephalad hand on the posterior aspect of the patient's affected hip. Grasp the anterior portion of the thigh on the affected side, just proximal to the knee using the caudad hand. Extend the patient's hip until feeling the restrictive barrier. Continue to engage the restrictive barrier and instruct the patient to pull the anterior hip down towards the table for 3 to 5 seconds (isometric contraction). Instruct the patient to relax and move the hip further into extension until the restrictive barrier is again felt. Repeat the last two steps 3 to 5 times. After the last repetition, passively return the patient's leg to a neutral position. Reassess the somatic dysfunction.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Technique or Treatment -- Muscle Energy Technique with the Patient in the Prone Position. Physician position: Standing on the contralateral side of the dysfunction Patient position: Lying prone Technique: Place the cephalad hand on the posterior aspect of the patient's affected hip. Grasp the anterior portion of the thigh on the affected side, just proximal to the knee using the caudad hand. Extend the patient's hip until feeling the restrictive barrier. Continue to engage the restrictive barrier and instruct the patient to pull the anterior hip down towards the table for 3 to 5 seconds (isometric contraction). Instruct the patient to relax and move the hip further into extension until the restrictive barrier is again felt. Repeat the last two steps 3 to 5 times. After the last repetition, passively return the patient's leg to a neutral position. Reassess the somatic dysfunction."}
+{"id": "article-102963_19", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Technique or Treatment -- Muscle Energy Technique with the Patient in the Supine Position", "content": "Physician position: Standing on the ipsilateral side of the dysfunction Patient position: Lying supine with lower leg hanging off the end of the table Technique: The patient flexes the contralateral hip and knee to hug the lower extremity to the chest. Using one hand to keep the contralateral leg flexed, the other hand will provide a downward force immediately proximal to the knee until reaching the restrictive barrier. Continue to engage the restrictive barrier and instruct the patient to bring the knee up toward the ceiling to achieve hip flexion for 3 to 5 seconds (isometric contraction). Instruct the patient to relax and move the hip further into extension by providing a downward force just proximal to the knee. Repeat the last two steps 3 to 5 times. After the last repetition, passively return the patient's leg to a neutral position. Reassess the somatic dysfunction. Counterstrain: Physician position: Standing on the ipsilateral side of the dysfunction", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Technique or Treatment -- Muscle Energy Technique with the Patient in the Supine Position. Physician position: Standing on the ipsilateral side of the dysfunction Patient position: Lying supine with lower leg hanging off the end of the table Technique: The patient flexes the contralateral hip and knee to hug the lower extremity to the chest. Using one hand to keep the contralateral leg flexed, the other hand will provide a downward force immediately proximal to the knee until reaching the restrictive barrier. Continue to engage the restrictive barrier and instruct the patient to bring the knee up toward the ceiling to achieve hip flexion for 3 to 5 seconds (isometric contraction). Instruct the patient to relax and move the hip further into extension by providing a downward force just proximal to the knee. Repeat the last two steps 3 to 5 times. After the last repetition, passively return the patient's leg to a neutral position. Reassess the somatic dysfunction. Counterstrain: Physician position: Standing on the ipsilateral side of the dysfunction"}
+{"id": "article-102963_20", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Technique or Treatment -- Muscle Energy Technique with the Patient in the Supine Position", "content": "Patient position: Lying supine Identify the tender point within the iliopsoas muscle, which is often located just medial to the ASIS. Assess the pain level at the tender point. Keep a finger on the tender point for monitoring purposes. Passively bring both of the patient's hips\u00a0into flexion and allow the lower legs to rest on the clinician's thigh, which is propped onto the treatment table. Cross the patient's ankles and allow the hips to rotate externally. Reassess the pain at the tenderpoint. Adjust the patient's position either with more hip flexion or external rotation to decrease the pain level by two-thirds. Hold the position for 90 seconds or until you feel the tender point softening beneath your finger. Passively return the patient to a neutral position. Reassess the tenderpoint.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Technique or Treatment -- Muscle Energy Technique with the Patient in the Supine Position. Patient position: Lying supine Identify the tender point within the iliopsoas muscle, which is often located just medial to the ASIS. Assess the pain level at the tender point. Keep a finger on the tender point for monitoring purposes. Passively bring both of the patient's hips\u00a0into flexion and allow the lower legs to rest on the clinician's thigh, which is propped onto the treatment table. Cross the patient's ankles and allow the hips to rotate externally. Reassess the pain at the tenderpoint. Adjust the patient's position either with more hip flexion or external rotation to decrease the pain level by two-thirds. Hold the position for 90 seconds or until you feel the tender point softening beneath your finger. Passively return the patient to a neutral position. Reassess the tenderpoint."}
+{"id": "article-102963_21", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Complications", "content": "When performed correctly, MET and CS are very safe procedures. However, patients may have mild soreness following treatment. The muscle soreness is often expected and self-limited. Patients are advised to ensure relative rest and adequate hydration following OMT to limit or decrease post-procedural discomfort.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Complications. When performed correctly, MET and CS are very safe procedures. However, patients may have mild soreness following treatment. The muscle soreness is often expected and self-limited. Patients are advised to ensure relative rest and adequate hydration following OMT to limit or decrease post-procedural discomfort."}
+{"id": "article-102963_22", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Clinical Significance", "content": "OMT is beneficial for the treatment of dysfunction of the iliopsoas muscle, including manifestations of psoas syndrome. The exact prevalence of psoas syndrome is unknown, but it is more common in those with pre-existing low back or hip conditions. A study done by Adib et al. reported the incidence of iliopsoas tendonitis in total hip arthroscopy patients to be 24%. [10]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Clinical Significance. OMT is beneficial for the treatment of dysfunction of the iliopsoas muscle, including manifestations of psoas syndrome. The exact prevalence of psoas syndrome is unknown, but it is more common in those with pre-existing low back or hip conditions. A study done by Adib et al. reported the incidence of iliopsoas tendonitis in total hip arthroscopy patients to be 24%. [10]"}
+{"id": "article-102963_23", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Clinical Significance", "content": "OMT is a treatment option with fewer complications than other proposed non-surgical measures like corticosteroid injections or pharmaceutical intervention. The iliopsoas muscle connects the lumbar spine, pelvis, and leg; therefore, untreated and undertreated psoas dysfunction leads to compensatory changes along\u00a0the kinetic chain and ultimately will result in pathology in other parts of the body, including the thorax, piriformis, sacrum, pelvis, and knee.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Clinical Significance. OMT is a treatment option with fewer complications than other proposed non-surgical measures like corticosteroid injections or pharmaceutical intervention. The iliopsoas muscle connects the lumbar spine, pelvis, and leg; therefore, untreated and undertreated psoas dysfunction leads to compensatory changes along\u00a0the kinetic chain and ultimately will result in pathology in other parts of the body, including the thorax, piriformis, sacrum, pelvis, and knee."}
+{"id": "article-102963_24", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Enhancing Healthcare Team Outcomes", "content": "Interprofessional communication is important for promoting safe and effective\u00a0osteopathic manipulative treatment. The interprofessional healthcare team includes clinicians (particularly osteopaths), nursing staff, and possibly physical therapists.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Enhancing Healthcare Team Outcomes. Interprofessional communication is important for promoting safe and effective\u00a0osteopathic manipulative treatment. The interprofessional healthcare team includes clinicians (particularly osteopaths), nursing staff, and possibly physical therapists."}
+{"id": "article-102963_25", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Enhancing Healthcare Team Outcomes", "content": "All healthcare team members need to understand the proper use of OMT and the risks and benefits of OMT for various medical conditions. Each healthcare team member can assist with patient education to promote the safe and appropriate use of OMT as well as explain differences between manual modalities available to the patient.\u00a0Muscle energy treatment and counterstrain treatments are amongst the safest and most effective osteopathic treatment modalities. [5] [6] [Level 2]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Enhancing Healthcare Team Outcomes. All healthcare team members need to understand the proper use of OMT and the risks and benefits of OMT for various medical conditions. Each healthcare team member can assist with patient education to promote the safe and appropriate use of OMT as well as explain differences between manual modalities available to the patient.\u00a0Muscle energy treatment and counterstrain treatments are amongst the safest and most effective osteopathic treatment modalities. [5] [6] [Level 2]"}
+{"id": "article-102963_26", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Nursing, Allied Health, and Interprofessional Team Interventions", "content": "Awareness of osteopathic manipulative treatment by nursing, allied health, and the interprofessional team is essential for continued use of osteopathic manipulative treatment.\u00a0It is an effective treatment option that can be taught to fellow clinicians and knowledge shared through the healthcare professions to improve patient care.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Nursing, Allied Health, and Interprofessional Team Interventions. Awareness of osteopathic manipulative treatment by nursing, allied health, and the interprofessional team is essential for continued use of osteopathic manipulative treatment.\u00a0It is an effective treatment option that can be taught to fellow clinicians and knowledge shared through the healthcare professions to improve patient care."}
+{"id": "article-102963_27", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Nursing, Allied Health, and Interprofessional Team Monitoring", "content": "Monitoring and feedback with osteopathic manipulative treatment are critical for the success of both the patient and physician.\u00a0Awareness of procedures utilized and the progression of patients after a visit can ensure the most effective and personalized healthcare is delivered.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Nursing, Allied Health, and Interprofessional Team Monitoring. Monitoring and feedback with osteopathic manipulative treatment are critical for the success of both the patient and physician.\u00a0Awareness of procedures utilized and the progression of patients after a visit can ensure the most effective and personalized healthcare is delivered."}
+{"id": "article-102963_28", "title": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy and Counterstrain Procedure - Psoas Muscle Procedures -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

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+{"id": "article-102966_0", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Continuing Education Activity", "content": "Rib dysfunctions can lead to chest wall pain, musculoskeletal pain, thoracic outlet syndrome, and intercostal neuralgia. Decreased rib motion can lead to excess lymphatic fluid in the subcutaneous tissues as well as the worsening of respiratory pathology. This activity reviews inhalation rib dysfunctions and how they can be treated to improve rib pain. It will cover the clinical presentation, treatment options, contraindications, and benefits of osteopathic manipulative treatment for rib inhalation dysfunctions.", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Continuing Education Activity. Rib dysfunctions can lead to chest wall pain, musculoskeletal pain, thoracic outlet syndrome, and intercostal neuralgia. Decreased rib motion can lead to excess lymphatic fluid in the subcutaneous tissues as well as the worsening of respiratory pathology. This activity reviews inhalation rib dysfunctions and how they can be treated to improve rib pain. It will cover the clinical presentation, treatment options, contraindications, and benefits of osteopathic manipulative treatment for rib inhalation dysfunctions."}
+{"id": "article-102966_1", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Continuing Education Activity", "content": "Objectives: Outline the indications for the treatment of inhalation rib dysfunctions. Review the contraindications to performing certain osteopathic manipulative techniques for inhalation rib dysfunctions. Identify clinical relevance in diagnosing and treating inhalation rib dysfunctions. Summarize how to perform four of the common treatment modalities for inhalation rib dysfunctions. Access free multiple choice questions on this topic.", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Continuing Education Activity. Objectives: Outline the indications for the treatment of inhalation rib dysfunctions. Review the contraindications to performing certain osteopathic manipulative techniques for inhalation rib dysfunctions. Identify clinical relevance in diagnosing and treating inhalation rib dysfunctions. Summarize how to perform four of the common treatment modalities for inhalation rib dysfunctions. Access free multiple choice questions on this topic."}
+{"id": "article-102966_2", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Introduction", "content": "Rib dysfunctions occur in many forms. This article aims to identify, diagnose, and discuss the treatment of inhaled rib dysfunctions with direct and indirect osteopathic treatments. Rib dysfunctions can lead to chest wall pain, musculoskeletal pain, thoracic outlet syndrome, and intercostal neuralgia. Decreased rib motion can lead to excess lymphatic fluid in the subcutaneous tissues as well as the worsening of respiratory pathology. [1] Inhaled rib dysfunctions occur when a set of two or more ribs are displaced cephalad (toward the patient's head) with associated physiologic motion dysfunction. The physiologic manifestation of an inhaled rib dysfunction presents when ribs are elevated in inspiration and do not move freely into a neutral position on expiration.", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Introduction. Rib dysfunctions occur in many forms. This article aims to identify, diagnose, and discuss the treatment of inhaled rib dysfunctions with direct and indirect osteopathic treatments. Rib dysfunctions can lead to chest wall pain, musculoskeletal pain, thoracic outlet syndrome, and intercostal neuralgia. Decreased rib motion can lead to excess lymphatic fluid in the subcutaneous tissues as well as the worsening of respiratory pathology. [1] Inhaled rib dysfunctions occur when a set of two or more ribs are displaced cephalad (toward the patient's head) with associated physiologic motion dysfunction. The physiologic manifestation of an inhaled rib dysfunction presents when ribs are elevated in inspiration and do not move freely into a neutral position on expiration."}
+{"id": "article-102966_3", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Introduction", "content": "When treating inhaled rib dysfunctions, the provider must identify the key rib to release the dysfunctional segment into normal physiologic motion. [2] Osteopathic treatments include direct and indirect treatments to restore physiologic motion. Direct treatments move the dysfunction into its physiologic barrier. Indirect treatments move the dysfunctional segments into their position of ease. [3] Osteopathic manipulative treatment of inhaled rib dysfunctions aims to relieve patient discomfort, improve lymphatic flow, and restore physiologic chest wall motion. [4]", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Introduction. When treating inhaled rib dysfunctions, the provider must identify the key rib to release the dysfunctional segment into normal physiologic motion. [2] Osteopathic treatments include direct and indirect treatments to restore physiologic motion. Direct treatments move the dysfunction into its physiologic barrier. Indirect treatments move the dysfunctional segments into their position of ease. [3] Osteopathic manipulative treatment of inhaled rib dysfunctions aims to relieve patient discomfort, improve lymphatic flow, and restore physiologic chest wall motion. [4]"}
+{"id": "article-102966_4", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Anatomy and Physiology", "content": "The thoracic cavity encloses and protects the body\u2019s vital organs. There are twelve sets of rib pairs that make up the thoracic cavity. Anteriorly, ribs attach to the sternum, costal cartilage of an adjacent rib, or have no attachment and are known as floating ribs. [5] Posteriorly, ribs attach to costovertebral articulations of the spine. [6] [7] Anteriorly ribs articulate with the hyaline, or costal, the cartilage of the adjacent rib. [5] Ribs 1\u00a0to 7 are true ribs and connect anteriorly to the sternum, including the sternal notch, manubrium, and sternal body. Ribs 8, 9, and 10 attach anteriorly to the hyaline cartilage of the rib above them and are known as false ribs. [5] False ribs do not have a bone-to-bone anterior articulation. Ribs 11 and 12 are floating ribs, denoting there is no anterior articular attachment to hyaline cartilage or the sternum. [5] Ribs 11 and 12 are otherwise known as caliper ribs because of their lack of anterior attachment.", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Anatomy and Physiology. The thoracic cavity encloses and protects the body\u2019s vital organs. There are twelve sets of rib pairs that make up the thoracic cavity. Anteriorly, ribs attach to the sternum, costal cartilage of an adjacent rib, or have no attachment and are known as floating ribs. [5] Posteriorly, ribs attach to costovertebral articulations of the spine. [6] [7] Anteriorly ribs articulate with the hyaline, or costal, the cartilage of the adjacent rib. [5] Ribs 1\u00a0to 7 are true ribs and connect anteriorly to the sternum, including the sternal notch, manubrium, and sternal body. Ribs 8, 9, and 10 attach anteriorly to the hyaline cartilage of the rib above them and are known as false ribs. [5] False ribs do not have a bone-to-bone anterior articulation. Ribs 11 and 12 are floating ribs, denoting there is no anterior articular attachment to hyaline cartilage or the sternum. [5] Ribs 11 and 12 are otherwise known as caliper ribs because of their lack of anterior attachment."}
+{"id": "article-102966_5", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Anatomy and Physiology", "content": "Bony rib anatomy consists of the anterior portion for attachment to the hyaline cartilage or sternum and the posterior portion for articulation with the spinal column. [5] The anatomy of the posterior rib attachment includes a head, neck, articular facet, and tubercle. [5] The anterior rib anatomy includes\u00a0the rib head, which is a flat portion for hyaline or sternal articulation. [5]", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Anatomy and Physiology. Bony rib anatomy consists of the anterior portion for attachment to the hyaline cartilage or sternum and the posterior portion for articulation with the spinal column. [5] The anatomy of the posterior rib attachment includes a head, neck, articular facet, and tubercle. [5] The anterior rib anatomy includes\u00a0the rib head, which is a flat portion for hyaline or sternal articulation. [5]"}
+{"id": "article-102966_6", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Anatomy and Physiology", "content": "Muscular attachments to the ribs include the scalenes, internal intercostals, external intercostals, and the diaphragm. [8] During inhalation and exhalation, the ribs move up and down as levers when pulled by their muscular attachments to expand the thoracic cavity, creating a negative pressure space, activating airflow into the lungs. [9] During the inhalation and exhalation, ribs 1\u00a0to 4 move in pump handle motion, meaning they are moving up (nuchal ) or cephalad and down (caudal ) or caudad. Ribs 1\u00a0to 4 on their anterior articulations move up and down . Ribs 5\u00a0to 10 are called bucket handle ribs because the shaft of the rib body on the lateral aspect of the chest wall moves up and down.", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Anatomy and Physiology. Muscular attachments to the ribs include the scalenes, internal intercostals, external intercostals, and the diaphragm. [8] During inhalation and exhalation, the ribs move up and down as levers when pulled by their muscular attachments to expand the thoracic cavity, creating a negative pressure space, activating airflow into the lungs. [9] During the inhalation and exhalation, ribs 1\u00a0to 4 move in pump handle motion, meaning they are moving up (nuchal ) or cephalad and down (caudal ) or caudad. Ribs 1\u00a0to 4 on their anterior articulations move up and down . Ribs 5\u00a0to 10 are called bucket handle ribs because the shaft of the rib body on the lateral aspect of the chest wall moves up and down."}
+{"id": "article-102966_7", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Anatomy and Physiology", "content": "Each rib has muscular attachments to facilitate inhalation and exhalation. [9] The first rib has muscular attachments at is base of the anterior and middle scalene, which elevate the first rib during inspiration. [9] The anterior scalene muscle originates from the C3-C6 transverse processes and attaches to the first rib. [9] The posterior and middle scalene originate from the posterior tubercles of C2-C6 and attach posteriorly to the subclavian groove on the first rib. The posterior scalene attaches to C2, elevating it during inspiration. Together with the first rib, they create the inter-scalene triangle. The scalenes side bend and flex the neck to their side of attachment. Intercostal muscles include the external, internal, innermost, and subcostal muscles.", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Anatomy and Physiology. Each rib has muscular attachments to facilitate inhalation and exhalation. [9] The first rib has muscular attachments at is base of the anterior and middle scalene, which elevate the first rib during inspiration. [9] The anterior scalene muscle originates from the C3-C6 transverse processes and attaches to the first rib. [9] The posterior and middle scalene originate from the posterior tubercles of C2-C6 and attach posteriorly to the subclavian groove on the first rib. The posterior scalene attaches to C2, elevating it during inspiration. Together with the first rib, they create the inter-scalene triangle. The scalenes side bend and flex the neck to their side of attachment. Intercostal muscles include the external, internal, innermost, and subcostal muscles."}
+{"id": "article-102966_8", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Anatomy and Physiology", "content": "The diaphragm moves in inspiration and expiration by expanding and re-doming as the diaphragm contracts and relaxes. [10] It is composed of two muscles, costal and crural, with innervation from the phrenic nerve C3-C5. [10] When the costal muscle of the diaphragm contracts, it expands the thoracic cage in the coronal plane with the pump handle ribs and sagittal plane with inhalation of bucket handle ribs. [11] [10] During inhalation, the diaphragm relaxed the dome shape of the muscle flattens, allowing for decreased intra-thoracic pressure and air to fill the lungs. [12] The diaphragm is key in returning lymph and venous blood to the heart. [10] This action moves lymph through the body from the subcutaneous tissues bringing it back into the intravascular system.", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Anatomy and Physiology. The diaphragm moves in inspiration and expiration by expanding and re-doming as the diaphragm contracts and relaxes. [10] It is composed of two muscles, costal and crural, with innervation from the phrenic nerve C3-C5. [10] When the costal muscle of the diaphragm contracts, it expands the thoracic cage in the coronal plane with the pump handle ribs and sagittal plane with inhalation of bucket handle ribs. [11] [10] During inhalation, the diaphragm relaxed the dome shape of the muscle flattens, allowing for decreased intra-thoracic pressure and air to fill the lungs. [12] The diaphragm is key in returning lymph and venous blood to the heart. [10] This action moves lymph through the body from the subcutaneous tissues bringing it back into the intravascular system."}
+{"id": "article-102966_9", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Indications -- Myofascial Release", "content": "Elderly Acutely Ill Degenerative diseases Down syndrome Pregnancy Can not tolerate a direct technique Bleeding disorders Lymphedema or need for improved lymphatic flow Asymptomatic patients", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Indications -- Myofascial Release. Elderly Acutely Ill Degenerative diseases Down syndrome Pregnancy Can not tolerate a direct technique Bleeding disorders Lymphedema or need for improved lymphatic flow Asymptomatic patients"}
+{"id": "article-102966_10", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Indications -- High-Velocity Low Amplitude", "content": "No underlying medical pathology Unsuccessful manipulation with other indirect techniques Stubborn dysfunctions", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Indications -- High-Velocity Low Amplitude. No underlying medical pathology Unsuccessful manipulation with other indirect techniques Stubborn dysfunctions"}
+{"id": "article-102966_11", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Indications -- Muscle Energy", "content": "Post-surgical patients ICU patients Anyone who can not participate in active muscle contraction Asymptomatic patients for stretching", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Indications -- Muscle Energy. Post-surgical patients ICU patients Anyone who can not participate in active muscle contraction Asymptomatic patients for stretching"}
+{"id": "article-102966_12", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Contraindications -- Myofascial Release or Re-doming the Thoracic Diaphragm", "content": "Rib fractures New surgical skin incisions near the area of treatment Metastatic cancer where increasing lymphatic flow and spread could worsen the patient's health", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Contraindications -- Myofascial Release or Re-doming the Thoracic Diaphragm. Rib fractures New surgical skin incisions near the area of treatment Metastatic cancer where increasing lymphatic flow and spread could worsen the patient's health"}
+{"id": "article-102966_13", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Contraindications -- High-Velocity Low Amplitude Techniques", "content": "Anyone suffering from degenerative bone disease Rib fractures Acute muscle sprains Vertebrobasilar disease Ligament laxity, such as in Down syndrome Concerns for possible contraindications noted by the physician provider when obtaining a patient's medical history Pregnancy Bleeding disorders Do not place thrusting pressure on costovertebral articulations with acute fractures or bone metastasis from cancer", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Contraindications -- High-Velocity Low Amplitude Techniques. Anyone suffering from degenerative bone disease Rib fractures Acute muscle sprains Vertebrobasilar disease Ligament laxity, such as in Down syndrome Concerns for possible contraindications noted by the physician provider when obtaining a patient's medical history Pregnancy Bleeding disorders Do not place thrusting pressure on costovertebral articulations with acute fractures or bone metastasis from cancer"}
+{"id": "article-102966_14", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Contraindications -- Rib Raising", "content": "Acute rib fractures Recent spinal surgery Overlying areas of skin infection Erythema Swelling overlying the skin", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Contraindications -- Rib Raising. Acute rib fractures Recent spinal surgery Overlying areas of skin infection Erythema Swelling overlying the skin"}
+{"id": "article-102966_15", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Equipment", "content": "Manual manipulative techniques involve a patient sitting upright or lying supine while they are passively manipulated or actively engage in the manipulative technique with their provider. A patient, the physician provider, and preferably a cushioned manipulation table are best for successful osteopathic manipulative treatments. If an appropriate treatment table is unavailable, it is possible to perform osteopathic techniques from a supine floor or seated position. [11]", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Equipment. Manual manipulative techniques involve a patient sitting upright or lying supine while they are passively manipulated or actively engage in the manipulative technique with their provider. A patient, the physician provider, and preferably a cushioned manipulation table are best for successful osteopathic manipulative treatments. If an appropriate treatment table is unavailable, it is possible to perform osteopathic techniques from a supine floor or seated position. [11]"}
+{"id": "article-102966_16", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Personnel", "content": "Patient Clinician provider", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Personnel. Patient Clinician provider"}
+{"id": "article-102966_17", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Preparation", "content": "Obtain verbal and/or written consent from all patients receiving osteopathic manipulative treatments. Explain the procedures in full and where your hand placement will be before beginning any hands-on patient care. Cover the risks and benefits of different kinds of treatment and how that pertains to the patient\u2019s specific needs. Make sure\u00a0to perform a thorough medical history and physical exam for new patients along with necessary radiologic imaging before performing high-velocity low amplitude treatments.", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Preparation. Obtain verbal and/or written consent from all patients receiving osteopathic manipulative treatments. Explain the procedures in full and where your hand placement will be before beginning any hands-on patient care. Cover the risks and benefits of different kinds of treatment and how that pertains to the patient\u2019s specific needs. Make sure\u00a0to perform a thorough medical history and physical exam for new patients along with necessary radiologic imaging before performing high-velocity low amplitude treatments."}
+{"id": "article-102966_18", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Technique or Treatment", "content": "Diagnosing inhaled rib dysfunctions can be started by assessing the patient's chest wall motion. With the patient lying supine or seated, the physician provider can place their palms flat on the patient's right and left anterior chest wall, careful not to touch delicate breast tissues. With hands stable on the chest wall, ask the patient to breathe in and out. Assess for symmetry in the rise and fall of the chest wall. [13] The physician provider can do this again by placing hands lower down on the right and left rib cage to assess for physiologic or dysfunctional motion. [13] Inhaled rib dysfunctions will present on physical assessment with increased intercostal space below the dysfunctional segment and a decreased intercostal space above the dysfunctional segment. Once the provider identifies the key rib, they can localize it for treatment. There are many techniques used to manipulate dysfunctional ribs back into place. [14]", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Technique or Treatment. Diagnosing inhaled rib dysfunctions can be started by assessing the patient's chest wall motion. With the patient lying supine or seated, the physician provider can place their palms flat on the patient's right and left anterior chest wall, careful not to touch delicate breast tissues. With hands stable on the chest wall, ask the patient to breathe in and out. Assess for symmetry in the rise and fall of the chest wall. [13] The physician provider can do this again by placing hands lower down on the right and left rib cage to assess for physiologic or dysfunctional motion. [13] Inhaled rib dysfunctions will present on physical assessment with increased intercostal space below the dysfunctional segment and a decreased intercostal space above the dysfunctional segment. Once the provider identifies the key rib, they can localize it for treatment. There are many techniques used to manipulate dysfunctional ribs back into place. [14]"}
+{"id": "article-102966_19", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Technique or Treatment", "content": "Rib Raising : Rib raising is an articular technique that places pressure on a restrictive barrier of the rib angle against the spine. It is a non-invasive, passive technique that can be useful with acutely ill, hospitalized patients. [3] During treatment, the patient lies supine or is seated and does not actively participate. This technique emphasizes the placement of a repetitive force to increase the range of motion of the posterior rib articulations, lessening somatic dysfunction of the spine. This technique stretches myofascial structures and increases chest wall motion, and normalizes the parathoracic sympathetic ganglia. [13] [14]", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Technique or Treatment. Rib Raising : Rib raising is an articular technique that places pressure on a restrictive barrier of the rib angle against the spine. It is a non-invasive, passive technique that can be useful with acutely ill, hospitalized patients. [3] During treatment, the patient lies supine or is seated and does not actively participate. This technique emphasizes the placement of a repetitive force to increase the range of motion of the posterior rib articulations, lessening somatic dysfunction of the spine. This technique stretches myofascial structures and increases chest wall motion, and normalizes the parathoracic sympathetic ganglia. [13] [14]"}
+{"id": "article-102966_20", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Technique or Treatment", "content": "To perform rib raising, the physician provider places their finger pads under the posterior rib angle and pushes upward, applying gentle pressure and traction on the rib angle, which the clinician does until there is release. Reassess for an increased articular range of motion; this inhibits sympathetics from the thoracic chain ganglia to the ribs and increases chest wall expansion and negative intrathoracic pressure. [15] This process increases the capacity for inhalation and improves lymph flow. [14]", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Technique or Treatment. To perform rib raising, the physician provider places their finger pads under the posterior rib angle and pushes upward, applying gentle pressure and traction on the rib angle, which the clinician does until there is release. Reassess for an increased articular range of motion; this inhibits sympathetics from the thoracic chain ganglia to the ribs and increases chest wall expansion and negative intrathoracic pressure. [15] This process increases the capacity for inhalation and improves lymph flow. [14]"}
+{"id": "article-102966_21", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Technique or Treatment", "content": "Myofascial release: increases lymphatic flow, releases muscle tension, and can be performed on acutely ill patients. Re-doming the diaphragm is an indirect myofascial technique that increases lymphatic flow and increases the mechanics of inspiration and expiration. [16] By re-doming, the diaphragm, the provider increases a patient's lymph return by optimizing thoracoabdominal pressure gradients. [3] Myofascial release has its basis in treating the fascia overlying the muscles and bones by placing a direct or indirect force on the tissues. [3] This approach, in turn, benefits inhaled rib dysfunctions by increasing the ability of the thoracic cage to move without restriction. [13] [14]", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Technique or Treatment. Myofascial release: increases lymphatic flow, releases muscle tension, and can be performed on acutely ill patients. Re-doming the diaphragm is an indirect myofascial technique that increases lymphatic flow and increases the mechanics of inspiration and expiration. [16] By re-doming, the diaphragm, the provider increases a patient's lymph return by optimizing thoracoabdominal pressure gradients. [3] Myofascial release has its basis in treating the fascia overlying the muscles and bones by placing a direct or indirect force on the tissues. [3] This approach, in turn, benefits inhaled rib dysfunctions by increasing the ability of the thoracic cage to move without restriction. [13] [14]"}
+{"id": "article-102966_22", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Technique or Treatment", "content": "To perform myofascial release to the thoracic diaphragm with the patient seated, the physician provider can stand behind the patient and wrap hands around their infra-costal margin until anteriorly palpating the fascia of the thoracic tissues. [3] The provider will place fingers into the tissues and palpate with traction infra-laterally to determine the restricted side. [13] [14] The restricted side will have less tissue softness and mobility.", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Technique or Treatment. To perform myofascial release to the thoracic diaphragm with the patient seated, the physician provider can stand behind the patient and wrap hands around their infra-costal margin until anteriorly palpating the fascia of the thoracic tissues. [3] The provider will place fingers into the tissues and palpate with traction infra-laterally to determine the restricted side. [13] [14] The restricted side will have less tissue softness and mobility."}
+{"id": "article-102966_23", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Technique or Treatment", "content": "To perform myofascial release to the thoracic diaphragm with the patient supine, the physician provider can place their thumbs under the costal margins, beneath the xiphoid process, on the right and left. To assess the restricted side, the physician provider should press with the thumbs on the right and left of the diaphragm, gently pressing with infra-lateral traction. For an indirect approach to treatment, hold the thumb into the side of the tissue to ease where the tissues move more freely and allow the fascia to release, gently unwinding. Always reassess after treatment for bilateral tissue softness and increased diaphragmatic range of motion. [3]", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Technique or Treatment. To perform myofascial release to the thoracic diaphragm with the patient supine, the physician provider can place their thumbs under the costal margins, beneath the xiphoid process, on the right and left. To assess the restricted side, the physician provider should press with the thumbs on the right and left of the diaphragm, gently pressing with infra-lateral traction. For an indirect approach to treatment, hold the thumb into the side of the tissue to ease where the tissues move more freely and allow the fascia to release, gently unwinding. Always reassess after treatment for bilateral tissue softness and increased diaphragmatic range of motion. [3]"}
+{"id": "article-102966_24", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Technique or Treatment", "content": "HVLA: High-Velocity Low Amplitude (HVLA) techniques are direct manipulative techniques bringing the dysfunctional segment into the restricted plane of motion. When performing HVLA, the physician provider is thrusting a short distance through the inhibited plane of motion of the dysfunctional segment. [14] [13] When using this technique, patients\u00a0can receive treatment in prone, seated, and supine positions.", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Technique or Treatment. HVLA: High-Velocity Low Amplitude (HVLA) techniques are direct manipulative techniques bringing the dysfunctional segment into the restricted plane of motion. When performing HVLA, the physician provider is thrusting a short distance through the inhibited plane of motion of the dysfunctional segment. [14] [13] When using this technique, patients\u00a0can receive treatment in prone, seated, and supine positions."}
+{"id": "article-102966_25", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Technique or Treatment", "content": "To perform HVLA on the first rib inhalation dysfunction (exhalation restriction): The physician provider is at the head of the bed. The patient lays supine. Assess for right or left first rib inhalation dysfunction (exhalation inhibited). The dysfunctional side will palpate as firmer and cephalad. Side bend the patient's head toward the side of dysfunction and rotate away from the dysfunctional rib. The physician provider places their thenar eminence on the side of dysfunction. The patient participates by inhaling, then exhaling. On the patient's exhalation, the physician provider administers a thrust caudad. Then reassess the patient's first rib. [17]", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Technique or Treatment. To perform HVLA on the first rib inhalation dysfunction (exhalation restriction): The physician provider is at the head of the bed. The patient lays supine. Assess for right or left first rib inhalation dysfunction (exhalation inhibited). The dysfunctional side will palpate as firmer and cephalad. Side bend the patient's head toward the side of dysfunction and rotate away from the dysfunctional rib. The physician provider places their thenar eminence on the side of dysfunction. The patient participates by inhaling, then exhaling. On the patient's exhalation, the physician provider administers a thrust caudad. Then reassess the patient's first rib. [17]"}
+{"id": "article-102966_26", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Technique or Treatment", "content": "HVLA to the thoracic ribs 2\u00a0through 10 can be performed by using the Kirksville Krunch. [14] This method is where the physician provider stands to the opposite side of the key dysfunctional rib. The patient is lying supine on a table approximately waist-high. Ask the patient to overlap their arms on their chest with the arm on the side of the key treatment rib under their non-treatment side. The clinician provider, standing on the opposite side of the patient's key rib, places their arm over the patient, and with the thenar eminence of that hand, presses on the posterior rib angle under the key rib. They then flex the patient so that the thoracic segment engages at the level of the key rib and gently side bend away. Ask the patient to breathe in and out. On exhalation, deliver a direct thrust with your chest onto their crossed arms, angling the energy to your thenar eminence on the posterior rib angle of the key rib.", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Technique or Treatment. HVLA to the thoracic ribs 2\u00a0through 10 can be performed by using the Kirksville Krunch. [14] This method is where the physician provider stands to the opposite side of the key dysfunctional rib. The patient is lying supine on a table approximately waist-high. Ask the patient to overlap their arms on their chest with the arm on the side of the key treatment rib under their non-treatment side. The clinician provider, standing on the opposite side of the patient's key rib, places their arm over the patient, and with the thenar eminence of that hand, presses on the posterior rib angle under the key rib. They then flex the patient so that the thoracic segment engages at the level of the key rib and gently side bend away. Ask the patient to breathe in and out. On exhalation, deliver a direct thrust with your chest onto their crossed arms, angling the energy to your thenar eminence on the posterior rib angle of the key rib."}
+{"id": "article-102966_27", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Technique or Treatment", "content": "Muscle Energy: Muscle Energy is a direct and active technique where a patient is placed into their restrictive barrier by a physician provider then participates in the treatment. [3] This treatment can apply to any part of the human body where a patient has a decreased range of motion. [13] [18] When the patient is placed into their restrictive barrier, they participate by actively moving back into a neutral position while the physician provider holds an isometric counterforce. [19] This looks like a physician provider placing a patient into a designated position of restriction, then placing a counterforce on the patient as the patient pushes against the physician provider. Then the relaxation of the patient allows the physician to move the patient into a passive stretch. [19] This action should be repeated three to five times, with the patient holding the isometric contraction against the physician provider for approximately 3\u00a0to 5 seconds each round. [18] After each round of isometric contraction, there is a relaxation phase. During relaxation, the clinician\u00a0provider pushes the patient into their new restrictive barrier. [13] [19]", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Technique or Treatment. Muscle Energy: Muscle Energy is a direct and active technique where a patient is placed into their restrictive barrier by a physician provider then participates in the treatment. [3] This treatment can apply to any part of the human body where a patient has a decreased range of motion. [13] [18] When the patient is placed into their restrictive barrier, they participate by actively moving back into a neutral position while the physician provider holds an isometric counterforce. [19] This looks like a physician provider placing a patient into a designated position of restriction, then placing a counterforce on the patient as the patient pushes against the physician provider. Then the relaxation of the patient allows the physician to move the patient into a passive stretch. [19] This action should be repeated three to five times, with the patient holding the isometric contraction against the physician provider for approximately 3\u00a0to 5 seconds each round. [18] After each round of isometric contraction, there is a relaxation phase. During relaxation, the clinician\u00a0provider pushes the patient into their new restrictive barrier. [13] [19]"}
+{"id": "article-102966_28", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Technique or Treatment", "content": "To perform muscle energy to a group of ribs with an inhalation dysfunction, place the patient supine on a waist-high cushioned treatment table if available. Identify the key rib; it will be the rib on the bottom of a group of dysfunctional ribs. [18] Once again, this is assessable by placing hands on the patient's thoracic cage while having them actively inhale and exhale. The key rib\u00a0is on the bottom of the dysfunctional segment and will remain elevated in expiration. Treatment\u00a0is\u00a0directed toward this rib. Once the key rib is identified, the physician provider will stand toward the patient's head, facing their feet to begin treatment. The physician provider places the fingers of their hand on the side of dysfunction on the key rib towards the superior aspect. The physician provider uses their free hand to flex and side bend the patient. If the key rib is a pump handle rib\u00a0(ribs 2 through 5), the physician provider will flex the patient's head and neck until the level of the rib is engaged. The physician provider will then ask\u00a0the patient to take a deep breath in and out. Have the patient\u00a0hold their exhalation for 3\u00a0to 5 seconds; this is the active participation part of the treatment. When the patient breathes out, the physician provider holds them into their restrictive barrier and adds slightly more flexion. When the 3\u00a0to 5 seconds are over, the patient can take another deep breath, but the\u00a0clinician should hold continuous caudad pressure on the superior aspect of the key rib to prevent movement into inhalation.", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Technique or Treatment. To perform muscle energy to a group of ribs with an inhalation dysfunction, place the patient supine on a waist-high cushioned treatment table if available. Identify the key rib; it will be the rib on the bottom of a group of dysfunctional ribs. [18] Once again, this is assessable by placing hands on the patient's thoracic cage while having them actively inhale and exhale. The key rib\u00a0is on the bottom of the dysfunctional segment and will remain elevated in expiration. Treatment\u00a0is\u00a0directed toward this rib. Once the key rib is identified, the physician provider will stand toward the patient's head, facing their feet to begin treatment. The physician provider places the fingers of their hand on the side of dysfunction on the key rib towards the superior aspect. The physician provider uses their free hand to flex and side bend the patient. If the key rib is a pump handle rib\u00a0(ribs 2 through 5), the physician provider will flex the patient's head and neck until the level of the rib is engaged. The physician provider will then ask\u00a0the patient to take a deep breath in and out. Have the patient\u00a0hold their exhalation for 3\u00a0to 5 seconds; this is the active participation part of the treatment. When the patient breathes out, the physician provider holds them into their restrictive barrier and adds slightly more flexion. When the 3\u00a0to 5 seconds are over, the patient can take another deep breath, but the\u00a0clinician should hold continuous caudad pressure on the superior aspect of the key rib to prevent movement into inhalation."}
+{"id": "article-102966_29", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Technique or Treatment", "content": "To perform muscle energy on bucket handle ribs (6-10), follow the steps above. However, when asking the\u00a0patient to breathe out\u00a0and hold their exhaled breath for 3\u00a0to 5 seconds, have them reach\u00a0for their knee on the side of the dysfunction. Follow the steps above to repeated rounds of treatment.", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Technique or Treatment. To perform muscle energy on bucket handle ribs (6-10), follow the steps above. However, when asking the\u00a0patient to breathe out\u00a0and hold their exhaled breath for 3\u00a0to 5 seconds, have them reach\u00a0for their knee on the side of the dysfunction. Follow the steps above to repeated rounds of treatment."}
+{"id": "article-102966_30", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Clinical Significance", "content": "Chest pain is a common presentation to any clinic or acute care facility. To determine cardiac vs. pulmonary vs. musculoskeletal origin is essential in ruling out deadly pathology. Assessing the chest wall and managing musculoskeletal complaints is beneficial to the medical community in reducing hospital admissions, cost of diagnostic testing, and length of inpatient stay. [20] [21] [22] Reducing the hospital length of stay includes decreasing the use of inhaled steroids, statins, and IV antibiotics to treat inflammatory lung diseases like pneumonia, asthma, and non-inflammatory diseases, such as COPD and emphysema. [23] [15]", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Clinical Significance. Chest pain is a common presentation to any clinic or acute care facility. To determine cardiac vs. pulmonary vs. musculoskeletal origin is essential in ruling out deadly pathology. Assessing the chest wall and managing musculoskeletal complaints is beneficial to the medical community in reducing hospital admissions, cost of diagnostic testing, and length of inpatient stay. [20] [21] [22] Reducing the hospital length of stay includes decreasing the use of inhaled steroids, statins, and IV antibiotics to treat inflammatory lung diseases like pneumonia, asthma, and non-inflammatory diseases, such as COPD and emphysema. [23] [15]"}
+{"id": "article-102966_31", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Clinical Significance", "content": "Lymphatic pump techniques have been shown to decrease hospital stays, antibiotic use for pneumonia, and increase immunity. [24] [25] Treating rib dysfunctions benefits patients suffering from intercostal neuralgia, slipping rib syndrome, cystic fibrosis, decreased lymphatic flow, decreased respirations, and lymphatic congestion. [8] [26] Articular techniques such as rib raising increase chest wall compliance and have been shown to benefit patients with viral pneumonia. [27] [25]", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Clinical Significance. Lymphatic pump techniques have been shown to decrease hospital stays, antibiotic use for pneumonia, and increase immunity. [24] [25] Treating rib dysfunctions benefits patients suffering from intercostal neuralgia, slipping rib syndrome, cystic fibrosis, decreased lymphatic flow, decreased respirations, and lymphatic congestion. [8] [26] Articular techniques such as rib raising increase chest wall compliance and have been shown to benefit patients with viral pneumonia. [27] [25]"}
+{"id": "article-102966_32", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Clinical Significance", "content": "Thoracic outlet syndrome is one common pathology seen in a clinical setting. It is a syndrome in which a person experiences numbness or tingling and loss of motor function or sensation in one of their upper extremities. [8] It can result from anomalies in cervical ribs, be induced by a trauma to the neck or shoulder, be simply musculoskeletal in nature, and secondary to callus of bone after fractures heal. Thoracic outlet syndrome can be improved with cervical rib treatments when secondary to musculoskeletal somatic dysfunction. [8]", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Clinical Significance. Thoracic outlet syndrome is one common pathology seen in a clinical setting. It is a syndrome in which a person experiences numbness or tingling and loss of motor function or sensation in one of their upper extremities. [8] It can result from anomalies in cervical ribs, be induced by a trauma to the neck or shoulder, be simply musculoskeletal in nature, and secondary to callus of bone after fractures heal. Thoracic outlet syndrome can be improved with cervical rib treatments when secondary to musculoskeletal somatic dysfunction. [8]"}
+{"id": "article-102966_33", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Clinical Significance", "content": "The brachial plexus is a set of nerves and vasculature that gives motor and sensory function to the upper extremity. [8] The anterior branch of seven crosses within the triangle made between the cervical rib head with anterior and middle scalene attachments can be the source of upper extremity anesthesia secondary to compression on the brachial plexus. [9]", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Clinical Significance. The brachial plexus is a set of nerves and vasculature that gives motor and sensory function to the upper extremity. [8] The anterior branch of seven crosses within the triangle made between the cervical rib head with anterior and middle scalene attachments can be the source of upper extremity anesthesia secondary to compression on the brachial plexus. [9]"}
+{"id": "article-102966_34", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Clinical Significance", "content": "According to a recent study,\u00a0the most common OMM inpatient consultations were for chest pain, rib pain, spinal pain, and adjunctive treatment for lower respiratory infections. [28] However, this study also noted, whether treated with myofascial release, rib raising, or thoracic lymphatic pump, there were no benefits in pulmonary function tests posttreatment. [28] Patients overall stated subjectively they benefitted from the osteopathic manipulative treatments and stated they had improved respiratory symptoms. [28]", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Clinical Significance. According to a recent study,\u00a0the most common OMM inpatient consultations were for chest pain, rib pain, spinal pain, and adjunctive treatment for lower respiratory infections. [28] However, this study also noted, whether treated with myofascial release, rib raising, or thoracic lymphatic pump, there were no benefits in pulmonary function tests posttreatment. [28] Patients overall stated subjectively they benefitted from the osteopathic manipulative treatments and stated they had improved respiratory symptoms. [28]"}
+{"id": "article-102966_35", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Enhancing Healthcare Team Outcomes", "content": "Coordinated patient care is key to the treatment of any disease. For patients with\u00a0persistent chest pain, multiple emergency room visits, and numerous cardiology workups,\u00a0osteopathic manipulative techniques need to be at the forefront of a provider's next treatment plan. Patients can be evaluated and assessed for underlying pathology while also being evaluated for musculoskeletal dysfunctions.", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Enhancing Healthcare Team Outcomes. Coordinated patient care is key to the treatment of any disease. For patients with\u00a0persistent chest pain, multiple emergency room visits, and numerous cardiology workups,\u00a0osteopathic manipulative techniques need to be at the forefront of a provider's next treatment plan. Patients can be evaluated and assessed for underlying pathology while also being evaluated for musculoskeletal dysfunctions."}
+{"id": "article-102966_36", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Enhancing Healthcare Team Outcomes", "content": "Clinicians\u00a0should take responsibility for patient referrals to osteopathic providers when deadly underlying pathologies have safely been ruled out. Patients benefit from a well-rounded treatment approach that includes pharmacology, diagnostic testing, physical medicine, and manipulative treatments. This was shown in a clinical trial using rats where the lungs of rats diagnosed with S treptococcus pneumoniae had reduced levels of bacteria after receiving lymphatic pump techniques along with antibiotics compared to controls. [25]", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Enhancing Healthcare Team Outcomes. Clinicians\u00a0should take responsibility for patient referrals to osteopathic providers when deadly underlying pathologies have safely been ruled out. Patients benefit from a well-rounded treatment approach that includes pharmacology, diagnostic testing, physical medicine, and manipulative treatments. This was shown in a clinical trial using rats where the lungs of rats diagnosed with S treptococcus pneumoniae had reduced levels of bacteria after receiving lymphatic pump techniques along with antibiotics compared to controls. [25]"}
+{"id": "article-102966_37", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Enhancing Healthcare Team Outcomes", "content": "It is essential for all patient providers, including nurses, urgent care workers, primary care physicians, emergency medicine physicians, and pharmacists, to\u00a0communicate\u00a0openly to formulate a healthy treatment plan. This approach will help to better monitor patients with chronic pain to reduce\u00a0opioid and other substance abuse. All of these methods of providing patient care will deliver a well-rounded systemic approach to healing patients with musculoskeletal discomfort from inhaled ribs and ruling out underlying deadly disease processes.", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Enhancing Healthcare Team Outcomes. It is essential for all patient providers, including nurses, urgent care workers, primary care physicians, emergency medicine physicians, and pharmacists, to\u00a0communicate\u00a0openly to formulate a healthy treatment plan. This approach will help to better monitor patients with chronic pain to reduce\u00a0opioid and other substance abuse. All of these methods of providing patient care will deliver a well-rounded systemic approach to healing patients with musculoskeletal discomfort from inhaled ribs and ruling out underlying deadly disease processes."}
+{"id": "article-102966_38", "title": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Osteopathic Manipulative Treatment: Inhaled Rib Dysfunction -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

statpearls/chunk/article-102968.jsonl

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+{"id": "article-102968_0", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Continuing Education Activity", "content": "The definition of somatic dysfunction is \"impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial and myofascial structures, and their related vascular, lymphatic, and neural elements.\" This activity describes the role of rib HVLA used by an appropriate healthcare provider in treating patients with somatic dysfunction.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Continuing Education Activity. The definition of somatic dysfunction is \"impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial and myofascial structures, and their related vascular, lymphatic, and neural elements.\" This activity describes the role of rib HVLA used by an appropriate healthcare provider in treating patients with somatic dysfunction."}
+{"id": "article-102968_1", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Continuing Education Activity", "content": "Objectives: Explain the importance of collaboration and communication amongst the interprofessional team to ensure the appropriate selection of candidates for the use of HVLA in rib somatic dysfunction. Review the contraindications to using HVLA in specific populations. Outline the steps to perform HVLA for rib somatic dysfunction. Summarize the risks associated with using HVLA for rib somatic dysfunction. Access free multiple choice questions on this topic.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Continuing Education Activity. Objectives: Explain the importance of collaboration and communication amongst the interprofessional team to ensure the appropriate selection of candidates for the use of HVLA in rib somatic dysfunction. Review the contraindications to using HVLA in specific populations. Outline the steps to perform HVLA for rib somatic dysfunction. Summarize the risks associated with using HVLA for rib somatic dysfunction. Access free multiple choice questions on this topic."}
+{"id": "article-102968_2", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Introduction", "content": "The definition of somatic dysfunction is \"impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial and myofascial structures, and their related vascular, lymphatic, and neural elements.\" [1] Andrew Taylor Still, MD, DO, was the founder of osteopathy in 1874. [2] Osteopathy, or osteopathic medicine, is practiced by osteopathic physicians licensed as a Doctor of Osteopathic Medicine (DO). A fundamental principle of osteopathic medicine is the treatment of somatic dysfunction by using osteopathic manipulative treatment (OMT); the body will be capable of self-healing. [3]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Introduction. The definition of somatic dysfunction is \"impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial and myofascial structures, and their related vascular, lymphatic, and neural elements.\" [1] Andrew Taylor Still, MD, DO, was the founder of osteopathy in 1874. [2] Osteopathy, or osteopathic medicine, is practiced by osteopathic physicians licensed as a Doctor of Osteopathic Medicine (DO). A fundamental principle of osteopathic medicine is the treatment of somatic dysfunction by using osteopathic manipulative treatment (OMT); the body will be capable of self-healing. [3]"}
+{"id": "article-102968_3", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Introduction", "content": "High-velocity low amplitude (HVLA) is one type of technique/procedure utilized by an osteopathic clinician that can be used to restore the body to health. Other types of OMT techniques include but are not limited to muscle energy, counterstrain, balanced ligamentous tension, cranial and myofascial release. In this article, the indications, techniques, contraindications, side-effects, and monitoring parameters of the HLVA technique related to the ribs as attachments to the thoracic vertebrae will be reviewed.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Introduction. High-velocity low amplitude (HVLA) is one type of technique/procedure utilized by an osteopathic clinician that can be used to restore the body to health. Other types of OMT techniques include but are not limited to muscle energy, counterstrain, balanced ligamentous tension, cranial and myofascial release. In this article, the indications, techniques, contraindications, side-effects, and monitoring parameters of the HLVA technique related to the ribs as attachments to the thoracic vertebrae will be reviewed."}
+{"id": "article-102968_4", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Anatomy and Physiology", "content": "Normally there are 12 ribs bilaterally in the human body. Each rib corresponds with each of the 12 vertebrae of the thoracic spine. The head of each rib articulates posteriorly with the bodies of the vertebra at its own level and of the one above it, except for the first rib, which only attaches to the first thoracic vertebra. [4] [5] Ribs 1\u00a0to 7 are considered \"true ribs\" because they connect\u00a0anteriorly to the sternum via costal cartilages. Ribs 8\u00a0to 10 are considered \"false ribs\" because they connect indirectly to the sternum through the seventh costal cartilage. Ribs 11\u00a0and 12 have the name \"floating ribs\" because they do not connect to the sternum at all. [5]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Anatomy and Physiology. Normally there are 12 ribs bilaterally in the human body. Each rib corresponds with each of the 12 vertebrae of the thoracic spine. The head of each rib articulates posteriorly with the bodies of the vertebra at its own level and of the one above it, except for the first rib, which only attaches to the first thoracic vertebra. [4] [5] Ribs 1\u00a0to 7 are considered \"true ribs\" because they connect\u00a0anteriorly to the sternum via costal cartilages. Ribs 8\u00a0to 10 are considered \"false ribs\" because they connect indirectly to the sternum through the seventh costal cartilage. Ribs 11\u00a0and 12 have the name \"floating ribs\" because they do not connect to the sternum at all. [5]"}
+{"id": "article-102968_5", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Anatomy and Physiology", "content": "Muscles that are associated with rib movement include the diaphragm, pectoralis major, pectoralis minor, external abdominal oblique, rectus abdominis, subclavius, serratus anterior, external intercostal, internal intercostal, innermost intercostal, quadratus lumborum, transversus thoracis, latissimus dorsi, anterior scalene, middle scalene, posterior scalene, serratus posterior superior, and serratus posterior inferior. [5] [6]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Anatomy and Physiology. Muscles that are associated with rib movement include the diaphragm, pectoralis major, pectoralis minor, external abdominal oblique, rectus abdominis, subclavius, serratus anterior, external intercostal, internal intercostal, innermost intercostal, quadratus lumborum, transversus thoracis, latissimus dorsi, anterior scalene, middle scalene, posterior scalene, serratus posterior superior, and serratus posterior inferior. [5] [6]"}
+{"id": "article-102968_6", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Anatomy and Physiology", "content": "Normal respiration is required for optimal lymphatic drainage to occur. The thoracic duct drains lymph from the left head and neck, the left thorax, the left upper extremity, and the rest of the lower body into the venous system at the junction of the left internal jugular vein and left subclavian vein. The right lymphatic duct drains the right head and neck, right thorax, and right upper extremity into the venous system. [7] A study by Noll et al. in 2016 suggested that OMT in reducing the length of stay (LOS) and mortality in a select population. [8]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Anatomy and Physiology. Normal respiration is required for optimal lymphatic drainage to occur. The thoracic duct drains lymph from the left head and neck, the left thorax, the left upper extremity, and the rest of the lower body into the venous system at the junction of the left internal jugular vein and left subclavian vein. The right lymphatic duct drains the right head and neck, right thorax, and right upper extremity into the venous system. [7] A study by Noll et al. in 2016 suggested that OMT in reducing the length of stay (LOS) and mortality in a select population. [8]"}
+{"id": "article-102968_7", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Anatomy and Physiology", "content": "Osteopathic physicians describe ribs by their motion with respect to the thoracic spine. Ribs fall into three categories; pump handle motion (ribs 1\u00a0to 5), bucket handle motion (ribs 6\u00a0to 10), and caliper motion (ribs 11\u00a0and 12). The diaphragm connects to ribs 6-12 and is domed\u00a0cephalad at rest. [9] During inhalation, the diaphragm contracts resulting in increased lung volume and displacement of the rib cage. [10] Optimal respiration may be affected by\u00a0any disturbance in the normal motion of these\u00a0musculoskeletal\u00a0structures. Rib somatic dysfunction can result from excessive physical activity, cough, poor posture, and increased kyphosis. [11] In an inhalation dysfunction, the dysfunctional rib will move freely cephalad but will have restriction to moving caudally during exhalation. Conversely, in an exhalation dysfunction, the\u00a0dysfunctional rib will move freely caudal but will have restriction to moving cephalad during inhalation. [9]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Anatomy and Physiology. Osteopathic physicians describe ribs by their motion with respect to the thoracic spine. Ribs fall into three categories; pump handle motion (ribs 1\u00a0to 5), bucket handle motion (ribs 6\u00a0to 10), and caliper motion (ribs 11\u00a0and 12). The diaphragm connects to ribs 6-12 and is domed\u00a0cephalad at rest. [9] During inhalation, the diaphragm contracts resulting in increased lung volume and displacement of the rib cage. [10] Optimal respiration may be affected by\u00a0any disturbance in the normal motion of these\u00a0musculoskeletal\u00a0structures. Rib somatic dysfunction can result from excessive physical activity, cough, poor posture, and increased kyphosis. [11] In an inhalation dysfunction, the dysfunctional rib will move freely cephalad but will have restriction to moving caudally during exhalation. Conversely, in an exhalation dysfunction, the\u00a0dysfunctional rib will move freely caudal but will have restriction to moving cephalad during inhalation. [9]"}
+{"id": "article-102968_8", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Anatomy and Physiology", "content": "The inferior scapular angle (ISA) can serve as a landmark for the spinous process of the T7 vertebra, but in a literature review of anatomical studies by Cooperstein et al., it was concluded that the ISA is not an acceptable landmark for identifying spinal levels. [12]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Anatomy and Physiology. The inferior scapular angle (ISA) can serve as a landmark for the spinous process of the T7 vertebra, but in a literature review of anatomical studies by Cooperstein et al., it was concluded that the ISA is not an acceptable landmark for identifying spinal levels. [12]"}
+{"id": "article-102968_9", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Indications", "content": "HVLA is\u00a0indicated to treat somatic dysfunction of the thoracic cage,\u00a0the thoracic vertebrae, and the ribs at the posterior rib angles. Somatic dysfunctions of the ribs are described as either\u00a0inhalation and exhalation dysfunctions. Acute chest pain is a frequent chief complaint of patients presenting to the emergency department; however, the leading cause of chest pain is musculoskeletal in origin in patients\u00a0without evidence of acute myocardial ischemia or infarction. [13] HVLA, solo or in combination with other OMT techniques, is\u00a0another option when\u00a0conventional treatment such as pharmaceutical pain medications are either contraindicated or not tolerated well. [14]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Indications. HVLA is\u00a0indicated to treat somatic dysfunction of the thoracic cage,\u00a0the thoracic vertebrae, and the ribs at the posterior rib angles. Somatic dysfunctions of the ribs are described as either\u00a0inhalation and exhalation dysfunctions. Acute chest pain is a frequent chief complaint of patients presenting to the emergency department; however, the leading cause of chest pain is musculoskeletal in origin in patients\u00a0without evidence of acute myocardial ischemia or infarction. [13] HVLA, solo or in combination with other OMT techniques, is\u00a0another option when\u00a0conventional treatment such as pharmaceutical pain medications are either contraindicated or not tolerated well. [14]"}
+{"id": "article-102968_10", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Contraindications", "content": "HVLA has the most contraindications of all OMT techniques. The following are contraindications for HVLA techniques, including its application to the ribs: [15] Anticoagulant therapy (relative contraindication) Connective tissue disease Fracture Malignancy (if local metastasis) Osteoporosis Patient uncooperative Severe rheumatoid arthritis Surgery (if local)", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Contraindications. HVLA has the most contraindications of all OMT techniques. The following are contraindications for HVLA techniques, including its application to the ribs: [15] Anticoagulant therapy (relative contraindication) Connective tissue disease Fracture Malignancy (if local metastasis) Osteoporosis Patient uncooperative Severe rheumatoid arthritis Surgery (if local)"}
+{"id": "article-102968_11", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Contraindications", "content": "Indirect OMT techniques such as muscle energy, myofascial release, rib raising, and soft tissue techniques are a few\u00a0alternative options to consider when HVLA is contraindicated. For example, in a recent study by Chin et al., the rib raising technique was used in 87 hospitalized non-intensive care unit patients admitted for respiratory issues, and the procedure was well tolerated. [16]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Contraindications. Indirect OMT techniques such as muscle energy, myofascial release, rib raising, and soft tissue techniques are a few\u00a0alternative options to consider when HVLA is contraindicated. For example, in a recent study by Chin et al., the rib raising technique was used in 87 hospitalized non-intensive care unit patients admitted for respiratory issues, and the procedure was well tolerated. [16]"}
+{"id": "article-102968_12", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Personnel", "content": "The technique requires a doctor of osteopathic medicine, a doctor of chiropractic, or a doctor of medicine certified to perform OMT. To successfully perform OMT, the patient must be cooperative and also comfortable enough to be placed in the proper positioning for treatment set up and execution. Also, the physician should be cognizant of the patient's position and set up to not injure themselves.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Personnel. The technique requires a doctor of osteopathic medicine, a doctor of chiropractic, or a doctor of medicine certified to perform OMT. To successfully perform OMT, the patient must be cooperative and also comfortable enough to be placed in the proper positioning for treatment set up and execution. Also, the physician should be cognizant of the patient's position and set up to not injure themselves."}
+{"id": "article-102968_13", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Preparation", "content": "OMT is considered a procedure and thus must have consent from the patient prior to the procedure.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Preparation. OMT is considered a procedure and thus must have consent from the patient prior to the procedure."}
+{"id": "article-102968_14", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Technique or Treatment", "content": "Kasten et al. best describe the use of HVLA for rib somatic dysfunction. and Pierce-Talsma et al. describe it for ribs 2\u00a0to 10: [9] [11]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Technique or Treatment. Kasten et al. best describe the use of HVLA for rib somatic dysfunction. and Pierce-Talsma et al. describe it for ribs 2\u00a0to 10: [9] [11]"}
+{"id": "article-102968_15", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Technique or Treatment", "content": "The patient is placed in a supine position\u00a0with the physician on the opposite\u00a0of the dysfunctional rib; the angle of the rib will feel more posterior since it is \"stuck\" either up or down in comparison to the rib above and below.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Technique or Treatment. The patient is placed in a supine position\u00a0with the physician on the opposite\u00a0of the dysfunctional rib; the angle of the rib will feel more posterior since it is \"stuck\" either up or down in comparison to the rib above and below."}
+{"id": "article-102968_16", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Technique or Treatment", "content": "The patient crosses their arms across their chest\u00a0such that the arm on top is the same side as the posterior rib.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Technique or Treatment. The patient crosses their arms across their chest\u00a0such that the arm on top is the same side as the posterior rib."}
+{"id": "article-102968_17", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Technique or Treatment", "content": "The healthcare provider then rolls the patient towards them and places their thenar eminence on the dysfunctional rib between the transverse process and the rib angle.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Technique or Treatment. The healthcare provider then rolls the patient towards them and places their thenar eminence on the dysfunctional rib between the transverse process and the rib angle."}
+{"id": "article-102968_18", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Technique or Treatment", "content": "Then the patient is rolled back onto the thenar eminence. The\u00a0clinician flexes the patient to the posterior transverse process just below the dysfunctional rib with their opposite hand.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Technique or Treatment. Then the patient is rolled back onto the thenar eminence. The\u00a0clinician flexes the patient to the posterior transverse process just below the dysfunctional rib with their opposite hand."}
+{"id": "article-102968_19", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Technique or Treatment", "content": "The patient takes a deep breath in, and as they exhale, apply force from the healthcare\u00a0provider's abdomen\u00a0through the patient's elbow to the posterior rib.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Technique or Treatment. The patient takes a deep breath in, and as they exhale, apply force from the healthcare\u00a0provider's abdomen\u00a0through the patient's elbow to the posterior rib."}
+{"id": "article-102968_20", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Technique or Treatment", "content": "At the end of exhalation, just prior to the patient inhaling, apply an HVLA thrust from the healthcare\u00a0provider's abdomen straight down to the posterior rib.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Technique or Treatment. At the end of exhalation, just prior to the patient inhaling, apply an HVLA thrust from the healthcare\u00a0provider's abdomen straight down to the posterior rib."}
+{"id": "article-102968_21", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Technique or Treatment", "content": "The thenar eminence against the posterior rib will feel a thrust, and\u00a0the\u00a0articulation may be palpated.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Technique or Treatment. The thenar eminence against the posterior rib will feel a thrust, and\u00a0the\u00a0articulation may be palpated."}
+{"id": "article-102968_22", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Technique or Treatment", "content": "A \"popping\" or \"cracking\" sound may also be heard", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Technique or Treatment. A \"popping\" or \"cracking\" sound may also be heard"}
+{"id": "article-102968_23", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Technique or Treatment", "content": "After the HVLA technique is complete, the healthcare provider should reassess the area of somatic dysfunction.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Technique or Treatment. After the HVLA technique is complete, the healthcare provider should reassess the area of somatic dysfunction."}
+{"id": "article-102968_24", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Technique or Treatment", "content": "The technique may be repeated if additional somatic dysfunction is found.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Technique or Treatment. The technique may be repeated if additional somatic dysfunction is found."}
+{"id": "article-102968_25", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Complications", "content": "Most patients tolerate OMT well if they have adequate screening for contraindications. [17] [18] Common side effects can include tenderness or soreness to the area of treatment. The recommended approach is\u00a0for patients to take a warm shower and drink plenty of water after a treatment session. Two previous reviews by Terrettl and Laughlin concluded that manipulation was very safe if performed by skilled practitioners. [19]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Complications. Most patients tolerate OMT well if they have adequate screening for contraindications. [17] [18] Common side effects can include tenderness or soreness to the area of treatment. The recommended approach is\u00a0for patients to take a warm shower and drink plenty of water after a treatment session. Two previous reviews by Terrettl and Laughlin concluded that manipulation was very safe if performed by skilled practitioners. [19]"}
+{"id": "article-102968_26", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Enhancing Healthcare Team Outcomes", "content": "Respiration is a biomechanical wonder that requires normal motion of fascia, diaphragm, ribs, and other thoracic cavity structures to function optimally. Somatic dysfunction may negatively affect respiration, especially if other disease processes are present such as musculoskeletal disorders, chronic obstructive pulmonary disease (COPD), pneumonia, and asthma.\u00a0HVLA, which is a type of OMT technique, can be utilized by a proficient\u00a0healthcare provider when\u00a0somatic dysfunction is present. In a pilot study by Zanotti et al., OMT was shown to improve exercise capacity in patients with severe COPD compared to soft manipulation. [17] However, in another study by Noll et al., elderly patients with COPD were found to have increased air trapping 30 minutes after receiving OMT. The results of having air trapping post-OMT were likely secondary to\u00a0their use of a technique called thoracic lymphatic pump with activation that includes taking multiple deep breaths. [18]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Enhancing Healthcare Team Outcomes. Respiration is a biomechanical wonder that requires normal motion of fascia, diaphragm, ribs, and other thoracic cavity structures to function optimally. Somatic dysfunction may negatively affect respiration, especially if other disease processes are present such as musculoskeletal disorders, chronic obstructive pulmonary disease (COPD), pneumonia, and asthma.\u00a0HVLA, which is a type of OMT technique, can be utilized by a proficient\u00a0healthcare provider when\u00a0somatic dysfunction is present. In a pilot study by Zanotti et al., OMT was shown to improve exercise capacity in patients with severe COPD compared to soft manipulation. [17] However, in another study by Noll et al., elderly patients with COPD were found to have increased air trapping 30 minutes after receiving OMT. The results of having air trapping post-OMT were likely secondary to\u00a0their use of a technique called thoracic lymphatic pump with activation that includes taking multiple deep breaths. [18]"}
+{"id": "article-102968_27", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Enhancing Healthcare Team Outcomes", "content": "One major weakness of both of these studies was that the number of patients receiving HVLA was not reported in their publication. Furthermore, in the study by Noll et al., a thorough description of how they performed HVLA was not reported, unlike seven of the other techniques that they used.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Enhancing Healthcare Team Outcomes. One major weakness of both of these studies was that the number of patients receiving HVLA was not reported in their publication. Furthermore, in the study by Noll et al., a thorough description of how they performed HVLA was not reported, unlike seven of the other techniques that they used."}
+{"id": "article-102968_28", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Enhancing Healthcare Team Outcomes", "content": "All doctors of osteopathic medicine and doctors of chiropractic receive training in performing OMT. Doctors of chiropractic commonly use HVLA. [20] Allopathic physicians can become certified to perform OMT if they take the appropriate steps. The curriculum for physician assistants, for example, does not include osteopathic principles. [21]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Enhancing Healthcare Team Outcomes. All doctors of osteopathic medicine and doctors of chiropractic receive training in performing OMT. Doctors of chiropractic commonly use HVLA. [20] Allopathic physicians can become certified to perform OMT if they take the appropriate steps. The curriculum for physician assistants, for example, does not include osteopathic principles. [21]"}
+{"id": "article-102968_29", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Enhancing Healthcare Team Outcomes", "content": "An osteopathic physician is a graduate of an osteopathic medical school. A survey done in the United States by Teng et al. found that third and fourth-year medical students that had additional OMT clinical exposure increased their comfort level with the underlying topic of musculoskeletal disorders and their comfort level with OMT. [22] Another survey in Michigan found that 57.1% of osteopathic students thought their musculoskeletal curriculum was adequate compared to 26.8% of allopathic students. [23]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Enhancing Healthcare Team Outcomes. An osteopathic physician is a graduate of an osteopathic medical school. A survey done in the United States by Teng et al. found that third and fourth-year medical students that had additional OMT clinical exposure increased their comfort level with the underlying topic of musculoskeletal disorders and their comfort level with OMT. [22] Another survey in Michigan found that 57.1% of osteopathic students thought their musculoskeletal curriculum was adequate compared to 26.8% of allopathic students. [23]"}
+{"id": "article-102968_30", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Enhancing Healthcare Team Outcomes", "content": "Musculoskeletal pain remains a major reason patients present to\u00a0emergency departments and primary care settings in both developed and developing countries. [23] [24] When it comes to treating disorders of the thorax,\u00a0HVLA is another tool in the toolbox of treatments. Nursing can help by monitoring hospitalized patients for improvement in symptoms or complications of OMT. Pharmacists can refer patients to an appropriate healthcare provider for OMT when conventional pharmacologic agents are not enough to control symptoms.\u00a0Respiratory therapists who see patients for pulmonary rehabilitation can refer to\u00a0an appropriate\u00a0clinician\u00a0for\u00a0patients that need additional support.\u00a0In conclusion, HVLA can be utilized by a proficient\u00a0healthcare provider to treat rib somatic dysfunction. [Level\u00a02]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Enhancing Healthcare Team Outcomes. Musculoskeletal pain remains a major reason patients present to\u00a0emergency departments and primary care settings in both developed and developing countries. [23] [24] When it comes to treating disorders of the thorax,\u00a0HVLA is another tool in the toolbox of treatments. Nursing can help by monitoring hospitalized patients for improvement in symptoms or complications of OMT. Pharmacists can refer patients to an appropriate healthcare provider for OMT when conventional pharmacologic agents are not enough to control symptoms.\u00a0Respiratory therapists who see patients for pulmonary rehabilitation can refer to\u00a0an appropriate\u00a0clinician\u00a0for\u00a0patients that need additional support.\u00a0In conclusion, HVLA can be utilized by a proficient\u00a0healthcare provider to treat rib somatic dysfunction. [Level\u00a02]"}
+{"id": "article-102968_31", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

statpearls/chunk/article-102971.jsonl

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+{"id": "article-102971_0", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Continuing Education Activity", "content": "High-Velocity Low-Amplitude (HVLA) incorporates rapid thrust techniques over a short distance through a pathologic barrier. HVLA techniques require a physician to locate immobile or asymmetrical joints using his or her hands. The physician controls the pathologic barrier by setting it in motion and applying rapid but short thrusts until usually a pop sound is heard, confirming the restoration of motion in the affected joint. This activity reviews the evaluation and treatment of exhalation dysfunctions and highlights the role of the HVLA techniques in evaluating and treating this condition.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Continuing Education Activity. High-Velocity Low-Amplitude (HVLA) incorporates rapid thrust techniques over a short distance through a pathologic barrier. HVLA techniques require a physician to locate immobile or asymmetrical joints using his or her hands. The physician controls the pathologic barrier by setting it in motion and applying rapid but short thrusts until usually a pop sound is heard, confirming the restoration of motion in the affected joint. This activity reviews the evaluation and treatment of exhalation dysfunctions and highlights the role of the HVLA techniques in evaluating and treating this condition."}
+{"id": "article-102971_1", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Continuing Education Activity", "content": "Objectives: Summarize the common HVLA treatment considerations for patients with exhaled ribs. Describe the classic exhalation physiology. Review the screening indications for exhaled ribs. Explain the importance of collaboration and communication amongst the MDs and DOs to enhance treatment considerations for patients affected by exhalation dysfunction. Access free multiple choice questions on this topic.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Continuing Education Activity. Objectives: Summarize the common HVLA treatment considerations for patients with exhaled ribs. Describe the classic exhalation physiology. Review the screening indications for exhaled ribs. Explain the importance of collaboration and communication amongst the MDs and DOs to enhance treatment considerations for patients affected by exhalation dysfunction. Access free multiple choice questions on this topic."}
+{"id": "article-102971_2", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Introduction", "content": "High-velocity low-amplitude (HVLA) incorporates rapid thrust techniques over a short distance through a pathologic barrier. [1] HVLA techniques require a physician to locate immobile or asymmetrical joints using his or her hands. The physician controls the pathologic barrier by setting it in motion and applying rapid but short thrusts until usually hearing an audible release, confirming the restoration of motion in the affected joint. HVLA techniques have been widely reported across medical literature and have been proven effective in subsiding neck and shoulder pain after their utilization in the cervicothoracic region. [2]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Introduction. High-velocity low-amplitude (HVLA) incorporates rapid thrust techniques over a short distance through a pathologic barrier. [1] HVLA techniques require a physician to locate immobile or asymmetrical joints using his or her hands. The physician controls the pathologic barrier by setting it in motion and applying rapid but short thrusts until usually hearing an audible release, confirming the restoration of motion in the affected joint. HVLA techniques have been widely reported across medical literature and have been proven effective in subsiding neck and shoulder pain after their utilization in the cervicothoracic region. [2]"}
+{"id": "article-102971_3", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Introduction", "content": "Exhalation dysfunction, formerly known as inhalation restriction, refers to the caudad movement of a dysfunctional rib during exhalation with an absent cephalad rib movement during inhalation. The physician notices one (in some cases) but, generally, a class of ribs stuck in exhalation. OMT (Osteopathic Manipulative Therapy) tends to heal compromises within a joint\u2019s normal range of motion via allocating the joint through the compromised pathologic barrier, generally not beyond the usual physiologic range of motion, which may justify the low incidence of harmful effects off OMT procedures. This review implores the usage of OMT in treating exhaled ribs under inhalation restriction. [3] [4]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Introduction. Exhalation dysfunction, formerly known as inhalation restriction, refers to the caudad movement of a dysfunctional rib during exhalation with an absent cephalad rib movement during inhalation. The physician notices one (in some cases) but, generally, a class of ribs stuck in exhalation. OMT (Osteopathic Manipulative Therapy) tends to heal compromises within a joint\u2019s normal range of motion via allocating the joint through the compromised pathologic barrier, generally not beyond the usual physiologic range of motion, which may justify the low incidence of harmful effects off OMT procedures. This review implores the usage of OMT in treating exhaled ribs under inhalation restriction. [3] [4]"}
+{"id": "article-102971_4", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Anatomy and Physiology", "content": "The rib cage consists of typical and atypical ribs. A typical rib will have the following landmarks: Angle Shaft Neck A head that joins with the superior and corresponding vertebra A tubercle that connects to the corresponding transverse process", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Anatomy and Physiology. The rib cage consists of typical and atypical ribs. A typical rib will have the following landmarks: Angle Shaft Neck A head that joins with the superior and corresponding vertebra A tubercle that connects to the corresponding transverse process"}
+{"id": "article-102971_5", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Anatomy and Physiology", "content": "Ribs 1, 2, 11, and 12 (sometimes 10) are atypical, while 3\u00a0through 10 are typical. Rib 1 is atypical as it connects only with T1 with no angle. Rib 2 is atypical due to its large tuberosity on the serratus anterior shaft. Rib 11 and 12 both articulate only with the corresponding vertebra but have no tubercles. Rib 10 is sometimes considered atypical as it only connects to T10. The ribs further classify as true, false, and floating ribs. Ribs 1\u00a0through 7 are true ribs as they connect to the sternum by costal cartilages. Ribs 8\u00a0to 12 are called false ribs as they do not directly connect to the sternum; ribs 11 to 12 are called floating ribs because they remain unarticulated anteriorly. There are three categories of rib movement: Pump-handle motion Bucket-handle motion Caliper motion Depending on their location amidst the ribcage, all ribs may have a mix of the above movements; however, they generally tend to follow the patterns below:", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Anatomy and Physiology. Ribs 1, 2, 11, and 12 (sometimes 10) are atypical, while 3\u00a0through 10 are typical. Rib 1 is atypical as it connects only with T1 with no angle. Rib 2 is atypical due to its large tuberosity on the serratus anterior shaft. Rib 11 and 12 both articulate only with the corresponding vertebra but have no tubercles. Rib 10 is sometimes considered atypical as it only connects to T10. The ribs further classify as true, false, and floating ribs. Ribs 1\u00a0through 7 are true ribs as they connect to the sternum by costal cartilages. Ribs 8\u00a0to 12 are called false ribs as they do not directly connect to the sternum; ribs 11 to 12 are called floating ribs because they remain unarticulated anteriorly. There are three categories of rib movement: Pump-handle motion Bucket-handle motion Caliper motion Depending on their location amidst the ribcage, all ribs may have a mix of the above movements; however, they generally tend to follow the patterns below:"}
+{"id": "article-102971_6", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Anatomy and Physiology", "content": "The upper ribs (1-5) generally move in a pump-handle motion. The middle ribs (6-10) generally move in a bucket-handle motion. The lower ribs (11 and 12) generally move in a caliper motion.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Anatomy and Physiology. The upper ribs (1-5) generally move in a pump-handle motion. The middle ribs (6-10) generally move in a bucket-handle motion. The lower ribs (11 and 12) generally move in a caliper motion."}
+{"id": "article-102971_7", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Anatomy and Physiology", "content": "Muscles of inspiration refer to those muscles that uplift the chest cage. Muscles of expiration refer to those muscles that push the chest cage downward. External intercostals are the most crucial muscles of inspiration, but other noteworthy muscles are: Sternocleidomastoid muscles that elevate the sternum Anterior serrati that uplift many ribs Scaleni which lifts ribs 1\u00a0and 2 The muscles that push the chest cage downward are primarily the: Abdominal recti, which is capable of pulling the lower ribs down when they and other abdominal muscles compact the abdominal contents up contra the diaphragm Internal intercostals The lungs can expand and contract in two ways: Downward and upward diaphragmatic motion to expand or shorten the thoracic cavity, and Elevation and depression of the ribs to lengthen and reduce the anteroposterior diameter.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Anatomy and Physiology. Muscles of inspiration refer to those muscles that uplift the chest cage. Muscles of expiration refer to those muscles that push the chest cage downward. External intercostals are the most crucial muscles of inspiration, but other noteworthy muscles are: Sternocleidomastoid muscles that elevate the sternum Anterior serrati that uplift many ribs Scaleni which lifts ribs 1\u00a0and 2 The muscles that push the chest cage downward are primarily the: Abdominal recti, which is capable of pulling the lower ribs down when they and other abdominal muscles compact the abdominal contents up contra the diaphragm Internal intercostals The lungs can expand and contract in two ways: Downward and upward diaphragmatic motion to expand or shorten the thoracic cavity, and Elevation and depression of the ribs to lengthen and reduce the anteroposterior diameter."}
+{"id": "article-102971_8", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Anatomy and Physiology", "content": "Normal quiet breathing almost exclusively involves the first method. Diaphragmatic contraction pulls the lower lung surfaces downward during inspiration; the diaphragm relaxes during expiration while the chest wall, elastic lung recoils, and abdominal structures press the lungs and expel the air. During rapid breathing, however, the contraction of abdominal muscles becomes necessary as the elastic forces are not strong enough to produce the vital rapid expiration. The second method mentioned earlier elevates the rib cage. At rest, the ribs incline downward to let the sternum fall backward to the vertebral column. When the rib cage uplifts, the ribs protrude directly forward, allowing the sternum to move forward and away from the spine, thickening the chest about 20 percent greater at utmost inspiration than during expiration anteroposteriorly. [5] [6] [7]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Anatomy and Physiology. Normal quiet breathing almost exclusively involves the first method. Diaphragmatic contraction pulls the lower lung surfaces downward during inspiration; the diaphragm relaxes during expiration while the chest wall, elastic lung recoils, and abdominal structures press the lungs and expel the air. During rapid breathing, however, the contraction of abdominal muscles becomes necessary as the elastic forces are not strong enough to produce the vital rapid expiration. The second method mentioned earlier elevates the rib cage. At rest, the ribs incline downward to let the sternum fall backward to the vertebral column. When the rib cage uplifts, the ribs protrude directly forward, allowing the sternum to move forward and away from the spine, thickening the chest about 20 percent greater at utmost inspiration than during expiration anteroposteriorly. [5] [6] [7]"}
+{"id": "article-102971_9", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Indications", "content": "In general, any form of somatic dysfunction that leads to motion loss can be an indication. Specifically, rib (11 or 12) inhalation restriction is related to but is not restricted to the following: Sacral pain Chest wall pain Back pain Pelvic pain Abdominal pain", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Indications. In general, any form of somatic dysfunction that leads to motion loss can be an indication. Specifically, rib (11 or 12) inhalation restriction is related to but is not restricted to the following: Sacral pain Chest wall pain Back pain Pelvic pain Abdominal pain"}
+{"id": "article-102971_10", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Indications", "content": "In exhalation dysfunction, the physician usually depresses pump-handle ribs anteriorly. The anterior portions of the rib mobilize caudad during expiration and are restricted on inspiration. The physician may also notice the narrowing of the anterior intercostal space beneath the compromised rib. The inferior edge of the posterior rib angle is usually protuberant in these cases. Tenderness may be felt in the: Chondrosternal junction Costochondral junction Posterior rib angles", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Indications. In exhalation dysfunction, the physician usually depresses pump-handle ribs anteriorly. The anterior portions of the rib mobilize caudad during expiration and are restricted on inspiration. The physician may also notice the narrowing of the anterior intercostal space beneath the compromised rib. The inferior edge of the posterior rib angle is usually protuberant in these cases. Tenderness may be felt in the: Chondrosternal junction Costochondral junction Posterior rib angles"}
+{"id": "article-102971_11", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Indications", "content": "Meanwhile, bucket-handle ribs are usually depressed laterally in exhalation dysfunction. The rib shafts slightly shift downward during expiration and are limited during inspiration. The physician may also notice constricting of the lateral side of the intercostal space beneath the compromised rib. Tenderness may be felt in the: Posterior rib angles Intercostal muscles at the mid-axillary line", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Indications. Meanwhile, bucket-handle ribs are usually depressed laterally in exhalation dysfunction. The rib shafts slightly shift downward during expiration and are limited during inspiration. The physician may also notice constricting of the lateral side of the intercostal space beneath the compromised rib. Tenderness may be felt in the: Posterior rib angles Intercostal muscles at the mid-axillary line"}
+{"id": "article-102971_12", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Contraindications", "content": "Though brief, HVLA techniques on compromised ribs do require powerful forces. It is the responsibility of the physician to reconsider treatment if the patient has the following: Acute rib fracture Pelvic fracture Rib or vertebral cancer Severe low back pain In most cases, the clinician should reconsider HVLA if the patient has the following conditions: Osteomyelitis Osteoporosis Fractures in the HVLA area Bone metastasis Down syndrome Rheumatoid arthritis (severe cases) Pregnancy Acute whiplash Herniated nucleus pulposus Postoperative conditions Vertebral artery ischemia History of hemophilia or ongoing anticoagulation therapy", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Contraindications. Though brief, HVLA techniques on compromised ribs do require powerful forces. It is the responsibility of the physician to reconsider treatment if the patient has the following: Acute rib fracture Pelvic fracture Rib or vertebral cancer Severe low back pain In most cases, the clinician should reconsider HVLA if the patient has the following conditions: Osteomyelitis Osteoporosis Fractures in the HVLA area Bone metastasis Down syndrome Rheumatoid arthritis (severe cases) Pregnancy Acute whiplash Herniated nucleus pulposus Postoperative conditions Vertebral artery ischemia History of hemophilia or ongoing anticoagulation therapy"}
+{"id": "article-102971_13", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Equipment", "content": "An OMT table An exam table A massage table An alternative place which comforts the patient in laying or sitting and allows the physician to perform the technique comfortably Although not necessary, physicians use a pillow for patient comfort, unless it tempers with the technique.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Equipment. An OMT table An exam table A massage table An alternative place which comforts the patient in laying or sitting and allows the physician to perform the technique comfortably Although not necessary, physicians use a pillow for patient comfort, unless it tempers with the technique."}
+{"id": "article-102971_14", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Personnel", "content": "A patient who has given consent A physician who has had formal training in OMT during medical school or postgraduate medical training", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Personnel. A patient who has given consent A physician who has had formal training in OMT during medical school or postgraduate medical training"}
+{"id": "article-102971_15", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Preparation", "content": "Ensure that the patient is well-informed about the procedure. Inform the patient about the benefits, risks, and alternative treatment options. Ensure that the patient has given their consent for the procedure. Warm both hands before performing the procedure by creating friction against the surfaces", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Preparation. Ensure that the patient is well-informed about the procedure. Inform the patient about the benefits, risks, and alternative treatment options. Ensure that the patient has given their consent for the procedure. Warm both hands before performing the procedure by creating friction against the surfaces"}
+{"id": "article-102971_16", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Technique or Treatment", "content": "This procedure uses the most cephalad rib as the main rib. The physician uses respiratory attempts and supplementary inhalation muscles to aid with treatment. In supine position: Stand on the opposite side of the compromised rib and plant your thenar eminence on top of the most medial aspect of that rib aiming the costotransverse articulation; Clutch the ASIS on the compromised rib\u2019s side with your other hand; Push the costotransverse articulation anterolaterally by inclining onto it while pulling the ASIS posteriorly; Request the patient to take a deep breath and exhale afterward. At maximum exhalation, apply a brief and quick thrust on the rib in an anterolateral direction; Reexamine rib mobility.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Technique or Treatment. This procedure uses the most cephalad rib as the main rib. The physician uses respiratory attempts and supplementary inhalation muscles to aid with treatment. In supine position: Stand on the opposite side of the compromised rib and plant your thenar eminence on top of the most medial aspect of that rib aiming the costotransverse articulation; Clutch the ASIS on the compromised rib\u2019s side with your other hand; Push the costotransverse articulation anterolaterally by inclining onto it while pulling the ASIS posteriorly; Request the patient to take a deep breath and exhale afterward. At maximum exhalation, apply a brief and quick thrust on the rib in an anterolateral direction; Reexamine rib mobility."}
+{"id": "article-102971_17", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Complications", "content": "In a 1925 to 1993 retrospective study conducted by a group of physicians, only 185 reports of injury caused by OMT appears in literature. HVLA techniques have not statistically caused significant adverse effects on patients; there are generally no side effects of OMT except for probable soreness for a day or two after the procedure; in fact, most manual procedures may cause transient adverse effects on patients. The degree of this potential soreness will depend on the approach taken by the physician.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Complications. In a 1925 to 1993 retrospective study conducted by a group of physicians, only 185 reports of injury caused by OMT appears in literature. HVLA techniques have not statistically caused significant adverse effects on patients; there are generally no side effects of OMT except for probable soreness for a day or two after the procedure; in fact, most manual procedures may cause transient adverse effects on patients. The degree of this potential soreness will depend on the approach taken by the physician."}
+{"id": "article-102971_18", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Complications", "content": "HVLA procedures are considered the riskiest in that band, as it produces rapid impulses. The literature records one harmful effect per 50,000 HVLA thrust procedures; however, there is currently no compelling evidence to prescribe that HVLA thrust techniques administered by well-trained providers should be terminated because of risk. In addition to experience and adequate training in these techniques, the way to a safe OMT session is taking a thorough patient history and performing a thorough physical examination before the administration of any procedure. [8]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Complications. HVLA procedures are considered the riskiest in that band, as it produces rapid impulses. The literature records one harmful effect per 50,000 HVLA thrust procedures; however, there is currently no compelling evidence to prescribe that HVLA thrust techniques administered by well-trained providers should be terminated because of risk. In addition to experience and adequate training in these techniques, the way to a safe OMT session is taking a thorough patient history and performing a thorough physical examination before the administration of any procedure. [8]"}
+{"id": "article-102971_19", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Clinical Significance", "content": "HVLA manipulation techniques intend to restore mobility to a compromised joint. These techniques have been used for a variety of conditions, but they are mostly used to treat low back and neck pain. Evidence suggests that HVLA spinal manipulation is as fruitful for those two conditions as other types of treatment. [9]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Clinical Significance. HVLA manipulation techniques intend to restore mobility to a compromised joint. These techniques have been used for a variety of conditions, but they are mostly used to treat low back and neck pain. Evidence suggests that HVLA spinal manipulation is as fruitful for those two conditions as other types of treatment. [9]"}
+{"id": "article-102971_20", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Enhancing Healthcare Team Outcomes", "content": "While contemporary Western surgical and medicinal knowledge is part of every practicing osteopathic physician (DO) in the United States, the current MD programs in the country refuse to incorporate the additional tool of OMT within their curriculum. With the 2020 merge of postgraduate medical education for both MDs and DOs, it is clear to us that the only difference between their overall education lies within the acceptance and refusal of OMT.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Enhancing Healthcare Team Outcomes. While contemporary Western surgical and medicinal knowledge is part of every practicing osteopathic physician (DO) in the United States, the current MD programs in the country refuse to incorporate the additional tool of OMT within their curriculum. With the 2020 merge of postgraduate medical education for both MDs and DOs, it is clear to us that the only difference between their overall education lies within the acceptance and refusal of OMT."}
+{"id": "article-102971_21", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Enhancing Healthcare Team Outcomes", "content": "As discussed in our review, OMT works as a less risky form of treatment that may be supplemented to the traditional medicine and surgery practiced by all physicians (both MDs and DOs); therefore, it is the responsibility of osteopaths to work towards achieving osteopathic recognition for ACGME-accredited residencies of all specialties across the country. This approach will allow for the MDs to learn some of the basic OMT procedures that the DOs have traditionally learned in their OMT classes during medical school, allowing both kinds of physicians to practice traditional medicine with a helpful tool by their side. [10] [11]", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Enhancing Healthcare Team Outcomes. As discussed in our review, OMT works as a less risky form of treatment that may be supplemented to the traditional medicine and surgery practiced by all physicians (both MDs and DOs); therefore, it is the responsibility of osteopaths to work towards achieving osteopathic recognition for ACGME-accredited residencies of all specialties across the country. This approach will allow for the MDs to learn some of the basic OMT procedures that the DOs have traditionally learned in their OMT classes during medical school, allowing both kinds of physicians to practice traditional medicine with a helpful tool by their side. [10] [11]"}
+{"id": "article-102971_22", "title": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

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+{"id": "article-102974_0", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Continuing Education Activity", "content": "Osteopathic manipulative treatment particularly focuses on muscle energy techniques (METs) and is utilized to address sacral dysfunctions in patients experiencing low back pain, aiming to alleviate symptoms. The sacrum is a triangular-shaped,\u00a0weight-transferring bone at the bottom of the vertebral column, which is highlighted as a crucial element in treating back pain and correcting abnormal gait.\u00a0Recent studies underscore the effectiveness of osteopathic manipulative medicine, which involves\u00a0various manual techniques and is used by healthcare providers to diagnose and address structural causes of back pain.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Continuing Education Activity. Osteopathic manipulative treatment particularly focuses on muscle energy techniques (METs) and is utilized to address sacral dysfunctions in patients experiencing low back pain, aiming to alleviate symptoms. The sacrum is a triangular-shaped,\u00a0weight-transferring bone at the bottom of the vertebral column, which is highlighted as a crucial element in treating back pain and correcting abnormal gait.\u00a0Recent studies underscore the effectiveness of osteopathic manipulative medicine, which involves\u00a0various manual techniques and is used by healthcare providers to diagnose and address structural causes of back pain."}
+{"id": "article-102974_1", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Continuing Education Activity", "content": "MET has been essential in correcting structural restrictions leading to low back pain, especially when related to sacral dysfunction. METs, particularly post-isometric isolation, offer a targeted approach for addressing soft tissue restrictive barriers and joint mobilization associated with sacral dysfunctions in cases where a significant percentage of back pain lacks precise diagnosis.\u00a0This activity focuses on the physiological principles of MET, the diagnosis of sacral dysfunctions, patient positioning, potential complications, and the broader implications of sacral dysfunction on gait, musculoskeletal health, and neurological function. This activity also emphasizes the significance of addressing dysfunctions elsewhere in the body that may impact sacral positioning. In addition, this activity provides healthcare professionals with the skills and tools to evaluate, diagnose, and treat patients with sacral dysfunctions using METs for effective correction, thus enhancing patient outcomes and quality of life.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Continuing Education Activity. MET has been essential in correcting structural restrictions leading to low back pain, especially when related to sacral dysfunction. METs, particularly post-isometric isolation, offer a targeted approach for addressing soft tissue restrictive barriers and joint mobilization associated with sacral dysfunctions in cases where a significant percentage of back pain lacks precise diagnosis.\u00a0This activity focuses on the physiological principles of MET, the diagnosis of sacral dysfunctions, patient positioning, potential complications, and the broader implications of sacral dysfunction on gait, musculoskeletal health, and neurological function. This activity also emphasizes the significance of addressing dysfunctions elsewhere in the body that may impact sacral positioning. In addition, this activity provides healthcare professionals with the skills and tools to evaluate, diagnose, and treat patients with sacral dysfunctions using METs for effective correction, thus enhancing patient outcomes and quality of life."}
+{"id": "article-102974_2", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Continuing Education Activity", "content": "Objectives: Identify sacral dysfunctions as potential contributors to patients' low back pain through comprehensive examination and assessment techniques. Implement muscle energy techniques effectively to address sacral dysfunctions in patients experiencing low back pain, ensuring safe and appropriate treatment delivery. Apply appropriate patient positioning techniques to optimize the effectiveness of muscle energy techniques in treating sacral dysfunctions. Collaborate with interdisciplinary healthcare teams to ensure comprehensive care for patients with sacral dysfunctions, incorporating input from various specialties as needed. Access free multiple choice questions on this topic.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Continuing Education Activity. Objectives: Identify sacral dysfunctions as potential contributors to patients' low back pain through comprehensive examination and assessment techniques. Implement muscle energy techniques effectively to address sacral dysfunctions in patients experiencing low back pain, ensuring safe and appropriate treatment delivery. Apply appropriate patient positioning techniques to optimize the effectiveness of muscle energy techniques in treating sacral dysfunctions. Collaborate with interdisciplinary healthcare teams to ensure comprehensive care for patients with sacral dysfunctions, incorporating input from various specialties as needed. Access free multiple choice questions on this topic."}
+{"id": "article-102974_3", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Introduction", "content": "Osteopathic manipulative treatment particularly focuses on\u00a0various manual techniques, such as\u00a0muscle energy techniques (METs), and is used by healthcare providers to diagnose and address structural causes of back pain. These techniques address sacral dysfunctions in patients experiencing low back pain, aiming to alleviate symptoms.\u00a0The sacrum is a triangular-shaped,\u00a0weight-transferring bone at the bottom of the vertebral column, which is highlighted as a crucial element in treating back pain and correcting abnormal gait. Low back pain is a common complaint and is a challenge to diagnose and treat. [1] [2] Studies indicate that approximately 85% of patients suffering from low back pain cannot receive a precise diagnosis for their symptoms. [3] Medical schools often instruct that a significant portion of back pain originates from musculoskeletal issues. However, as specific etiologies are less commonly identified, persistent pain leading to restricted activities can substantially diminish patients' quality of life. [3] [4] METs have been essential in correcting structural restrictions leading to low back pain, especially when related to sacral dysfunction. [5]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Introduction. Osteopathic manipulative treatment particularly focuses on\u00a0various manual techniques, such as\u00a0muscle energy techniques (METs), and is used by healthcare providers to diagnose and address structural causes of back pain. These techniques address sacral dysfunctions in patients experiencing low back pain, aiming to alleviate symptoms.\u00a0The sacrum is a triangular-shaped,\u00a0weight-transferring bone at the bottom of the vertebral column, which is highlighted as a crucial element in treating back pain and correcting abnormal gait. Low back pain is a common complaint and is a challenge to diagnose and treat. [1] [2] Studies indicate that approximately 85% of patients suffering from low back pain cannot receive a precise diagnosis for their symptoms. [3] Medical schools often instruct that a significant portion of back pain originates from musculoskeletal issues. However, as specific etiologies are less commonly identified, persistent pain leading to restricted activities can substantially diminish patients' quality of life. [3] [4] METs have been essential in correcting structural restrictions leading to low back pain, especially when related to sacral dysfunction. [5]"}
+{"id": "article-102974_4", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Introduction", "content": "Dr Fred Mitchell, Sr initially developed these techniques in the 1950s after deducing the kinematic motion of the pelvis. MET is largely considered a direct, active treatment, as patients are often positioned toward a barrier, prompting them to move to generate an activating force. There are 9 physiological principles in muscle energy, including post-isometric relaxation, respiratory assist, joint mobilization using muscle force, oculocephalic reflex, reciprocal inhibition, crossed extensor reflex, isokinetic strengthening, isolytic lengthening, and muscle force in one region of the body to achieve movement in another. Among the 9 types of METs, post-isometric isolation stands out as the most commonly used technique. In this approach, the patient is positioned toward a barrier and applies an activating force toward freedom. The isometric contraction induced by this method leads to reciprocal inhibition and relaxation of the antagonistic muscle, effectively addressing soft tissue restrictive barriers and mobilizing joints. This process contributes to pain reduction and improved circulation. [6] [7] Furthermore, sacral motion within the sacroiliac joint can result in 10 somatic dysfunctions, including left-on-right torsion, right-on-left torsion, left-on-left torsions, right-on-right torsions, left or right unilateral flexion or extension, and bilateral flexion or extensions. This article elaborates on diagnosing such sacral dysfunctions and describes the METs used for their correction.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Introduction. Dr Fred Mitchell, Sr initially developed these techniques in the 1950s after deducing the kinematic motion of the pelvis. MET is largely considered a direct, active treatment, as patients are often positioned toward a barrier, prompting them to move to generate an activating force. There are 9 physiological principles in muscle energy, including post-isometric relaxation, respiratory assist, joint mobilization using muscle force, oculocephalic reflex, reciprocal inhibition, crossed extensor reflex, isokinetic strengthening, isolytic lengthening, and muscle force in one region of the body to achieve movement in another. Among the 9 types of METs, post-isometric isolation stands out as the most commonly used technique. In this approach, the patient is positioned toward a barrier and applies an activating force toward freedom. The isometric contraction induced by this method leads to reciprocal inhibition and relaxation of the antagonistic muscle, effectively addressing soft tissue restrictive barriers and mobilizing joints. This process contributes to pain reduction and improved circulation. [6] [7] Furthermore, sacral motion within the sacroiliac joint can result in 10 somatic dysfunctions, including left-on-right torsion, right-on-left torsion, left-on-left torsions, right-on-right torsions, left or right unilateral flexion or extension, and bilateral flexion or extensions. This article elaborates on diagnosing such sacral dysfunctions and describes the METs used for their correction."}
+{"id": "article-102974_5", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Anatomy and Physiology", "content": "Understanding muscle physiology is crucial for grasping METs. There are 4 types of muscle contraction\u2014isolytic, concentric, isometric, and eccentric. Isolytic contraction occurs when an external force lengthens muscle contraction, whereas concentric contraction involves muscles shortening during contraction. Isometric contraction happens when muscles contract, but the origin and insertion do not draw closer to each other. Lastly, eccentric contraction occurs when the muscle lengthens during contraction. [8]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Anatomy and Physiology. Understanding muscle physiology is crucial for grasping METs. There are 4 types of muscle contraction\u2014isolytic, concentric, isometric, and eccentric. Isolytic contraction occurs when an external force lengthens muscle contraction, whereas concentric contraction involves muscles shortening during contraction. Isometric contraction happens when muscles contract, but the origin and insertion do not draw closer to each other. Lastly, eccentric contraction occurs when the muscle lengthens during contraction. [8]"}
+{"id": "article-102974_6", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Anatomy and Physiology", "content": "A muscle is made up of many spindles. Each spindle comprises a large extrafusal muscle fiber surrounding 3 to 12 intrafusal fibers. The extrafusal fibers are innervated by\u00a0alpha (\u03b1) motor neurons, and the intrafusal fibers by gamma\u00a0(\u03b3) motor neurons. The sensory fibers\u00a0include the Ia and II fibers, which innervate muscle spindles, and the Ib fingers, which innervate the Golgi tendon organs at the myotendinous junction. [9] A Golgi tendon organ is stimulated with increased muscle tension and provides a negative feedback loop to prevent the Ia fibers from contracting the muscle. Therefore, activating a Golgi tendon organ with a post-isometric relaxation mechanism is crucial during MET. [10]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Anatomy and Physiology. A muscle is made up of many spindles. Each spindle comprises a large extrafusal muscle fiber surrounding 3 to 12 intrafusal fibers. The extrafusal fibers are innervated by\u00a0alpha (\u03b1) motor neurons, and the intrafusal fibers by gamma\u00a0(\u03b3) motor neurons. The sensory fibers\u00a0include the Ia and II fibers, which innervate muscle spindles, and the Ib fingers, which innervate the Golgi tendon organs at the myotendinous junction. [9] A Golgi tendon organ is stimulated with increased muscle tension and provides a negative feedback loop to prevent the Ia fibers from contracting the muscle. Therefore, activating a Golgi tendon organ with a post-isometric relaxation mechanism is crucial during MET. [10]"}
+{"id": "article-102974_7", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Anatomy and Physiology", "content": "MET with post-isometric relaxation is the most commonly used form of the technique. One hypothesis suggests that after an isometric contraction, the muscle is in a refractory state where it may be passively stretched without a reflexive contraction. Therefore, placing the patient\u00a0against\u00a0a barrier is essential and puts more tension on the muscle fibers.\u00a0When the patient contracts against the physician's counterforce, it allows activation of the Golgi tendon organ. When activated, the muscle will relax via the Ia fibers, and the physician may passively stretch the muscle further during this refractory state. [10]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Anatomy and Physiology. MET with post-isometric relaxation is the most commonly used form of the technique. One hypothesis suggests that after an isometric contraction, the muscle is in a refractory state where it may be passively stretched without a reflexive contraction. Therefore, placing the patient\u00a0against\u00a0a barrier is essential and puts more tension on the muscle fibers.\u00a0When the patient contracts against the physician's counterforce, it allows activation of the Golgi tendon organ. When activated, the muscle will relax via the Ia fibers, and the physician may passively stretch the muscle further during this refractory state. [10]"}
+{"id": "article-102974_8", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Anatomy and Physiology", "content": "The sacrum is a triangular-shaped bone at the bottom of the vertebral column.\u00a0The sacrum originates from\u00a05 vertebrae fusing by ossification in the first year of life. [11] The sacrum articulates with the fifth lumbar vertebra at its superior surface, inferiorly with the coccyx, and lateral articulations with the ilium. This anatomical relationship is crucial for palpation and locating sacral landmarks. One of its primary functions is believed to be as a load-transferring bone, facilitating smooth gait. [12]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Anatomy and Physiology. The sacrum is a triangular-shaped bone at the bottom of the vertebral column.\u00a0The sacrum originates from\u00a05 vertebrae fusing by ossification in the first year of life. [11] The sacrum articulates with the fifth lumbar vertebra at its superior surface, inferiorly with the coccyx, and lateral articulations with the ilium. This anatomical relationship is crucial for palpation and locating sacral landmarks. One of its primary functions is believed to be as a load-transferring bone, facilitating smooth gait. [12]"}
+{"id": "article-102974_9", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Anatomy and Physiology", "content": "The sacrum and its function relative to the sacroiliac joint have been identified as a source of lower back pain since the early 20th century. The sacroiliac joint is an L-shaped diarthrodial joint containing synovial fluid encompassed by a fibrous capsule. The stabilization of the sacroiliac joint is provided by ligamentous attachments, tendinous attachments from the gluteus maximus and piriformis muscles, and the thoracolumbar fascia extending from the latissimus dorsi. [13]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Anatomy and Physiology. The sacrum and its function relative to the sacroiliac joint have been identified as a source of lower back pain since the early 20th century. The sacroiliac joint is an L-shaped diarthrodial joint containing synovial fluid encompassed by a fibrous capsule. The stabilization of the sacroiliac joint is provided by ligamentous attachments, tendinous attachments from the gluteus maximus and piriformis muscles, and the thoracolumbar fascia extending from the latissimus dorsi. [13]"}
+{"id": "article-102974_10", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Anatomy and Physiology", "content": "The sacrum has an inverted triangle wedge shape, with the broadest portion forming the sacral base superiorly and the apex inferiorly toward the coccyx. [11] The sacral base can be located by palpating just inferiomedial to the posterior superior iliac spines (PSIS). The most inferior aspect of the sacrum forms projections known as the inferior lateral angle (ILA). This structure is identifiable by following the convex dorsal surface of the sacrum with the palm or pads of the fingers until there is a drop-off superior to the coccyx. These landmarks help test sacral motion and identify dysfunctions. [5]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Anatomy and Physiology. The sacrum has an inverted triangle wedge shape, with the broadest portion forming the sacral base superiorly and the apex inferiorly toward the coccyx. [11] The sacral base can be located by palpating just inferiomedial to the posterior superior iliac spines (PSIS). The most inferior aspect of the sacrum forms projections known as the inferior lateral angle (ILA). This structure is identifiable by following the convex dorsal surface of the sacrum with the palm or pads of the fingers until there is a drop-off superior to the coccyx. These landmarks help test sacral motion and identify dysfunctions. [5]"}
+{"id": "article-102974_11", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Anatomy and Physiology", "content": "Initially, it was believed that the sacroiliac joint was immobile. However, recent studies have unveiled complex motions occurring at this joint. [2] [13] [14] The sacrum has\u00a03 transverse axes\u2014the superior, middle, and inferior transverse axes. The superior transverse axis is located at the level of S1, and its motion depends on respiratory and craniosacral motion. The middle transverse axis, situated at the level of S2, is dependent on postural motion, serving as the point where the sacrum rotates about the innominate bones. Lastly, the inferior transverse axis is at the level of S3, where the innominate bones move about the sacrum. To accommodate weight transfer and innominate motion during gait, the middle transverse axis tilts to become either the right oblique or left oblique axis, which can cause sacral somatic dysfunctions. [2] The right oblique axis runs diagonally through the left ILA from the right sacral base, whereas the left oblique axis runs through the right ILA. Due to these\u00a05 different axes co-occurring, the sacrum has a gyroscopic effect where it appears to have\u00a0little motion relative to other bones.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Anatomy and Physiology. Initially, it was believed that the sacroiliac joint was immobile. However, recent studies have unveiled complex motions occurring at this joint. [2] [13] [14] The sacrum has\u00a03 transverse axes\u2014the superior, middle, and inferior transverse axes. The superior transverse axis is located at the level of S1, and its motion depends on respiratory and craniosacral motion. The middle transverse axis, situated at the level of S2, is dependent on postural motion, serving as the point where the sacrum rotates about the innominate bones. Lastly, the inferior transverse axis is at the level of S3, where the innominate bones move about the sacrum. To accommodate weight transfer and innominate motion during gait, the middle transverse axis tilts to become either the right oblique or left oblique axis, which can cause sacral somatic dysfunctions. [2] The right oblique axis runs diagonally through the left ILA from the right sacral base, whereas the left oblique axis runs through the right ILA. Due to these\u00a05 different axes co-occurring, the sacrum has a gyroscopic effect where it appears to have\u00a0little motion relative to other bones."}
+{"id": "article-102974_12", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Anatomy and Physiology", "content": "Nutation refers to the anteroinferior movement of the sacral base along a transverse axis, while counternutation involves its posterosuperior movement. [13] Nutation typically occurs during exhalation and extension of the lumbar spine, whereas counternutation happens during inhalation or lumbar flexion. Clinicians can palpate these motions by directly palpating medial and inferior to the PSIS over the sacral base and monitoring for anterior or posterior translation of the sacral base during truncal extension or flexion, respectively. [14] [15]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Anatomy and Physiology. Nutation refers to the anteroinferior movement of the sacral base along a transverse axis, while counternutation involves its posterosuperior movement. [13] Nutation typically occurs during exhalation and extension of the lumbar spine, whereas counternutation happens during inhalation or lumbar flexion. Clinicians can palpate these motions by directly palpating medial and inferior to the PSIS over the sacral base and monitoring for anterior or posterior translation of the sacral base during truncal extension or flexion, respectively. [14] [15]"}
+{"id": "article-102974_13", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Anatomy and Physiology", "content": "With the extensive network of fasciae, muscles, and ligaments supporting and interconnecting skeletal structures, the sacrum's movement about these axes is strongly related to the lumbar spine. [2] [15] The rotation of the fifth lumbar vertebra, which sits directly superior over the sacral base, causes rotation of the sacrum as a unit in the opposite direction over one of the oblique axes. Side-bending of the fifth vertebrae engages the oblique axis on the same side, indicating the oblique axis on which the sacrum is rotating. The opposite relationship between the L5 and the sacrum is important as the body's compensatory mechanism keeps the patient's eyes level while walking. Understanding the anatomical relationships between structures of the sacrum and sacroiliac joint makes it\u00a0possible to diagnose sacral dysfunctions and treat them accordingly.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Anatomy and Physiology. With the extensive network of fasciae, muscles, and ligaments supporting and interconnecting skeletal structures, the sacrum's movement about these axes is strongly related to the lumbar spine. [2] [15] The rotation of the fifth lumbar vertebra, which sits directly superior over the sacral base, causes rotation of the sacrum as a unit in the opposite direction over one of the oblique axes. Side-bending of the fifth vertebrae engages the oblique axis on the same side, indicating the oblique axis on which the sacrum is rotating. The opposite relationship between the L5 and the sacrum is important as the body's compensatory mechanism keeps the patient's eyes level while walking. Understanding the anatomical relationships between structures of the sacrum and sacroiliac joint makes it\u00a0possible to diagnose sacral dysfunctions and treat them accordingly."}
+{"id": "article-102974_14", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Indications", "content": "MET is most commonly used for treating low back pain complaints associated with sacral dysfunction. However, due to the close relationship between the sacral plexus innervation in the pelvis, the sacrum, and surrounding structures, dysfunction may also lead to changes in parasympathetic tone, affecting the large intestine and genitourinary systems. Therefore, conditions such as constipation and dysmenorrhea may also benefit from treating sacral dysfunction. [16]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Indications. MET is most commonly used for treating low back pain complaints associated with sacral dysfunction. However, due to the close relationship between the sacral plexus innervation in the pelvis, the sacrum, and surrounding structures, dysfunction may also lead to changes in parasympathetic tone, affecting the large intestine and genitourinary systems. Therefore, conditions such as constipation and dysmenorrhea may also benefit from treating sacral dysfunction. [16]"}
+{"id": "article-102974_15", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Contraindications", "content": "METs are generally considered safe procedures with minimal complications. MET uses\u00a0a controlled, equal, and opposite force to lengthen a contracted muscle, posing few risks and proving tolerable for patients experiencing acute pain. [17] [18] However, METs should be approached with caution or avoided altogether if there are concerns regarding muscle ruptures or tears, fractures in the treated area, or spinal or vertebral joint ligament rupture. [19] In addition, as METs\u00a0require patient cooperation, individuals should be able to follow instructions effectively.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Contraindications. METs are generally considered safe procedures with minimal complications. MET uses\u00a0a controlled, equal, and opposite force to lengthen a contracted muscle, posing few risks and proving tolerable for patients experiencing acute pain. [17] [18] However, METs should be approached with caution or avoided altogether if there are concerns regarding muscle ruptures or tears, fractures in the treated area, or spinal or vertebral joint ligament rupture. [19] In addition, as METs\u00a0require patient cooperation, individuals should be able to follow instructions effectively."}
+{"id": "article-102974_16", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Equipment", "content": "A flat surface, such as a hospital bed or massage table with padding, is adequate for performing MET. Adjustable table height facilitates easy patient positioning and reduces strain on the clinician administering the treatment.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Equipment. A flat surface, such as a hospital bed or massage table with padding, is adequate for performing MET. Adjustable table height facilitates easy patient positioning and reduces strain on the clinician administering the treatment."}
+{"id": "article-102974_17", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Preparation", "content": "Diagnosing sacral somatic dysfunction involves multiple steps and differs significantly from diagnosing other vertebral segments, given the existence of 10 potential somatic dysfunctions. As a result, diagnostic efforts encompass both static and dynamic tests. [20]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Preparation. Diagnosing sacral somatic dysfunction involves multiple steps and differs significantly from diagnosing other vertebral segments, given the existence of 10 potential somatic dysfunctions. As a result, diagnostic efforts encompass both static and dynamic tests. [20]"}
+{"id": "article-102974_18", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Preparation", "content": "A crucial dynamic test for sacral dysfunction is the seated flexion test.\u00a0With the patient seated, this stabilizes the innominate, allowing the assessment of sacral motion without the influence of the innominate bones. The seated flexion test is performed with the patient sitting flat on the floor. The clinician monitors the movement with thumbs inferior to the patient's PSIS as the patient flexes forward. The side of the dysfunction that moves the most superior or cranial is observed by the PSIS movement, indicating a positive seated flexion test. [21] The side of the sacrum in the dysfunction is unable to articulate against the innominate efficiently; therefore, during flexion, the sacrum will \"catch\" the innominate and pull it more cephalad. If a sacral dysfunction occurs along an oblique axis, it is considered a torsion, with the oblique axis located at the sacral base opposite the \"stuck\" side of the sacrum. In other words, the oblique axis aligns with the opposite direction of the seated flexion test. Therefore, if the test yields a positive result with the left PSIS moving more cranially, the sacrum rotates on the right oblique axis. In cases of unilateral sacral dysfunction (unilateral extension or flexion), the side of the positive seated flexion test corresponds to the side of the sacral dysfunction. Conversely, if the seated flexion test is negative, the patient may not have a sacral dysfunction or may have bilateral dysfunction (bilateral sacral flexion or extension).", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Preparation. A crucial dynamic test for sacral dysfunction is the seated flexion test.\u00a0With the patient seated, this stabilizes the innominate, allowing the assessment of sacral motion without the influence of the innominate bones. The seated flexion test is performed with the patient sitting flat on the floor. The clinician monitors the movement with thumbs inferior to the patient's PSIS as the patient flexes forward. The side of the dysfunction that moves the most superior or cranial is observed by the PSIS movement, indicating a positive seated flexion test. [21] The side of the sacrum in the dysfunction is unable to articulate against the innominate efficiently; therefore, during flexion, the sacrum will \"catch\" the innominate and pull it more cephalad. If a sacral dysfunction occurs along an oblique axis, it is considered a torsion, with the oblique axis located at the sacral base opposite the \"stuck\" side of the sacrum. In other words, the oblique axis aligns with the opposite direction of the seated flexion test. Therefore, if the test yields a positive result with the left PSIS moving more cranially, the sacrum rotates on the right oblique axis. In cases of unilateral sacral dysfunction (unilateral extension or flexion), the side of the positive seated flexion test corresponds to the side of the sacral dysfunction. Conversely, if the seated flexion test is negative, the patient may not have a sacral dysfunction or may have bilateral dysfunction (bilateral sacral flexion or extension)."}
+{"id": "article-102974_19", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Preparation", "content": "Other crucial dynamic tests include the spring test and the sphinx test. During the spring test, the patient assumes a prone position, and the physician applies a slow downward force through the lumbosacral junction. A negative result is characterized by a soft, regular, and bouncy return, whereas a positive outcome indicates a hard end point. A positive result typically suggests a restriction in the anterior motion of the sacral base against L5, most likely indicative of bilateral sacral extension or a backward sacral torsion.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Preparation. Other crucial dynamic tests include the spring test and the sphinx test. During the spring test, the patient assumes a prone position, and the physician applies a slow downward force through the lumbosacral junction. A negative result is characterized by a soft, regular, and bouncy return, whereas a positive outcome indicates a hard end point. A positive result typically suggests a restriction in the anterior motion of the sacral base against L5, most likely indicative of bilateral sacral extension or a backward sacral torsion."}
+{"id": "article-102974_20", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Preparation", "content": "The sphinx test aims to identify findings similar to those observed in the spring test. Initially, the patient assumes a prone position while the physician observes the sulcus or ILAs. Next, the patient raises their torso to a position supported on their elbow (the sphinx position), inducing lumbar extension, which flexes the sacrum. If the asymmetrical ILA or sacral sulcus becomes symmetrical during lumbar extension, the patient likely has a forward sacral torsion or flexed sacral dysfunction. Conversely, if the landmark findings become asymmetrical or cause increased pain, the patient likely has a backward sacral torsion or extension dysfunction.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Preparation. The sphinx test aims to identify findings similar to those observed in the spring test. Initially, the patient assumes a prone position while the physician observes the sulcus or ILAs. Next, the patient raises their torso to a position supported on their elbow (the sphinx position), inducing lumbar extension, which flexes the sacrum. If the asymmetrical ILA or sacral sulcus becomes symmetrical during lumbar extension, the patient likely has a forward sacral torsion or flexed sacral dysfunction. Conversely, if the landmark findings become asymmetrical or cause increased pain, the patient likely has a backward sacral torsion or extension dysfunction."}
+{"id": "article-102974_21", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Preparation", "content": "For static tests of the sacrum, clinicians must be able to palpate the sacral sulcus (base of the sacrum) located at a finger-width medial and inferior of the PSIS and the ILA. Depending on the dysfunction, the sacrum may exhibit a unilateral deep sulcus and a unilateral posterior ILA.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Preparation. For static tests of the sacrum, clinicians must be able to palpate the sacral sulcus (base of the sacrum) located at a finger-width medial and inferior of the PSIS and the ILA. Depending on the dysfunction, the sacrum may exhibit a unilateral deep sulcus and a unilateral posterior ILA."}
+{"id": "article-102974_22", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Preparation -- Unilateral Sacral Dysfunctions", "content": "There are\u00a02 types of unilateral sacral dysfunctions\u2014flexion or extension, depending on the\u00a0relative depth of the sacral sulcus (or position of the sacral base)\u00a0and the direction of the seated flexion test. The dysfunction is named for the side of the positive seated flexion test. A unilateral sacral flexion has a positive seated flexion test, a deep sacral sulcus (sacral base is anterior), and a posterior ILA is posterior on the same side. If the positive seated flexion test corresponds with a shallow sacral sulcus (posterior sacral base)\u00a0and\u00a0an anterior ILA, it is diagnosed as a unilateral extension to the side of the positive seated flexion test.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Preparation -- Unilateral Sacral Dysfunctions. There are\u00a02 types of unilateral sacral dysfunctions\u2014flexion or extension, depending on the\u00a0relative depth of the sacral sulcus (or position of the sacral base)\u00a0and the direction of the seated flexion test. The dysfunction is named for the side of the positive seated flexion test. A unilateral sacral flexion has a positive seated flexion test, a deep sacral sulcus (sacral base is anterior), and a posterior ILA is posterior on the same side. If the positive seated flexion test corresponds with a shallow sacral sulcus (posterior sacral base)\u00a0and\u00a0an anterior ILA, it is diagnosed as a unilateral extension to the side of the positive seated flexion test."}
+{"id": "article-102974_23", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Preparation -- Anterior Sacral Torsion", "content": "The patient exhibits a sacral torsion dysfunction when the deep sulcus and the posterior ILA are on opposite sides. The sacrum may have an anterior or a posterior torsion. The physician may do either the sphinx or the spring test to determine whether it is an anterior torsion.\u00a0A torsion dysfunction is along an oblique axis on the opposite side of the seated flexion test. If a patient exhibits a positive right seated flexion test, indicating a dysfunction, their oblique axis will be on the left side. Consequently, the sacrum will rotate toward the left, indicating an anterior sacral torsion. The appropriate terminology in this case is that the sacrum has a left rotation on a left axis, denoted as a left-on-left sacrum.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Preparation -- Anterior Sacral Torsion. The patient exhibits a sacral torsion dysfunction when the deep sulcus and the posterior ILA are on opposite sides. The sacrum may have an anterior or a posterior torsion. The physician may do either the sphinx or the spring test to determine whether it is an anterior torsion.\u00a0A torsion dysfunction is along an oblique axis on the opposite side of the seated flexion test. If a patient exhibits a positive right seated flexion test, indicating a dysfunction, their oblique axis will be on the left side. Consequently, the sacrum will rotate toward the left, indicating an anterior sacral torsion. The appropriate terminology in this case is that the sacrum has a left rotation on a left axis, denoted as a left-on-left sacrum."}
+{"id": "article-102974_24", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Preparation -- Posterior Sacral Torsion", "content": "The patient exhibits a sacral torsion dysfunction when the deep sulcus and the posterior ILA are on opposite sides. The sacrum may have an anterior or a posterior torsion. The physician may do either the sphinx or the spring test to determine whether it is a posterior torsion.\u00a0A torsion dysfunction is along an oblique axis on the opposite side of the seated flexion test. If a patient demonstrates a positive right seated flexion test, indicating dysfunction, their oblique axis will be on the left side. Consequently, the sacrum will rotate toward the right, indicating a posterior sacral torsion. The correct terminology in this scenario is that the sacrum has a right rotation on a left axis, referred to as a right-on-left sacrum.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Preparation -- Posterior Sacral Torsion. The patient exhibits a sacral torsion dysfunction when the deep sulcus and the posterior ILA are on opposite sides. The sacrum may have an anterior or a posterior torsion. The physician may do either the sphinx or the spring test to determine whether it is a posterior torsion.\u00a0A torsion dysfunction is along an oblique axis on the opposite side of the seated flexion test. If a patient demonstrates a positive right seated flexion test, indicating dysfunction, their oblique axis will be on the left side. Consequently, the sacrum will rotate toward the right, indicating a posterior sacral torsion. The correct terminology in this scenario is that the sacrum has a right rotation on a left axis, referred to as a right-on-left sacrum."}
+{"id": "article-102974_25", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Preparation -- Bilateral Sacral Dysfunctions", "content": "Bilateral sacral dysfunctions are rare and commonly missed. The patient usually presents with pain in the lumbosacral junction and the sacroiliac joint. They will exhibit a negative seated flexion test, equal sulci, and equal ILA. The sphinx and the spring tests will be positive in the case of bilateral sacral extension and negative in bilateral sacral flexion.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Preparation -- Bilateral Sacral Dysfunctions. Bilateral sacral dysfunctions are rare and commonly missed. The patient usually presents with pain in the lumbosacral junction and the sacroiliac joint. They will exhibit a negative seated flexion test, equal sulci, and equal ILA. The sphinx and the spring tests will be positive in the case of bilateral sacral extension and negative in bilateral sacral flexion."}
+{"id": "article-102974_26", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Technique or Treatment", "content": "Several manual approaches exist for treating the sacrum and the sacroiliac joint. [22] [23] However, this article focuses on METs with post-isometric relaxation, as initially taught by Dr Fred Mitchell Sr and modern American Osteopathic Medical Schools. Treating the sacrum with MET can be challenging due to patient positioning. When positioning the patient, keeping the lumbosacral junction free to move is important. Therefore, part of the MET is directed at L5 to reciprocate the changes to the sacrum. As mentioned earlier, the oblique axis aligns with the same side as the L5 side-bending, and the rotation along the axis opposes the L5 rotation.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Technique or Treatment. Several manual approaches exist for treating the sacrum and the sacroiliac joint. [22] [23] However, this article focuses on METs with post-isometric relaxation, as initially taught by Dr Fred Mitchell Sr and modern American Osteopathic Medical Schools. Treating the sacrum with MET can be challenging due to patient positioning. When positioning the patient, keeping the lumbosacral junction free to move is important. Therefore, part of the MET is directed at L5 to reciprocate the changes to the sacrum. As mentioned earlier, the oblique axis aligns with the same side as the L5 side-bending, and the rotation along the axis opposes the L5 rotation."}
+{"id": "article-102974_27", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Technique or Treatment -- Anterior Torsion", "content": "The patient is placed in a Sims position where the chest and torso are prone while the lower body is flexed on the side so that the side of the axis faces the table (ie, if the patient has left-on-left dysfunction, they are laid down on the left). Next, the upper body is further rotated to restrict motion in all segments above the L5. Subsequently, the hips and legs are flexed until movement is localized at S2 (the level where the sacrum moves against the ilia). The physician then takes the bilateral leg and pushes it down toward the table to further engage the barrier. The patient is then instructed to lift both feet to the ceiling as the clinician applies an equal and opposite resistance, holding for approximately 5 seconds or until a change in tissue texture is noted, and then they are asked to relax. After relaxing, the hip flexion increases, and the feet are dropped toward the ground to engage the next barrier. Each cycle is repeated 3 to 5 times, and the correction of the dysfunction is rechecked after completing the treatment.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Technique or Treatment -- Anterior Torsion. The patient is placed in a Sims position where the chest and torso are prone while the lower body is flexed on the side so that the side of the axis faces the table (ie, if the patient has left-on-left dysfunction, they are laid down on the left). Next, the upper body is further rotated to restrict motion in all segments above the L5. Subsequently, the hips and legs are flexed until movement is localized at S2 (the level where the sacrum moves against the ilia). The physician then takes the bilateral leg and pushes it down toward the table to further engage the barrier. The patient is then instructed to lift both feet to the ceiling as the clinician applies an equal and opposite resistance, holding for approximately 5 seconds or until a change in tissue texture is noted, and then they are asked to relax. After relaxing, the hip flexion increases, and the feet are dropped toward the ground to engage the next barrier. Each cycle is repeated 3 to 5 times, and the correction of the dysfunction is rechecked after completing the treatment."}
+{"id": "article-102974_28", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Technique or Treatment -- Posterior Torsion", "content": "The patient is positioned in a lateral recumbent position with the side of the oblique axis facing the table and flexing their knees. While monitoring the lumbosacral junction, the physician rotates the patient's upper body towards the back to immobilize the motion of all segments above L5. The superior knee is then flexed until movement can be sensed at the level of S2. Subsequently, the inferior lower extremity is extended while the superior leg is dropped off the table. The physician lowers the upper leg until motion is detected under the monitoring hand. The patient is instructed to lift their leg toward the ceiling as the clinician exerts the opposing force, creating an isometric contraction. This position is held for 5 seconds or until a change in tissue texture is observed. To engage the next barrier, the physician increases hip extension, drops the leg toward the floor between each effort, and repeats the process 3 to 5 times. The resolution of the dysfunction is continually reassessed after completing the treatment.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Technique or Treatment -- Posterior Torsion. The patient is positioned in a lateral recumbent position with the side of the oblique axis facing the table and flexing their knees. While monitoring the lumbosacral junction, the physician rotates the patient's upper body towards the back to immobilize the motion of all segments above L5. The superior knee is then flexed until movement can be sensed at the level of S2. Subsequently, the inferior lower extremity is extended while the superior leg is dropped off the table. The physician lowers the upper leg until motion is detected under the monitoring hand. The patient is instructed to lift their leg toward the ceiling as the clinician exerts the opposing force, creating an isometric contraction. This position is held for 5 seconds or until a change in tissue texture is observed. To engage the next barrier, the physician increases hip extension, drops the leg toward the floor between each effort, and repeats the process 3 to 5 times. The resolution of the dysfunction is continually reassessed after completing the treatment."}
+{"id": "article-102974_29", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Technique or Treatment -- Unilateral Flexion", "content": "The patient is positioned prone, with the leg on the side of the seated flexion test slightly abducted and internally rotated. This abduction and internal rotation permit motion at the sacroiliac joint while immobilizing the hip joint. Next, the physician places the heel of the hand on the ipsilateral ILA (the most posterior ILA) and detects sacral motion throughout the patient's respiratory cycle. As the patient inhales, causing counternutation of the sacrum, the ILA is followed anteriorly and cephalad. Resistance is maintained at this point to prevent the ILA from moving posteriorly as the patient exhales. This motion is repeated 3 to 5 times, after which sacral mobility is reassessed, and any other dysfunctions are identified.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Technique or Treatment -- Unilateral Flexion. The patient is positioned prone, with the leg on the side of the seated flexion test slightly abducted and internally rotated. This abduction and internal rotation permit motion at the sacroiliac joint while immobilizing the hip joint. Next, the physician places the heel of the hand on the ipsilateral ILA (the most posterior ILA) and detects sacral motion throughout the patient's respiratory cycle. As the patient inhales, causing counternutation of the sacrum, the ILA is followed anteriorly and cephalad. Resistance is maintained at this point to prevent the ILA from moving posteriorly as the patient exhales. This motion is repeated 3 to 5 times, after which sacral mobility is reassessed, and any other dysfunctions are identified."}
+{"id": "article-102974_30", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Technique or Treatment -- Unilateral Extension", "content": "The patient is positioned prone, with the leg on the side of the seated flexion test slightly abducted and internally rotated, allowing motion at the sacroiliac joint while immobilizing the hip joint. The clinician is situated at the head of the patient, with the base of one hand on the dysfunctional sacral base. Lumbar extension is added by instructing the patient to come up onto their elbows. The patient is then asked to take a deep breath and follow the sacral base anterior and caudad upon exhalation. Resistance is maintained in this position as the patient inhales again, preventing posterior motion of the sacral base. This cycle is repeated 3 to 5 times, after which any residual asymmetry is reassessed.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Technique or Treatment -- Unilateral Extension. The patient is positioned prone, with the leg on the side of the seated flexion test slightly abducted and internally rotated, allowing motion at the sacroiliac joint while immobilizing the hip joint. The clinician is situated at the head of the patient, with the base of one hand on the dysfunctional sacral base. Lumbar extension is added by instructing the patient to come up onto their elbows. The patient is then asked to take a deep breath and follow the sacral base anterior and caudad upon exhalation. Resistance is maintained in this position as the patient inhales again, preventing posterior motion of the sacral base. This cycle is repeated 3 to 5 times, after which any residual asymmetry is reassessed."}
+{"id": "article-102974_31", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Technique or Treatment -- Bilateral Flexion and Extension", "content": "Positioning for bilateral flexion and extension mirrors that of unilateral flexion and extension. The patient is placed prone, with both legs abducted and internally rotated. Depending on the diagnosis, the physician positions their hands on the center of the sacral base or the sacral apex. In the case of bilateral flexion, the physician applies force to the sacral apex during inhalation. Conversely, the physician applies force to the sacral base for bilateral extension during inhalation.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Technique or Treatment -- Bilateral Flexion and Extension. Positioning for bilateral flexion and extension mirrors that of unilateral flexion and extension. The patient is placed prone, with both legs abducted and internally rotated. Depending on the diagnosis, the physician positions their hands on the center of the sacral base or the sacral apex. In the case of bilateral flexion, the physician applies force to the sacral apex during inhalation. Conversely, the physician applies force to the sacral base for bilateral extension during inhalation."}
+{"id": "article-102974_32", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Complications", "content": "Patients undergoing treatment with MET should be informed that they may experience muscle soreness and fatigue afterward. The physician should recommend increasing water intake following treatment. Using excessive force can lead to inappropriate treatment, as the body may start recruiting larger muscles instead of engaging the targeted smaller muscles for specific adjustments. To minimize force during post-isometric relaxation, patients should be instructed to resist just enough to engage the treated segment.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Complications. Patients undergoing treatment with MET should be informed that they may experience muscle soreness and fatigue afterward. The physician should recommend increasing water intake following treatment. Using excessive force can lead to inappropriate treatment, as the body may start recruiting larger muscles instead of engaging the targeted smaller muscles for specific adjustments. To minimize force during post-isometric relaxation, patients should be instructed to resist just enough to engage the treated segment."}
+{"id": "article-102974_33", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Clinical Significance", "content": "Somatic dysfunction of the sacrum commonly leads to back pain and discomfort, prompting patients to seek medical attention. Osteopathic techniques, including MET, offer a conservative, non-pharmacological approach to relieving pain and correcting musculoskeletal somatic dysfunctions in the thoracic spine, thereby enhancing the range of motion in affected joints. [6] [24]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Clinical Significance. Somatic dysfunction of the sacrum commonly leads to back pain and discomfort, prompting patients to seek medical attention. Osteopathic techniques, including MET, offer a conservative, non-pharmacological approach to relieving pain and correcting musculoskeletal somatic dysfunctions in the thoracic spine, thereby enhancing the range of motion in affected joints. [6] [24]"}
+{"id": "article-102974_34", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Clinical Significance", "content": "Proper sacral mechanics play a large role in normal gait; addressing somatic dysfunctions can improve gait and reduce potential injuries from instability. [25] Treating the sacrum can also help resolve pain in the sacroiliac joint, which can cause lower back pain in up to 25% of patients. [26] Addressing sacral and sacroiliac joint issues without resorting to surgery or medication can greatly benefit patient wellness and mobility. [27] [28]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Clinical Significance. Proper sacral mechanics play a large role in normal gait; addressing somatic dysfunctions can improve gait and reduce potential injuries from instability. [25] Treating the sacrum can also help resolve pain in the sacroiliac joint, which can cause lower back pain in up to 25% of patients. [26] Addressing sacral and sacroiliac joint issues without resorting to surgery or medication can greatly benefit patient wellness and mobility. [27] [28]"}
+{"id": "article-102974_35", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Clinical Significance", "content": "Beyond musculoskeletal pain, physicians should consider the potential neurological implications of sacral dysfunctions. The parasympathetic splanchnic nerves originate from the sacral plexus.\u00a0A hypothesis exists that addressing sacral dysfunctions could potentially improve conditions related to the lower gastrointestinal system, uterine, or bladder function.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Clinical Significance. Beyond musculoskeletal pain, physicians should consider the potential neurological implications of sacral dysfunctions. The parasympathetic splanchnic nerves originate from the sacral plexus.\u00a0A hypothesis exists that addressing sacral dysfunctions could potentially improve conditions related to the lower gastrointestinal system, uterine, or bladder function."}
+{"id": "article-102974_36", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Clinical Significance", "content": "If the physician determines that a high-velocity, low-amplitude technique would be more suitable for treating the sacrum, MET can be used beforehand to facilitate greater soft tissue relaxation and enhance the effectiveness of the treatment. Additionally, it can aid in resolving hypertonic tissue before applying myofascial release techniques.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Clinical Significance. If the physician determines that a high-velocity, low-amplitude technique would be more suitable for treating the sacrum, MET can be used beforehand to facilitate greater soft tissue relaxation and enhance the effectiveness of the treatment. Additionally, it can aid in resolving hypertonic tissue before applying myofascial release techniques."}
+{"id": "article-102974_37", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Clinical Significance", "content": "Importantly, somatic dysfunctions in the sacrum are commonly\u00a0caused by dysfunction elsewhere in the body. Other nearby regions should be examined and treated before treating the sacrum. Areas that may affect the positioning of the sacrum include the L5 and the innominate or anatomic leg-length discrepancies.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Clinical Significance. Importantly, somatic dysfunctions in the sacrum are commonly\u00a0caused by dysfunction elsewhere in the body. Other nearby regions should be examined and treated before treating the sacrum. Areas that may affect the positioning of the sacrum include the L5 and the innominate or anatomic leg-length discrepancies."}
+{"id": "article-102974_38", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Enhancing Healthcare Team Outcomes", "content": "METs provide an efficient and relatively safe treatment approach\u00a0for patients experiencing various complaints, ranging from lower back pain to constipation. Effective interprofessional communication among clinicians managing patients with persistent low back pain remains crucial, especially considering pharmacologic therapies such as spinal injections and narcotic analgesics. MET could serve as a treatment alternative the healthcare team may not have previously considered. By comprehending the principles underlying osteopathic medicine for diagnosing structural dysfunctions and understanding the potential for manual manipulation to successfully address such dysfunctions, clinicians can provide patients with less invasive and nonpharmacologic options to potentially restore their productivity and overall happiness despite persistent pain. [6] [18]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Enhancing Healthcare Team Outcomes. METs provide an efficient and relatively safe treatment approach\u00a0for patients experiencing various complaints, ranging from lower back pain to constipation. Effective interprofessional communication among clinicians managing patients with persistent low back pain remains crucial, especially considering pharmacologic therapies such as spinal injections and narcotic analgesics. MET could serve as a treatment alternative the healthcare team may not have previously considered. By comprehending the principles underlying osteopathic medicine for diagnosing structural dysfunctions and understanding the potential for manual manipulation to successfully address such dysfunctions, clinicians can provide patients with less invasive and nonpharmacologic options to potentially restore their productivity and overall happiness despite persistent pain. [6] [18]"}
+{"id": "article-102974_39", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Enhancing Healthcare Team Outcomes", "content": "In efforts to combat the opioid epidemic, coordinating care among healthcare professionals by referring patients for osteopathic evaluations and utilizing MET as treatment strategies can enhance patient-centered care. These approaches can potentially improve outcomes for patients experiencing conditions associated with sacral dysfunctions.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Enhancing Healthcare Team Outcomes. In efforts to combat the opioid epidemic, coordinating care among healthcare professionals by referring patients for osteopathic evaluations and utilizing MET as treatment strategies can enhance patient-centered care. These approaches can potentially improve outcomes for patients experiencing conditions associated with sacral dysfunctions."}
+{"id": "article-102974_40", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Sacral Dysfunctions -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

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+{"id": "article-102975_0", "title": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Continuing Education Activity", "content": "Sacral dysfunctions are a common cause of low back pain and autonomic dysfunction. Sacral rocking (articulation) is one type of osteopathic technique that can be used to correct sacral dysfunctions. This activity outlines sacral rocking and explains the role of the interprofessional team in patients who undergo sacral rocking.", "contents": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Continuing Education Activity. Sacral dysfunctions are a common cause of low back pain and autonomic dysfunction. Sacral rocking (articulation) is one type of osteopathic technique that can be used to correct sacral dysfunctions. This activity outlines sacral rocking and explains the role of the interprofessional team in patients who undergo sacral rocking."}
+{"id": "article-102975_1", "title": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Continuing Education Activity", "content": "Objectives: Identify common symptoms of sacral somatic dysfunctions. Summarize the basic anatomy of the sacrum, and how the nerves exiting the sacrum affect the visceral organs. Outline the procedure for performing sacral articulation/ sacral rocking. Identify the absolute contraindications for sacral articulation/ sacral rocking. Access free multiple choice questions on this topic.", "contents": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Continuing Education Activity. Objectives: Identify common symptoms of sacral somatic dysfunctions. Summarize the basic anatomy of the sacrum, and how the nerves exiting the sacrum affect the visceral organs. Outline the procedure for performing sacral articulation/ sacral rocking. Identify the absolute contraindications for sacral articulation/ sacral rocking. Access free multiple choice questions on this topic."}
+{"id": "article-102975_2", "title": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Introduction", "content": "The sacrum contributes to several musculoskeletal and visceral health conditions. The spinal segment plays a primary role in the transmission of weight throughout the gait cycle, sitting, and standing. [1] [2] It also houses the sacral nerves, which provide autonomic innervation to many of the lower abdominal and pelvic organs.\u00a0It has long been a belief that the autonomic activity of the sacral nerves is parasympathetic; however, more recent studies suggest that the nerves may have sympathetic activity. [3]", "contents": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Introduction. The sacrum contributes to several musculoskeletal and visceral health conditions. The spinal segment plays a primary role in the transmission of weight throughout the gait cycle, sitting, and standing. [1] [2] It also houses the sacral nerves, which provide autonomic innervation to many of the lower abdominal and pelvic organs.\u00a0It has long been a belief that the autonomic activity of the sacral nerves is parasympathetic; however, more recent studies suggest that the nerves may have sympathetic activity. [3]"}
+{"id": "article-102975_3", "title": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Introduction", "content": "It is possible that the sacral nerves are more complex and cannot be simplified as transmitting parasympathetic or sympathetic activity alone. [4] Regardless, the nerves exiting the sacrum have significant contributions to the autonomic nervous system, influencing the function of the gastrointestinal, urinary, and reproductive systems. The sacrum is an often overlooked structure in evaluating patients with autonomic dysfunctions and/or low back pain. [1]", "contents": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Introduction. It is possible that the sacral nerves are more complex and cannot be simplified as transmitting parasympathetic or sympathetic activity alone. [4] Regardless, the nerves exiting the sacrum have significant contributions to the autonomic nervous system, influencing the function of the gastrointestinal, urinary, and reproductive systems. The sacrum is an often overlooked structure in evaluating patients with autonomic dysfunctions and/or low back pain. [1]"}
+{"id": "article-102975_4", "title": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Anatomy and Physiology", "content": "The sacrum is a large triangular bone made up of five separate vertebrae, which fuse during childhood and early adulthood. [5] The sacrum articulates with four different bones: the five lumbar vertebrae (with a disc space and a facet joint), the coccyx below (a symphysis with a thin fibro-cartilaginous disc), and the ilia on either side via the sacroiliac joints.\u00a0 The sacroiliac joints are made up of a synovial joint anteriorly and strong ligamentous attachments posteriorly. [5] The sacroiliac complex has a significant amount of mobility, and restrictions in its mobility (termed somatic dysfunctions) are readily palpable. [6]", "contents": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Anatomy and Physiology. The sacrum is a large triangular bone made up of five separate vertebrae, which fuse during childhood and early adulthood. [5] The sacrum articulates with four different bones: the five lumbar vertebrae (with a disc space and a facet joint), the coccyx below (a symphysis with a thin fibro-cartilaginous disc), and the ilia on either side via the sacroiliac joints.\u00a0 The sacroiliac joints are made up of a synovial joint anteriorly and strong ligamentous attachments posteriorly. [5] The sacroiliac complex has a significant amount of mobility, and restrictions in its mobility (termed somatic dysfunctions) are readily palpable. [6]"}
+{"id": "article-102975_5", "title": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Anatomy and Physiology", "content": "Nerves from the S2-S4 spinal levels leave the spinal canal via the ventral rami of the sacrum. The nerve roots form pelvic splenic nerves, which serve to innervate the lower gastrointestinal tract, urinary tract, and sexual organs. [7] Thus, somatic dysfunctions of the sacrum have the potential to impede proper innervation of these organs.\u00a0Articulatory techniques (ART) make up one category of techniques that have been shown effective in treating the sacral somatic dysfunctions.\u00a0 These techniques are low-velocity and low-amplitude; they include a passive, direct force from the physician through a restrictive barrier. [8]", "contents": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Anatomy and Physiology. Nerves from the S2-S4 spinal levels leave the spinal canal via the ventral rami of the sacrum. The nerve roots form pelvic splenic nerves, which serve to innervate the lower gastrointestinal tract, urinary tract, and sexual organs. [7] Thus, somatic dysfunctions of the sacrum have the potential to impede proper innervation of these organs.\u00a0Articulatory techniques (ART) make up one category of techniques that have been shown effective in treating the sacral somatic dysfunctions.\u00a0 These techniques are low-velocity and low-amplitude; they include a passive, direct force from the physician through a restrictive barrier. [8]"}
+{"id": "article-102975_6", "title": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Anatomy and Physiology", "content": "ART is often performed repetitively to free all ranges of motion of a joint. The articulatory technique described here, sacral rocking, accentuates the physiologic respiratory motion of the sacrum. During exhalation, the base (superior portion) of the sacrum moves posteriorly, termed counternutation/extension. In contrast, during inhalation, the sacrum nutates/flexes as the sacral base moves anteriorly. By accentuating the natural motion of the sacrum with respiration, sacral rocking can restore physiological freedom of motion in each of the sacrum\u2019s four articulations, without putting excessive stress on ligaments and surrounding structures.", "contents": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Anatomy and Physiology. ART is often performed repetitively to free all ranges of motion of a joint. The articulatory technique described here, sacral rocking, accentuates the physiologic respiratory motion of the sacrum. During exhalation, the base (superior portion) of the sacrum moves posteriorly, termed counternutation/extension. In contrast, during inhalation, the sacrum nutates/flexes as the sacral base moves anteriorly. By accentuating the natural motion of the sacrum with respiration, sacral rocking can restore physiological freedom of motion in each of the sacrum\u2019s four articulations, without putting excessive stress on ligaments and surrounding structures."}
+{"id": "article-102975_7", "title": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Indications", "content": "The indications for sacral ART, or sacral rocking, include somatic dysfunction of the sacrum.\u00a0 Sacral ART is one of many techniques that can help to treat somatic dysfunction of the sacrum. [9] Sacral rocking is often a preferred modality when patients present with pelvic symptoms relating to the visceral organs, such as constipation and dysmenorrhea. [10] Sacral rocking requires minimal patient participation; however, the patient must be able to lie prone for several minutes.", "contents": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Indications. The indications for sacral ART, or sacral rocking, include somatic dysfunction of the sacrum.\u00a0 Sacral ART is one of many techniques that can help to treat somatic dysfunction of the sacrum. [9] Sacral rocking is often a preferred modality when patients present with pelvic symptoms relating to the visceral organs, such as constipation and dysmenorrhea. [10] Sacral rocking requires minimal patient participation; however, the patient must be able to lie prone for several minutes."}
+{"id": "article-102975_8", "title": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Indications", "content": "The hands positioned on the sacral bone must not slide on the tissue, but must induce harmonious movements. The manual approach ends when the practitioner judges the tissue under the hands or the tissues under the sacral bone to have shown improvement. This technique can have other goals. For example, improve the relationship between the base of the sacrum and L5, and consequently, positively influence craniosacral mobility. The sacroiliac joint is innervated and can give painful symptoms; this approach could improve the articular relationship of these joints and reduce nociceptive afference.", "contents": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Indications. The hands positioned on the sacral bone must not slide on the tissue, but must induce harmonious movements. The manual approach ends when the practitioner judges the tissue under the hands or the tissues under the sacral bone to have shown improvement. This technique can have other goals. For example, improve the relationship between the base of the sacrum and L5, and consequently, positively influence craniosacral mobility. The sacroiliac joint is innervated and can give painful symptoms; this approach could improve the articular relationship of these joints and reduce nociceptive afference."}
+{"id": "article-102975_9", "title": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Indications", "content": "Other indications are related to soft tissues. The sacral area is covered by the thoracolumbar fascia, which is known to be a source of pain because if there is a tension dysfunction, the receptors can turn into nociceptors. The technique described could alleviate fascial tensions and improve the symptomatic picture.", "contents": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Indications. Other indications are related to soft tissues. The sacral area is covered by the thoracolumbar fascia, which is known to be a source of pain because if there is a tension dysfunction, the receptors can turn into nociceptors. The technique described could alleviate fascial tensions and improve the symptomatic picture."}
+{"id": "article-102975_10", "title": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Indications", "content": "The technique can mitigate the fascial tensions of the endopelvic fascia, the sacrospinous and sacrotuberous ligaments, the urogenital diaphragm or triangular ligament, the long dorsal sacroiliac ligament.", "contents": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Indications. The technique can mitigate the fascial tensions of the endopelvic fascia, the sacrospinous and sacrotuberous ligaments, the urogenital diaphragm or triangular ligament, the long dorsal sacroiliac ligament."}
+{"id": "article-102975_11", "title": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Contraindications", "content": "OMT is generally safe; however, there are still risks involved. Sacral rocking should not be done if it produces pain. Other contraindications for sacral rocking include vertebral malignancy near the sacrum, infection or inflammation, cauda equina syndrome, vertebral bone disease, and bony joint instability.", "contents": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Contraindications. OMT is generally safe; however, there are still risks involved. Sacral rocking should not be done if it produces pain. Other contraindications for sacral rocking include vertebral malignancy near the sacrum, infection or inflammation, cauda equina syndrome, vertebral bone disease, and bony joint instability."}
+{"id": "article-102975_12", "title": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Equipment", "content": "An osteopathic manipulative treatment (OMT) table is the only piece of equipment necessary for this technique.\u00a0If no OMT table is present, this technique could be performed on any medical exam table.", "contents": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Equipment. An osteopathic manipulative treatment (OMT) table is the only piece of equipment necessary for this technique.\u00a0If no OMT table is present, this technique could be performed on any medical exam table."}
+{"id": "article-102975_13", "title": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Personnel", "content": "The clinician is the only person needed to perform sacral rocking.\u00a0Since the procedure involves palpating a sensitive area, the patient should have an offer for a\u00a0chaperone such as a medical assistant or nurse.", "contents": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Personnel. The clinician is the only person needed to perform sacral rocking.\u00a0Since the procedure involves palpating a sensitive area, the patient should have an offer for a\u00a0chaperone such as a medical assistant or nurse."}
+{"id": "article-102975_14", "title": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Preparation", "content": "The physician should discuss the procedure with the patient and explain all risks and benefits.\u00a0The patient must understand precisely what the clinician will be doing and gives consent before proceeding. Additionally, the physician should ensure that the patient is comfortable lying prone. Before performing OMT, the physician should palpate the motion of the sacrum to compare the motion after completion of the treatment.", "contents": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Preparation. The physician should discuss the procedure with the patient and explain all risks and benefits.\u00a0The patient must understand precisely what the clinician will be doing and gives consent before proceeding. Additionally, the physician should ensure that the patient is comfortable lying prone. Before performing OMT, the physician should palpate the motion of the sacrum to compare the motion after completion of the treatment."}
+{"id": "article-102975_15", "title": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Technique or Treatment", "content": "The physician instructs the patient to lie prone on the table. The clinician places the heel of his/her cephalad hand on S1 and allows his/her fingers to drape over the sacrum. The physician\u2019s caudal hand is placed over his/her other hand with the heel\u00a0over\u00a0S4-S5 and fingers facing the patient\u2019s head. The physician instructs the patient to inhale deeply, and the physician follows the natural motion of the sacral base posteriorly. At the end of inhalation, the physician applies a slight pressure with the caudal hand to exaggerate sacral extension. The physician then instructs the patient to exhale and follows the sacrum into flexion. At the end of exhalation, the physician applies and holds a slight pressure with his\u00a0cephalad hand to exaggerate sacral flexion.\u00a0This process is repeated\u00a0for 2\u00a0or 3 minutes or until the release of tissues is felt.\u00a0The physician should then reassess the motion of the sacrum.", "contents": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Technique or Treatment. The physician instructs the patient to lie prone on the table. The clinician places the heel of his/her cephalad hand on S1 and allows his/her fingers to drape over the sacrum. The physician\u2019s caudal hand is placed over his/her other hand with the heel\u00a0over\u00a0S4-S5 and fingers facing the patient\u2019s head. The physician instructs the patient to inhale deeply, and the physician follows the natural motion of the sacral base posteriorly. At the end of inhalation, the physician applies a slight pressure with the caudal hand to exaggerate sacral extension. The physician then instructs the patient to exhale and follows the sacrum into flexion. At the end of exhalation, the physician applies and holds a slight pressure with his\u00a0cephalad hand to exaggerate sacral flexion.\u00a0This process is repeated\u00a0for 2\u00a0or 3 minutes or until the release of tissues is felt.\u00a0The physician should then reassess the motion of the sacrum."}
+{"id": "article-102975_16", "title": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Complications", "content": "Sacral rocking is a very safe technique. As with any osteopathic manipulative treatment, physicians should warn their patients of potential mild soreness the following day.", "contents": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Complications. Sacral rocking is a very safe technique. As with any osteopathic manipulative treatment, physicians should warn their patients of potential mild soreness the following day."}
+{"id": "article-102975_17", "title": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Clinical Significance", "content": "The sacrum is integral in providing a foundation of support for the body and gait mechanics. [2] Somatic dysfunctions of the sacrum are a common cause of low back pain and can contribute to autonomic dysfunction of the lower abdominal and pelvic organs, including the genitourinary system and gastrointestinal system. This autonomic dysfunction could lead to symptoms, including constipation, urinary incontinence, and impotence. [7]", "contents": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Clinical Significance. The sacrum is integral in providing a foundation of support for the body and gait mechanics. [2] Somatic dysfunctions of the sacrum are a common cause of low back pain and can contribute to autonomic dysfunction of the lower abdominal and pelvic organs, including the genitourinary system and gastrointestinal system. This autonomic dysfunction could lead to symptoms, including constipation, urinary incontinence, and impotence. [7]"}
+{"id": "article-102975_18", "title": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Clinical Significance", "content": "Osteopathic manipulative treatment is a useful tool in correcting somatic dysfunctions to optimize the biomechanics of the sacrum as well as improve the autonomic outflow from the sacral nerves. OMT is a safe, effective, and efficient treatment option for patients with sacral dysfunctions. [9] Specifically, sacral rocking is a gentle articulatory technique that accentuates the sacrum\u2019s normal physiologic respiratory motion; it can be useful in correcting any respiratory restrictions of the sacrum. [10]", "contents": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Clinical Significance. Osteopathic manipulative treatment is a useful tool in correcting somatic dysfunctions to optimize the biomechanics of the sacrum as well as improve the autonomic outflow from the sacral nerves. OMT is a safe, effective, and efficient treatment option for patients with sacral dysfunctions. [9] Specifically, sacral rocking is a gentle articulatory technique that accentuates the sacrum\u2019s normal physiologic respiratory motion; it can be useful in correcting any respiratory restrictions of the sacrum. [10]"}
+{"id": "article-102975_19", "title": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Clinical Significance", "content": "From a neurological point of view, the diaphragm muscle connects to the tongue and pelvic floor. Dysfunction of these anatomical areas could create further dysfunctions, not only at the level of the symptom. It would be more appropriate, after finishing the articulatory technique on the sacral bone, to also check the districts such as tongue and diaphragm muscle; if the most important dysfunction is the sacral area, the other districts should improve independently.", "contents": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Clinical Significance. From a neurological point of view, the diaphragm muscle connects to the tongue and pelvic floor. Dysfunction of these anatomical areas could create further dysfunctions, not only at the level of the symptom. It would be more appropriate, after finishing the articulatory technique on the sacral bone, to also check the districts such as tongue and diaphragm muscle; if the most important dysfunction is the sacral area, the other districts should improve independently."}
+{"id": "article-102975_20", "title": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Clinical Significance", "content": "Working the sacral area has an autonomic systemic aspect, as the anatomical area is rich in sympathetic and parasympathetic pathways; balancing a somatic sacral tension, could help rebalance the vegetative neurological function. It is possible to work on the sacral bone to resolve or relieve cranial symptoms when it is not possible to place the hands on the area of the dysfunctioning skull.", "contents": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Clinical Significance. Working the sacral area has an autonomic systemic aspect, as the anatomical area is rich in sympathetic and parasympathetic pathways; balancing a somatic sacral tension, could help rebalance the vegetative neurological function. It is possible to work on the sacral bone to resolve or relieve cranial symptoms when it is not possible to place the hands on the area of the dysfunctioning skull."}
+{"id": "article-102975_21", "title": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Enhancing Healthcare Team Outcomes", "content": "The osteopathic physician is primarily involved in diagnosing and treating somatic dysfunctions. Others in the healthcare team need to be aware of somatic dysfunctions as a common etiology of low back pain. Primary care\u00a0physicians and pain management physicians alike should\u00a0be educated to refer their patients to receive adjunctive OMT when indicated; this can reduce unnecessary medications and surgical procedures. Surgeons should also be aware of OMT as an adjunct to physical therapy to aid in recovery postoperatively.", "contents": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Enhancing Healthcare Team Outcomes. The osteopathic physician is primarily involved in diagnosing and treating somatic dysfunctions. Others in the healthcare team need to be aware of somatic dysfunctions as a common etiology of low back pain. Primary care\u00a0physicians and pain management physicians alike should\u00a0be educated to refer their patients to receive adjunctive OMT when indicated; this can reduce unnecessary medications and surgical procedures. Surgeons should also be aware of OMT as an adjunct to physical therapy to aid in recovery postoperatively."}
+{"id": "article-102975_22", "title": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Osteopathic Manipulative Treatment: Articulatory Procedure - Sacral Dysfunctions -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

statpearls/chunk/article-102976.jsonl

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+{"id": "article-102976_0", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Continuing Education Activity", "content": "Somatic dysfunctions cause pain and suboptimal muscle function. The pelvis, a crucial structural and functional component of the musculoskeletal system, is pivotal in maintaining overall biomechanical balance. This sturdy, bony structure contains various muscles that allow the upper and lower body to function as one. Recognizing the interconnectedness of the body's systems, osteopathic practitioners employ the muscle energy procedure to assess and address pelvic dysfunctions with a hands-on, patient-tailored approach.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Continuing Education Activity. Somatic dysfunctions cause pain and suboptimal muscle function. The pelvis, a crucial structural and functional component of the musculoskeletal system, is pivotal in maintaining overall biomechanical balance. This sturdy, bony structure contains various muscles that allow the upper and lower body to function as one. Recognizing the interconnectedness of the body's systems, osteopathic practitioners employ the muscle energy procedure to assess and address pelvic dysfunctions with a hands-on, patient-tailored approach."}
+{"id": "article-102976_1", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Continuing Education Activity", "content": "This activity for healthcare professionals is designed to enhance the learners' competence in using the muscle energy procedure in evaluating and managing pelvic dysfunctions. This activity is also designed to equip learners to collaborate effectively with an interprofessional team caring for patients with pelvic dysfunction.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Continuing Education Activity. This activity for healthcare professionals is designed to enhance the learners' competence in using the muscle energy procedure in evaluating and managing pelvic dysfunctions. This activity is also designed to equip learners to collaborate effectively with an interprofessional team caring for patients with pelvic dysfunction."}
+{"id": "article-102976_2", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Continuing Education Activity", "content": "Objectives: Identify the signs and symptoms indicative of pelvic somatic dysfunction. Determine a diagnostic plan for evaluating\u00a0individuals with somatic pelvic dysfunction. Compare the different pelvic somatic dysfunction treatment options and develop a personalized plan for a patient with the condition. Coordinate with an interprofessional team managing patients with pelvic dysfunction, formulating short- and long-term care plans to improve outcomes. Access free multiple choice questions on this topic.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Continuing Education Activity. Objectives: Identify the signs and symptoms indicative of pelvic somatic dysfunction. Determine a diagnostic plan for evaluating\u00a0individuals with somatic pelvic dysfunction. Compare the different pelvic somatic dysfunction treatment options and develop a personalized plan for a patient with the condition. Coordinate with an interprofessional team managing patients with pelvic dysfunction, formulating short- and long-term care plans to improve outcomes. Access free multiple choice questions on this topic."}
+{"id": "article-102976_3", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Introduction", "content": "The pelvis is composed of various ligaments, muscles, bones, and other structures that connect the axial skeleton to the lower extremities. Pelvic dysfunctions cause muscle pain, gait abnormalities, and viscerosomatic disturbances. Irritable bowel syndrome is a common functional problem that may arise from either a nerve disturbance or psychosomatic issues. [1]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Introduction. The pelvis is composed of various ligaments, muscles, bones, and other structures that connect the axial skeleton to the lower extremities. Pelvic dysfunctions cause muscle pain, gait abnormalities, and viscerosomatic disturbances. Irritable bowel syndrome is a common functional problem that may arise from either a nerve disturbance or psychosomatic issues. [1]"}
+{"id": "article-102976_4", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Introduction", "content": "Osteopathic manipulative treatment (OMT)\u00a0is a direct technique engaging and stretching the targeted muscles toward their restrictive barrier. The muscle energy (ME) procedure requires patient participation and, thus, clear patient-physician communication. ME effectively treats pain in various body areas, from the pelvis to the elbow and neck. [2] Understanding the proper application of this procedure enables providers to treat muscular and non-muscular pelvic pain.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Introduction. Osteopathic manipulative treatment (OMT)\u00a0is a direct technique engaging and stretching the targeted muscles toward their restrictive barrier. The muscle energy (ME) procedure requires patient participation and, thus, clear patient-physician communication. ME effectively treats pain in various body areas, from the pelvis to the elbow and neck. [2] Understanding the proper application of this procedure enables providers to treat muscular and non-muscular pelvic pain."}
+{"id": "article-102976_5", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Anatomy and Physiology", "content": "The pelvis' main function is to transmit weight from the torso to the lower body when sitting, standing upright, or ambulating (see Image . Hip Anatomy). [3] The pelvic girdle is a basin-shaped bone consolidation comprised of the ilium, ischium, and pubis (see Image . Male Pelvis Anatomy).", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Anatomy and Physiology. The pelvis' main function is to transmit weight from the torso to the lower body when sitting, standing upright, or ambulating (see Image . Hip Anatomy). [3] The pelvic girdle is a basin-shaped bone consolidation comprised of the ilium, ischium, and pubis (see Image . Male Pelvis Anatomy)."}
+{"id": "article-102976_6", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Anatomy and Physiology", "content": "The ilium is the fan-shaped, superior hip bone. The ilium alae (wings) are the fan-like projections, while the ilium's body resembles a fan's handle. The body of the ilium comprises part of the acetabulum. The iliac crest occupies the ilium's superior edge. The iliac crest curves anteriorly to the anterior superior iliac spine (ASIS), superiorly to the internal lip of the iliac crest, and posteriorly to the posterior superior iliac spine (PSIS). The iliac fossa is the anteromedial concave surface of the iliac alae. The ilium articulates posteriorly with the sacrum via its sacropelvic surface and the iliac tuberosity.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Anatomy and Physiology. The ilium is the fan-shaped, superior hip bone. The ilium alae (wings) are the fan-like projections, while the ilium's body resembles a fan's handle. The body of the ilium comprises part of the acetabulum. The iliac crest occupies the ilium's superior edge. The iliac crest curves anteriorly to the anterior superior iliac spine (ASIS), superiorly to the internal lip of the iliac crest, and posteriorly to the posterior superior iliac spine (PSIS). The iliac fossa is the anteromedial concave surface of the iliac alae. The ilium articulates posteriorly with the sacrum via its sacropelvic surface and the iliac tuberosity."}
+{"id": "article-102976_7", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Anatomy and Physiology", "content": "The ischium occupies the inferoposterior region of the pelvic girdle. The ischial body forms part of the acetabulum. The ischial ramus comprises part of the obturator foramen. The ischial tuberosity is a large posteroinferior projection of this bone, while the ischial spine is a smaller posteromedial protrusion. The lesser sciatic notch is the small recession between the ischial spine and tuberosity, while the larger furrow between the ischial spine and ilium posteriorly is the greater sciatic notch.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Anatomy and Physiology. The ischium occupies the inferoposterior region of the pelvic girdle. The ischial body forms part of the acetabulum. The ischial ramus comprises part of the obturator foramen. The ischial tuberosity is a large posteroinferior projection of this bone, while the ischial spine is a smaller posteromedial protrusion. The lesser sciatic notch is the small recession between the ischial spine and tuberosity, while the larger furrow between the ischial spine and ilium posteriorly is the greater sciatic notch."}
+{"id": "article-102976_8", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Anatomy and Physiology", "content": "The anteriorinferior pubis has superior and inferior rami. The superior ramus occupies part of the acetabulum, while the inferior ramus helps form the obturator foramen. The pubic crest is the anterior thickening on the pubic body that continues laterally with the pubic tubercle. The pectineal line of the pubis (pecten pubis) is an inclined ridge on the lateral aspect of the superior pubic ramus.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Anatomy and Physiology. The anteriorinferior pubis has superior and inferior rami. The superior ramus occupies part of the acetabulum, while the inferior ramus helps form the obturator foramen. The pubic crest is the anterior thickening on the pubic body that continues laterally with the pubic tubercle. The pectineal line of the pubis (pecten pubis) is an inclined ridge on the lateral aspect of the superior pubic ramus."}
+{"id": "article-102976_9", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Anatomy and Physiology", "content": "The pelvic inlet divides the pelvis into the lesser (true) and greater (false) pelves. The pelvic brim is the bony region bordering the pelvic inlet. The right and left ischiopubic rami, which articulate at the pubic symphysis, comprise the pubic arch.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Anatomy and Physiology. The pelvic inlet divides the pelvis into the lesser (true) and greater (false) pelves. The pelvic brim is the bony region bordering the pelvic inlet. The right and left ischiopubic rami, which articulate at the pubic symphysis, comprise the pubic arch."}
+{"id": "article-102976_10", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Anatomy and Physiology", "content": "Pelvic muscles are involved in somatic dysfunctions in the area (see Image . Muscles of the Hip and Thigh). The main pelvic flexors include the iliacus, psoas, and rectus femoris, all receiving blood from the abdominal aorta and femoral artery [4] . Hip flexor injury is a common cause of acute groin pain. [5] The lumbar plexus innervates the iliacus and psoas, while the femoral nerve innervates the rectus femoris. [6]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Anatomy and Physiology. Pelvic muscles are involved in somatic dysfunctions in the area (see Image . Muscles of the Hip and Thigh). The main pelvic flexors include the iliacus, psoas, and rectus femoris, all receiving blood from the abdominal aorta and femoral artery [4] . Hip flexor injury is a common cause of acute groin pain. [5] The lumbar plexus innervates the iliacus and psoas, while the femoral nerve innervates the rectus femoris. [6]"}
+{"id": "article-102976_11", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Anatomy and Physiology", "content": "The gluteus maximus is the primary pelvic extensor, supplied by the inferior and superior gluteal arteries and innervated by the inferior gluteal nerve. [7] The hip adductors include the pectineus and adductor magnus, longus, and brevis. The obturator artery supplies the thigh adductor compartment, which originates from the internal iliac artery. [8] Branches of the lumbar and sacral plexuses innervate the hip adductors.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Anatomy and Physiology. The gluteus maximus is the primary pelvic extensor, supplied by the inferior and superior gluteal arteries and innervated by the inferior gluteal nerve. [7] The hip adductors include the pectineus and adductor magnus, longus, and brevis. The obturator artery supplies the thigh adductor compartment, which originates from the internal iliac artery. [8] Branches of the lumbar and sacral plexuses innervate the hip adductors."}
+{"id": "article-102976_12", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Anatomy and Physiology", "content": "The hip abductors include the gluteus minimus and medius and tensor fascia lata. These muscles are supplied mostly by the superior gluteal artery, with minor branches from the inferior gluteal artery. [9] The superior gluteal nerve innervates the hip abductors. [10] The hip abductors are vital to pelvic function and stability and proper ambulation. [11]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Anatomy and Physiology. The hip abductors include the gluteus minimus and medius and tensor fascia lata. These muscles are supplied mostly by the superior gluteal artery, with minor branches from the inferior gluteal artery. [9] The superior gluteal nerve innervates the hip abductors. [10] The hip abductors are vital to pelvic function and stability and proper ambulation. [11]"}
+{"id": "article-102976_13", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Indications", "content": "OMT's indications include pain in the following regions: Sacroiliac Hip Groin Lower back Leg Pelvic girdle [12] Physicians widely practice ME for pelvic dysfunction management because of its safety and effectiveness. However, the technique\u00a0requires\u00a0patient participation in the treatment process.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Indications. OMT's indications include pain in the following regions: Sacroiliac Hip Groin Lower back Leg Pelvic girdle [12] Physicians widely practice ME for pelvic dysfunction management because of its safety and effectiveness. However, the technique\u00a0requires\u00a0patient participation in the treatment process."}
+{"id": "article-102976_14", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Contraindications", "content": "OMT is generally safe,\u00a0involving only minimal risks. ME should not be used if muscle contraction causes severe pain or the patient has local fractures and unstable joints. Recent\u00a0surgery is also a contraindication.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Contraindications. OMT is generally safe,\u00a0involving only minimal risks. ME should not be used if muscle contraction causes severe pain or the patient has local fractures and unstable joints. Recent\u00a0surgery is also a contraindication."}
+{"id": "article-102976_15", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Equipment", "content": "Equipment needed for this procedure includes an OMT table and stool. OMT tables and stools have different features enabling the proper execution of the technique. The choice of\u00a0equipment\u00a0depends on individual treatment styles and clinic requirements.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Equipment. Equipment needed for this procedure includes an OMT table and stool. OMT tables and stools have different features enabling the proper execution of the technique. The choice of\u00a0equipment\u00a0depends on individual treatment styles and clinic requirements."}
+{"id": "article-102976_16", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Personnel", "content": "Only the clinician is required to perform ME.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Personnel. Only the clinician is required to perform ME."}
+{"id": "article-102976_17", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Preparation", "content": "The physician should discuss the procedure's risks\u00a0and benefits with the patient before the session. Additionally, the patient's pain severity must be assessed before the session as a baseline for posttreatment comparison.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Preparation. The physician should discuss the procedure's risks\u00a0and benefits with the patient before the session. Additionally, the patient's pain severity must be assessed before the session as a baseline for posttreatment comparison."}
+{"id": "article-102976_18", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Technique or Treatment", "content": "The patient must be evaluated for pubic dysfunction before treating the pelvis. However, the physician must ask for permission before examining this sensitive area. When examining the pubis, the patient is placed supine with the legs extended. The physician places the heel of the hand inferior to the umbilicus, palpating caudally until the pubic symphysis is located. Once located, pubic evenness may be assessed by placing an index finger on each side of the symphysis, pressing caudally, and assessing the pubic bones visually. Pubic tenderness and alignment must be established.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Technique or Treatment. The patient must be evaluated for pubic dysfunction before treating the pelvis. However, the physician must ask for permission before examining this sensitive area. When examining the pubis, the patient is placed supine with the legs extended. The physician places the heel of the hand inferior to the umbilicus, palpating caudally until the pubic symphysis is located. Once located, pubic evenness may be assessed by placing an index finger on each side of the symphysis, pressing caudally, and assessing the pubic bones visually. Pubic tenderness and alignment must be established."}
+{"id": "article-102976_19", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Technique or Treatment", "content": "To begin the muscle energy procedure, the patient must bend their knees to at least 90\u00b0. Afterward, the patient must place their ankles together and allow the knees to fall laterally. The physician then gently pushes a fist or full forearm between the knees and asks the patient to adduct the legs against force. The knees are held together for 3 counts before relaxing. Afterward, the physician holds the patient's knees together. The physician then wraps their arms around the patient's knees, instructing them to abduct against resistance for 3 counts. The treatment is complete if articulation is heard. Otherwise, the treatment must be repeated 2 more times. Afterward, the patient is asked to briefly raise and then lower their buttocks in a bridge, allowing the pelvis to reset. The pubic symphysis should be reexamined for evenness. The treatment must be repeated if this area is lopsided.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Technique or Treatment. To begin the muscle energy procedure, the patient must bend their knees to at least 90\u00b0. Afterward, the patient must place their ankles together and allow the knees to fall laterally. The physician then gently pushes a fist or full forearm between the knees and asks the patient to adduct the legs against force. The knees are held together for 3 counts before relaxing. Afterward, the physician holds the patient's knees together. The physician then wraps their arms around the patient's knees, instructing them to abduct against resistance for 3 counts. The treatment is complete if articulation is heard. Otherwise, the treatment must be repeated 2 more times. Afterward, the patient is asked to briefly raise and then lower their buttocks in a bridge, allowing the pelvis to reset. The pubic symphysis should be reexamined for evenness. The treatment must be repeated if this area is lopsided."}
+{"id": "article-102976_20", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Technique or Treatment", "content": "The characteristics of pelvic dysfunction that must be identified before treatment are laterality, ASIS and PSIS orientation, inflare or outflare, and superior innominate shear. Proper identification allows for the osteopathic technique's effective execution.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Technique or Treatment. The characteristics of pelvic dysfunction that must be identified before treatment are laterality, ASIS and PSIS orientation, inflare or outflare, and superior innominate shear. Proper identification allows for the osteopathic technique's effective execution."}
+{"id": "article-102976_21", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Technique or Treatment", "content": "The tests that can determine laterality are the standing flexion and ASIS compression tests. In the standing flexion test, the patient must be standing and facing away from the physician. The physician then places both thumbs on the patient's PSIS and asks them to bend forward slowly. Laterality is determined by which side the PSIS travels a greater distance relative to its original position. The sacroiliac joint on that side is dysfunctional. The patient's hamstrings must be stretched before doing this test because tight hamstrings could lead to a false negative and not allow the dysfunctional sacroiliac joint to rise.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Technique or Treatment. The tests that can determine laterality are the standing flexion and ASIS compression tests. In the standing flexion test, the patient must be standing and facing away from the physician. The physician then places both thumbs on the patient's PSIS and asks them to bend forward slowly. Laterality is determined by which side the PSIS travels a greater distance relative to its original position. The sacroiliac joint on that side is dysfunctional. The patient's hamstrings must be stretched before doing this test because tight hamstrings could lead to a false negative and not allow the dysfunctional sacroiliac joint to rise."}
+{"id": "article-102976_22", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Technique or Treatment", "content": "Meanwhile, the ASIS compression test is performed while the patient is supine. The physician places both hands on the patient's right and left ASIS, applying pressure to these areas in a rocking motion one side at a time. The side that shows greater resistance has a positive ASIS compression test. After determining laterality, the physician must compare the ASIS and PSIS orientation on both sides.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Technique or Treatment. Meanwhile, the ASIS compression test is performed while the patient is supine. The physician places both hands on the patient's right and left ASIS, applying pressure to these areas in a rocking motion one side at a time. The side that shows greater resistance has a positive ASIS compression test. After determining laterality, the physician must compare the ASIS and PSIS orientation on both sides."}
+{"id": "article-102976_23", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Technique or Treatment", "content": "The laterality test should be positive on the left in patients with a left anterior rotation. The left ASIS would then be lower than the right ASIS, while the left PSIS would be higher than the right PSIS. To treat a left anterior rotation, the patient should lie supine on the table, with the physician flexing the patient's left knee and hip until a barrier is met. The physician will then hold this position and provide isometric force while the patient pushes against the physician with their hip extensors for 3 to 5 seconds. The physician then flexes the hip against another restrictive barrier, repeating the process 2 to 4 more times or until the restrictive barriers disappear. The ASIS and PSIS heights are then assessed to confirm the resolution of the somatic dysfunction.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Technique or Treatment. The laterality test should be positive on the left in patients with a left anterior rotation. The left ASIS would then be lower than the right ASIS, while the left PSIS would be higher than the right PSIS. To treat a left anterior rotation, the patient should lie supine on the table, with the physician flexing the patient's left knee and hip until a barrier is met. The physician will then hold this position and provide isometric force while the patient pushes against the physician with their hip extensors for 3 to 5 seconds. The physician then flexes the hip against another restrictive barrier, repeating the process 2 to 4 more times or until the restrictive barriers disappear. The ASIS and PSIS heights are then assessed to confirm the resolution of the somatic dysfunction."}
+{"id": "article-102976_24", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Technique or Treatment", "content": "In patients with a left posterior rotation, the laterality test should be positive on the left. The left ASIS would then be higher than the right ASIS, while the left PSIS would be lower than the right PSIS. To treat a left posterior rotation, the patient is asked to lie supine. The physician then drops the patient's left leg off the table and pushes down the knee until it encounters a barrier. The physician then holds this position and provides isometric force while the patient pushes back with their hip flexors for 3 to 5 seconds. Afterward, the physician extends the patient's hip toward a new restrictive barrier. The whole process is repeated 2 to 4 more times or until the restrictive barriers disappear. The physician re-examines the ASIS and PSIS heights at the end of the treatment to confirm the resolution of the dysfunction.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Technique or Treatment. In patients with a left posterior rotation, the laterality test should be positive on the left. The left ASIS would then be higher than the right ASIS, while the left PSIS would be lower than the right PSIS. To treat a left posterior rotation, the patient is asked to lie supine. The physician then drops the patient's left leg off the table and pushes down the knee until it encounters a barrier. The physician then holds this position and provides isometric force while the patient pushes back with their hip flexors for 3 to 5 seconds. Afterward, the physician extends the patient's hip toward a new restrictive barrier. The whole process is repeated 2 to 4 more times or until the restrictive barriers disappear. The physician re-examines the ASIS and PSIS heights at the end of the treatment to confirm the resolution of the dysfunction."}
+{"id": "article-102976_25", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Technique or Treatment", "content": "An inflare exists when the ASIS is closer to the midline and the PSIS moves away from the midline. The reverse is true for an outflare. Physicians should use the umbilicus as a landmark to determine the ASIS and PSIS distance from the midline.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Technique or Treatment. An inflare exists when the ASIS is closer to the midline and the PSIS moves away from the midline. The reverse is true for an outflare. Physicians should use the umbilicus as a landmark to determine the ASIS and PSIS distance from the midline."}
+{"id": "article-102976_26", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Technique or Treatment", "content": "Patients with a left inflare have the laterality test positive on the left. The left ASIS is then closer to the midline than the right ASIS, while the left PSIS is farther from the midline than the right PSIS. To treat a left inflare, the patient is asked to lie supine, with the left lower extremity in a \"figure four\" position. The physician then pushes towards the ground on the patient's knee until they feel a restrictive barrier. The patient will then push upwards against the physician using the adductors for 3 to 5 seconds. Afterward, the physician pushes down on the patient's knee again until another restrictive barrier is felt. The process is repeated 2 to 4 times or until no more restrictive barrier is appreciated. The physician will assess the ASIS and PSIS heights after the treatment to determine if the somatic dysfunction has resolved.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Technique or Treatment. Patients with a left inflare have the laterality test positive on the left. The left ASIS is then closer to the midline than the right ASIS, while the left PSIS is farther from the midline than the right PSIS. To treat a left inflare, the patient is asked to lie supine, with the left lower extremity in a \"figure four\" position. The physician then pushes towards the ground on the patient's knee until they feel a restrictive barrier. The patient will then push upwards against the physician using the adductors for 3 to 5 seconds. Afterward, the physician pushes down on the patient's knee again until another restrictive barrier is felt. The process is repeated 2 to 4 times or until no more restrictive barrier is appreciated. The physician will assess the ASIS and PSIS heights after the treatment to determine if the somatic dysfunction has resolved."}
+{"id": "article-102976_27", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Technique or Treatment", "content": "Meanwhile, patients with a left outflare will have a positive laterality test on the left. The left ASIS would thus be farther from the midline than the right ASIS. The left PSIS would be closer to the midline than the right PSIS. To treat a left outflare, the patient must lie supine and flex their hip to 90\u00b0. The physician then pushes the patient's knee medially until they feel a restrictive barrier. Then, the patient will push against the physician for 3 to 5 seconds using their abductors. Afterward, the physician flexes the patient's hip to 90\u00b0 again and pushes the knee medially to the new restrictive barrier. The process is repeated 2 to 4 times more or until the restrictive barrier disappears. At the end of the session, the physician examines the ASIS and PSIS heights to confirm the resolution of the somatic dysfunction.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Technique or Treatment. Meanwhile, patients with a left outflare will have a positive laterality test on the left. The left ASIS would thus be farther from the midline than the right ASIS. The left PSIS would be closer to the midline than the right PSIS. To treat a left outflare, the patient must lie supine and flex their hip to 90\u00b0. The physician then pushes the patient's knee medially until they feel a restrictive barrier. Then, the patient will push against the physician for 3 to 5 seconds using their abductors. Afterward, the physician flexes the patient's hip to 90\u00b0 again and pushes the knee medially to the new restrictive barrier. The process is repeated 2 to 4 times more or until the restrictive barrier disappears. At the end of the session, the physician examines the ASIS and PSIS heights to confirm the resolution of the somatic dysfunction."}
+{"id": "article-102976_28", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Technique or Treatment", "content": "A superior innominate shear occurs when the ASIS and PSIS on one side are superior to their contralateral counterparts. Treatments for this dysfunction do not involve ME techniques, though the condition is diagnosed similarly.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Technique or Treatment. A superior innominate shear occurs when the ASIS and PSIS on one side are superior to their contralateral counterparts. Treatments for this dysfunction do not involve ME techniques, though the condition is diagnosed similarly."}
+{"id": "article-102976_29", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Technique or Treatment", "content": "Patients with a left superior shear will have a positive left laterality test. Thus, the left ASIS is higher than the right ASIS, and the left PSIS is higher than the right ASIS. To treat a left superior shear, the patient must lie supine, holding firmly onto the table. The physician then grasps the patient's left ankle with both hands while adding traction and slight internal rotation. Next, the patient takes a deep breath in, and on exhalation, the physician pulls quickly and firmly on the ankle caudad. This technique is called \"high velocity, low amplitude\" (HVLA). Afterward, the physician reassesses the ASIS and PSIS heights to determine that somatic dysfunction has resolved.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Technique or Treatment. Patients with a left superior shear will have a positive left laterality test. Thus, the left ASIS is higher than the right ASIS, and the left PSIS is higher than the right ASIS. To treat a left superior shear, the patient must lie supine, holding firmly onto the table. The physician then grasps the patient's left ankle with both hands while adding traction and slight internal rotation. Next, the patient takes a deep breath in, and on exhalation, the physician pulls quickly and firmly on the ankle caudad. This technique is called \"high velocity, low amplitude\" (HVLA). Afterward, the physician reassesses the ASIS and PSIS heights to determine that somatic dysfunction has resolved."}
+{"id": "article-102976_30", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Technique or Treatment", "content": "Patients with a left inferior shear also have a positive laterality test on the left. The left ASIS is lower than the right, and the left PSIS is lower than the right. To treat a left inferior shear, the patient must hop on their left leg for 10 to 15 seconds. The physician will then examine the ASIS and PSIS heights to determine somatic dysfunction resolution. The techniques explained above are described only for one side of the pelvis. However, these techniques apply to either side of the innominate bone.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Technique or Treatment. Patients with a left inferior shear also have a positive laterality test on the left. The left ASIS is lower than the right, and the left PSIS is lower than the right. To treat a left inferior shear, the patient must hop on their left leg for 10 to 15 seconds. The physician will then examine the ASIS and PSIS heights to determine somatic dysfunction resolution. The techniques explained above are described only for one side of the pelvis. However, these techniques apply to either side of the innominate bone."}
+{"id": "article-102976_31", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Complications", "content": "The physician should warn the patient of posttreatment soreness that may last\u00a024\u00a0to 72 hours. Staying well-hydrated, resting, and using ice or heat packs on the treated area may help alleviate this symptom.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Complications. The physician should warn the patient of posttreatment soreness that may last\u00a024\u00a0to 72 hours. Staying well-hydrated, resting, and using ice or heat packs on the treated area may help alleviate this symptom."}
+{"id": "article-102976_32", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Clinical Significance", "content": "Pelvic somatic dysfunctions can manifest in\u00a0various ways. Groin\u00a0and lower back pain\u00a0are the most concerning symptoms, as these manifestations may start unnecessary medications or require imaging and invasive procedures. OMT can be\u00a0performed\u00a0in the office by any osteopathic physician. The provider\u00a0can save patients time and money\u00a0and improve\u00a0their quality of life if\u00a0properly trained to\u00a0recognize these dysfunctions.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Clinical Significance. Pelvic somatic dysfunctions can manifest in\u00a0various ways. Groin\u00a0and lower back pain\u00a0are the most concerning symptoms, as these manifestations may start unnecessary medications or require imaging and invasive procedures. OMT can be\u00a0performed\u00a0in the office by any osteopathic physician. The provider\u00a0can save patients time and money\u00a0and improve\u00a0their quality of life if\u00a0properly trained to\u00a0recognize these dysfunctions."}
+{"id": "article-102976_33", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Enhancing Healthcare Team Outcomes", "content": "OMT is typically only\u00a0performed by the osteopathic physician.\u00a0However,\u00a0medical\u00a0and\u00a0osteopathic doctors\u00a0must\u00a0collaborate to educate\u00a0patients\u00a0about cost-effective and safe treatments, especially in cases where neither surgery nor medications are suitable. Medical doctors should\u00a0thus help patients understand that OMT can relieve various forms of pelvic dysfunction more effectively than\u00a0conventional treatments. This modality\u00a0provides a non-invasive\u00a0alternative that can benefit patients.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Enhancing Healthcare Team Outcomes. OMT is typically only\u00a0performed by the osteopathic physician.\u00a0However,\u00a0medical\u00a0and\u00a0osteopathic doctors\u00a0must\u00a0collaborate to educate\u00a0patients\u00a0about cost-effective and safe treatments, especially in cases where neither surgery nor medications are suitable. Medical doctors should\u00a0thus help patients understand that OMT can relieve various forms of pelvic dysfunction more effectively than\u00a0conventional treatments. This modality\u00a0provides a non-invasive\u00a0alternative that can benefit patients."}
+{"id": "article-102976_34", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - Pelvic Dysfunctions -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

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+{"id": "article-102978_0", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Continuing Education Activity", "content": "Balanced ligamentous tension (BLT) is a treatment modality in osteopathic medicine that works on the principle of balancing the tension among ligaments supporting a joint to reset the normal proprioceptive feedback of that joint. While BLT can be used in any region of the body. This activity reviews the evaluation and treatment of sacroiliac and lumbosacral somatic dysfunctions and highlights the role of interprofessional teams in evaluating and treating patients with this condition.", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Continuing Education Activity. Balanced ligamentous tension (BLT) is a treatment modality in osteopathic medicine that works on the principle of balancing the tension among ligaments supporting a joint to reset the normal proprioceptive feedback of that joint. While BLT can be used in any region of the body. This activity reviews the evaluation and treatment of sacroiliac and lumbosacral somatic dysfunctions and highlights the role of interprofessional teams in evaluating and treating patients with this condition."}
+{"id": "article-102978_1", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Continuing Education Activity", "content": "Objectives: Review the typical anatomy and physiology that are involved in pelvic somatic dysfunctions. Outline the management considerations for patients with absolute contraindications to using BLT in the pelvis. Describe the common treatments using BLT to address somatic dysfunction in the pelvis as discussed in this article. Explain the importance of collaboration and communication amongst the interprofessional team to improve outcomes for patients affected by pelvic somatic dysfunction. Access free multiple choice questions on this topic.", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Continuing Education Activity. Objectives: Review the typical anatomy and physiology that are involved in pelvic somatic dysfunctions. Outline the management considerations for patients with absolute contraindications to using BLT in the pelvis. Describe the common treatments using BLT to address somatic dysfunction in the pelvis as discussed in this article. Explain the importance of collaboration and communication amongst the interprofessional team to improve outcomes for patients affected by pelvic somatic dysfunction. Access free multiple choice questions on this topic."}
+{"id": "article-102978_2", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Introduction", "content": "Balanced ligamentous tension (BLT) (also referred to as ligamentous articular strain depending on geographic location), relies on the principle that the ligaments of the body provide proprioceptive feedback when tension is appropriately balanced along with the respective ligaments in a joint. According to the Sutherland model, an unequal distribution in the tension among ligaments can cause imbalances in the joint that result in a new pathological \u201cnormal\u201d. By altering the strain on certain ligaments, the \u201cspring\u201d of a ligament can be returned to back to the normal physiologic range, and proper proprioceptive feedback in the joint can be re-established.", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Introduction. Balanced ligamentous tension (BLT) (also referred to as ligamentous articular strain depending on geographic location), relies on the principle that the ligaments of the body provide proprioceptive feedback when tension is appropriately balanced along with the respective ligaments in a joint. According to the Sutherland model, an unequal distribution in the tension among ligaments can cause imbalances in the joint that result in a new pathological \u201cnormal\u201d. By altering the strain on certain ligaments, the \u201cspring\u201d of a ligament can be returned to back to the normal physiologic range, and proper proprioceptive feedback in the joint can be re-established."}
+{"id": "article-102978_3", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Introduction", "content": "Different institutions across the country vary in their description of BLT techniques (with some distinctly separating direct and indirect methods), for example, some schools of thought describe the technique as having three primary steps which include: disengagement at the joint in question, exaggeration of the joint by carrying it into the position of its original injury, and finally balance, which involves feeling for release in the form of a \u201cwobble point\u201d indicating that the ligaments involved in the dysfunction have been rebalanced. When applying this concept to the pelvis, the joints of primary focus include the lumbosacral and sacroiliac.", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Introduction. Different institutions across the country vary in their description of BLT techniques (with some distinctly separating direct and indirect methods), for example, some schools of thought describe the technique as having three primary steps which include: disengagement at the joint in question, exaggeration of the joint by carrying it into the position of its original injury, and finally balance, which involves feeling for release in the form of a \u201cwobble point\u201d indicating that the ligaments involved in the dysfunction have been rebalanced. When applying this concept to the pelvis, the joints of primary focus include the lumbosacral and sacroiliac."}
+{"id": "article-102978_4", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Anatomy and Physiology", "content": "Sacrum", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Anatomy and Physiology. Sacrum"}
+{"id": "article-102978_5", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Anatomy and Physiology", "content": "The pelvis, consisting of a sacrum and two innominate, provides the foundational stability necessary for proper ambulation and posture. In regards to the sacrum, the anatomy involves the fusion of sacral vertebrae S1-S5, noting that this fusion is not fully completed until age 18-30. Important landmarks include the sacroiliac (SI) joints on either wings or ala of the sacrum, which articulate with the ilium and are critical for proper sacral motion, as well as the lumbosacral joint which articulates with the L5 lumbar vertebra. Moving inferiorly, the lower part of the sacrum, termed the coccyx is the final vertebral segment. The coccyx is connected to the sacrum via a fibrocartilaginous joint known as the sacrococcygeal symphysis. [1]", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Anatomy and Physiology. The pelvis, consisting of a sacrum and two innominate, provides the foundational stability necessary for proper ambulation and posture. In regards to the sacrum, the anatomy involves the fusion of sacral vertebrae S1-S5, noting that this fusion is not fully completed until age 18-30. Important landmarks include the sacroiliac (SI) joints on either wings or ala of the sacrum, which articulate with the ilium and are critical for proper sacral motion, as well as the lumbosacral joint which articulates with the L5 lumbar vertebra. Moving inferiorly, the lower part of the sacrum, termed the coccyx is the final vertebral segment. The coccyx is connected to the sacrum via a fibrocartilaginous joint known as the sacrococcygeal symphysis. [1]"}
+{"id": "article-102978_6", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Anatomy and Physiology", "content": "The proper sacral motion requires the use of various ligaments such as the sacroiliac ligament, which connects the sacrum to the ilium and limits excessive anterior and inferior sacral motion. The sacrotuberous ligament comes together with the posterior sacroiliac ligament to function in resisting the nutation of the sacrum during normal gait. [2] The greater and lesser sciatic foramen house the sciatic nerve, superior and inferior gluteal nerve, pudendal nerve, posterior femoral cutaneous nerve, nerve to quadratus femoris, and nerve to internal obturator muscle as well as several major vessels such as the superior and inferior gluteal artery and vein along with the internal pudendal artery and vein. [3]", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Anatomy and Physiology. The proper sacral motion requires the use of various ligaments such as the sacroiliac ligament, which connects the sacrum to the ilium and limits excessive anterior and inferior sacral motion. The sacrotuberous ligament comes together with the posterior sacroiliac ligament to function in resisting the nutation of the sacrum during normal gait. [2] The greater and lesser sciatic foramen house the sciatic nerve, superior and inferior gluteal nerve, pudendal nerve, posterior femoral cutaneous nerve, nerve to quadratus femoris, and nerve to internal obturator muscle as well as several major vessels such as the superior and inferior gluteal artery and vein along with the internal pudendal artery and vein. [3]"}
+{"id": "article-102978_7", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Anatomy and Physiology", "content": "Important ligaments involving the ilium include the iliolumbar and ilioinguinal ligaments, both of which contribute to overall pelvic stability. Finally, the true pelvic ligaments (which form a direct bone-to-bone connection) include the sacroiliac and interosseous sacroiliac ligaments. Accessory pelvic ligaments consist of the iliolumbar ligament, inguinal ligaments, sacrotuberous ligaments, and sacrospinous ligaments. [4]", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Anatomy and Physiology. Important ligaments involving the ilium include the iliolumbar and ilioinguinal ligaments, both of which contribute to overall pelvic stability. Finally, the true pelvic ligaments (which form a direct bone-to-bone connection) include the sacroiliac and interosseous sacroiliac ligaments. Accessory pelvic ligaments consist of the iliolumbar ligament, inguinal ligaments, sacrotuberous ligaments, and sacrospinous ligaments. [4]"}
+{"id": "article-102978_8", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Anatomy and Physiology", "content": "The sacral anatomy plays an important role in the proper physiological motion of the pelvis, specifically in regards to understanding the important axes of motion of the sacrum. Two diagonal oblique axes are present and go from the superior portion of the sacroiliac articulation to the contralateral inferior sacroiliac articulation and can be named either left or right, depending on their superior origin. The superior transverse axis passes through the posterior dural attachment at the second sacral segment and allows for sacral motion during the primary respiration. The middle transverse axis passes horizontally through the second sacral segment on the anterior aspect of the sacrum and is involved in postural stability that allows for appropriate sacral motion in a standing position as well as thoracic respiration. Finally, the inferior transverse axis (also at the second sacral segment) is involved in innominate motion in the way of the articulation between the ilia on the sacrum.", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Anatomy and Physiology. The sacral anatomy plays an important role in the proper physiological motion of the pelvis, specifically in regards to understanding the important axes of motion of the sacrum. Two diagonal oblique axes are present and go from the superior portion of the sacroiliac articulation to the contralateral inferior sacroiliac articulation and can be named either left or right, depending on their superior origin. The superior transverse axis passes through the posterior dural attachment at the second sacral segment and allows for sacral motion during the primary respiration. The middle transverse axis passes horizontally through the second sacral segment on the anterior aspect of the sacrum and is involved in postural stability that allows for appropriate sacral motion in a standing position as well as thoracic respiration. Finally, the inferior transverse axis (also at the second sacral segment) is involved in innominate motion in the way of the articulation between the ilia on the sacrum."}
+{"id": "article-102978_9", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Anatomy and Physiology", "content": "Innominate", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Anatomy and Physiology. Innominate"}
+{"id": "article-102978_10", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Anatomy and Physiology", "content": "The innominate is not a singular structure, but instead, the combination of three embryologically formed bones; the ilium, ischium, and pubis. Over time, these bones fuse to form the complete innominate which includes the acetabulum, or \u201chip socket\u201d that houses the femoral head. [5] Points of contact between the sacrum and innominate include the ligamentous attachments at the pubic symphysis and the sacroiliac joint, both of which provide pelvic stability during ambulation. When identifying important landmarks used in the diagnosis of pelvic somatic dysfunction, the anterior and posterior superior iliac spines (ASIS and PSIS) are commonly referenced due to their relatively easy palpable nature and reliability consistent pelvic landmarks.", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Anatomy and Physiology. The innominate is not a singular structure, but instead, the combination of three embryologically formed bones; the ilium, ischium, and pubis. Over time, these bones fuse to form the complete innominate which includes the acetabulum, or \u201chip socket\u201d that houses the femoral head. [5] Points of contact between the sacrum and innominate include the ligamentous attachments at the pubic symphysis and the sacroiliac joint, both of which provide pelvic stability during ambulation. When identifying important landmarks used in the diagnosis of pelvic somatic dysfunction, the anterior and posterior superior iliac spines (ASIS and PSIS) are commonly referenced due to their relatively easy palpable nature and reliability consistent pelvic landmarks."}
+{"id": "article-102978_11", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Anatomy and Physiology", "content": "From a physiologic point of view, the innominate has the important feature of maintaining overall human stability when standing, walking, or running. [5] It is not an immobile structure and allows for a slight degree of mobility at its ligamentous attachments with the sacrum allowing for proper axial rotation of the pelvis with normal physical activities.", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Anatomy and Physiology. From a physiologic point of view, the innominate has the important feature of maintaining overall human stability when standing, walking, or running. [5] It is not an immobile structure and allows for a slight degree of mobility at its ligamentous attachments with the sacrum allowing for proper axial rotation of the pelvis with normal physical activities."}
+{"id": "article-102978_12", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Indications", "content": "Indications include findings of pelvic somatic dysfunction with an associated complaint where other explanations of the potential source of the complaint have been ruled out.", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Indications. Indications include findings of pelvic somatic dysfunction with an associated complaint where other explanations of the potential source of the complaint have been ruled out."}
+{"id": "article-102978_13", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Contraindications", "content": "Pelvic BLT is an incredibly safe treatment modality due to its passive and direct or indirect approach. Many patients with pelvic somatic dysfunction that may not be able to tolerate more active and direct treatments such as high-velocity, low-amplitude (HVLA), muscle energy, or articulatory techniques can tolerate BLT well. Some absolute contraindications include patient refusal, inability to consent to treatment, fractures at the location being treated, as well as certain bone malignancies or osteomyelitis leading to compromised bone structure.", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Contraindications. Pelvic BLT is an incredibly safe treatment modality due to its passive and direct or indirect approach. Many patients with pelvic somatic dysfunction that may not be able to tolerate more active and direct treatments such as high-velocity, low-amplitude (HVLA), muscle energy, or articulatory techniques can tolerate BLT well. Some absolute contraindications include patient refusal, inability to consent to treatment, fractures at the location being treated, as well as certain bone malignancies or osteomyelitis leading to compromised bone structure."}
+{"id": "article-102978_14", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Equipment", "content": "No special equipment is necessary to perform pelvic BLT. Providers may benefit from the use of an adjustable table and stool to aid with practitioner comfort and ensure proper ergonomics.", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Equipment. No special equipment is necessary to perform pelvic BLT. Providers may benefit from the use of an adjustable table and stool to aid with practitioner comfort and ensure proper ergonomics."}
+{"id": "article-102978_15", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Personnel", "content": "The only personnel needed is the physician.", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Personnel. The only personnel needed is the physician."}
+{"id": "article-102978_16", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Preparation", "content": "Communication is very important, both when performing the exam and treating the patient. The physician should describe to the patient the procedure and clinical reasoning behind the treatment as well as the risks, benefits, and alternatives. Consent needs to be obtained prior to treatment. The physician then performs an osteopathic structural exam, taking note of somatic dysfunctions and areas of greatest restriction.", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Preparation. Communication is very important, both when performing the exam and treating the patient. The physician should describe to the patient the procedure and clinical reasoning behind the treatment as well as the risks, benefits, and alternatives. Consent needs to be obtained prior to treatment. The physician then performs an osteopathic structural exam, taking note of somatic dysfunctions and areas of greatest restriction."}
+{"id": "article-102978_17", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Technique or Treatment", "content": "SI BLT- Short Lever", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Technique or Treatment. SI BLT- Short Lever"}
+{"id": "article-102978_18", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Technique or Treatment", "content": "The patient is lying supine on the table. Diagnose the side of restriction with the ASIS compression test. Sit facing the patient on the side of the SI restriction. Contact under the pelvis at the SI joint with the cephalad hand, so the finger pads are on the medial aspect of the SI joint and place the caudad hand on the ipsilateral ASIS. Bring the innominate through a range of motion, including superior/inferior shear, anterior/posterior rotation, and inflare/outflare. When using indirect BLT, bring the innominate into its position of ease in all the motions tested and fine-tune until a point of balanced tension between physiologic neutral and the direct articular barrier is reached. Make sure that the ligaments still feel engaged. The same is true when using direct BLT, except the innominate is brought into its restriction in all the motions tested. Anterior pressure may need to be applied to the sacrum with the hand under the SI joint, which will facilitate the release by decompressing the SI joint.", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Technique or Treatment. The patient is lying supine on the table. Diagnose the side of restriction with the ASIS compression test. Sit facing the patient on the side of the SI restriction. Contact under the pelvis at the SI joint with the cephalad hand, so the finger pads are on the medial aspect of the SI joint and place the caudad hand on the ipsilateral ASIS. Bring the innominate through a range of motion, including superior/inferior shear, anterior/posterior rotation, and inflare/outflare. When using indirect BLT, bring the innominate into its position of ease in all the motions tested and fine-tune until a point of balanced tension between physiologic neutral and the direct articular barrier is reached. Make sure that the ligaments still feel engaged. The same is true when using direct BLT, except the innominate is brought into its restriction in all the motions tested. Anterior pressure may need to be applied to the sacrum with the hand under the SI joint, which will facilitate the release by decompressing the SI joint."}
+{"id": "article-102978_19", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Technique or Treatment", "content": "Once the point of balanced tension is found, hold this position until softening under the hand that is contacting the SI joint is felt. Warmth increased motion, or a sensation that less force is needed to hold the joint in its treatment position might also be felt. Once this happens, subtle motions can be used to find the next point of balanced tension. Repeat this process until no further change is appreciated. Reassess with the ASIS compression test. It should be noted that not all schools teach direct and indirect BLT. Those that do not may instead focus on finding a point of balanced tension without specifying whether this was achieved by first going into the direction of ease or restriction. SI BLT- Long Lever", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Technique or Treatment. Once the point of balanced tension is found, hold this position until softening under the hand that is contacting the SI joint is felt. Warmth increased motion, or a sensation that less force is needed to hold the joint in its treatment position might also be felt. Once this happens, subtle motions can be used to find the next point of balanced tension. Repeat this process until no further change is appreciated. Reassess with the ASIS compression test. It should be noted that not all schools teach direct and indirect BLT. Those that do not may instead focus on finding a point of balanced tension without specifying whether this was achieved by first going into the direction of ease or restriction. SI BLT- Long Lever"}
+{"id": "article-102978_20", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Technique or Treatment", "content": "The patient is lying supine on the table. Diagnose the side of restriction with the ASIS compression test. Stand on the side of the SI restriction facing the patient\u2019s head. Contact the SI joint with the hand that is away from the patient, which will be used to monitor for changes. Use the arm closest to the patient to hold the ipsilateral leg and use it as a long lever to create balanced tension at the SI joint. Internally rotate the femur in the acetabulum to engage the SI joint. Bring the leg into abduction/adduction, flexion/extension, and distraction/compression into the SI joint, noticing which motions soften and create tension at the SI joint. Stack all of the motions that create ease at the SI joint if indirect BLT is being used or all of the motions that create tension if direct BLT is being used, and fine-tune to a point of balanced tension.", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Technique or Treatment. The patient is lying supine on the table. Diagnose the side of restriction with the ASIS compression test. Stand on the side of the SI restriction facing the patient\u2019s head. Contact the SI joint with the hand that is away from the patient, which will be used to monitor for changes. Use the arm closest to the patient to hold the ipsilateral leg and use it as a long lever to create balanced tension at the SI joint. Internally rotate the femur in the acetabulum to engage the SI joint. Bring the leg into abduction/adduction, flexion/extension, and distraction/compression into the SI joint, noticing which motions soften and create tension at the SI joint. Stack all of the motions that create ease at the SI joint if indirect BLT is being used or all of the motions that create tension if direct BLT is being used, and fine-tune to a point of balanced tension."}
+{"id": "article-102978_21", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Technique or Treatment", "content": "Once the point of balanced tension is found to hold this position until softening under the hand that is contacting the SI joint is felt. Warmth increased motion, or a sensation that less force is needed to hold the joint in its treatment position might also be felt. Once this happens, subtle motions can be used to find the next point of balanced tension. Repeat this process until no further change is appreciated. Reassess with the ASIS compression test. SI Decompression, direct- Supine", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Technique or Treatment. Once the point of balanced tension is found to hold this position until softening under the hand that is contacting the SI joint is felt. Warmth increased motion, or a sensation that less force is needed to hold the joint in its treatment position might also be felt. Once this happens, subtle motions can be used to find the next point of balanced tension. Repeat this process until no further change is appreciated. Reassess with the ASIS compression test. SI Decompression, direct- Supine"}
+{"id": "article-102978_22", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Technique or Treatment", "content": "This technique is applicable in the treatment of SI compression and is performed in a direct manner. Diagnose the side of restriction with the ASIS compression test. With the patient lying supine and the provider seated at the side of SI restriction, the provider contacts the sacrum with the caudad hand, fingers pointing cephalad (typically by positioning the hand between the patient\u2019s legs) in order to provide stability to the sacrum.\u00a0 Following this, the provider\u2019s cephalad hand applies lateral traction to the PSIS on the affected side until a release of the joint is felt. An optional respiratory component may be included in this technique by having the patient inhale and exhale deeply while palpating for motion at the SI joint space and using this respiratory cooperation to encourage the release and balance of the affected ligaments.", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Technique or Treatment. This technique is applicable in the treatment of SI compression and is performed in a direct manner. Diagnose the side of restriction with the ASIS compression test. With the patient lying supine and the provider seated at the side of SI restriction, the provider contacts the sacrum with the caudad hand, fingers pointing cephalad (typically by positioning the hand between the patient\u2019s legs) in order to provide stability to the sacrum.\u00a0 Following this, the provider\u2019s cephalad hand applies lateral traction to the PSIS on the affected side until a release of the joint is felt. An optional respiratory component may be included in this technique by having the patient inhale and exhale deeply while palpating for motion at the SI joint space and using this respiratory cooperation to encourage the release and balance of the affected ligaments."}
+{"id": "article-102978_23", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Technique or Treatment", "content": "A release may be felt as a slight pull of the innominate as the ligaments balance at the SI joint. Often an increase in warmth, softening of the surrounding tissues, and/or an improvement in sacral motion with either primary or secondary respiration may be noticed. An increase in motion at the SI joint is observed upon retest as an increase in mobility with the ASIS compression test. LS Decompression- Prone", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Technique or Treatment. A release may be felt as a slight pull of the innominate as the ligaments balance at the SI joint. Often an increase in warmth, softening of the surrounding tissues, and/or an improvement in sacral motion with either primary or secondary respiration may be noticed. An increase in motion at the SI joint is observed upon retest as an increase in mobility with the ASIS compression test. LS Decompression- Prone"}
+{"id": "article-102978_24", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Technique or Treatment", "content": "The patient is lying prone on the table. Stand on either side of the patient and face the table. Contact the sacrum with the cephalad hand, so the heel of the hand is at the sacral base. Be mindful that the fingertips are not contacting sensitive areas. Cross the other arm over and contact the lower lumbar segments with the caudad hand. Position the caudad hand perpendicular to the cephalad hand, so the hands form the letter \u201cT,\u201d or contact the lower lumbar segments with the palm of the caudad hand, so the fingertips point superiorly. To assess for restriction, have the patient take deep breaths and notice the motion of the sacrum and lumbar spine at the LS junction. With an inhalation, the sacrum should go into counternutation, and the lumbar lordosis should flatten. With an exhalation, the sacrum should go into nutation, and the lumbar lordosis should increase. To treat, keep the arms fairly straight with a slight bend at the elbows, and lean over the patient. The hands will naturally separate from each other and create a distraction at the LS junction. Notice the amount of restriction at the LS junction when distraction is applied at the joint, so the initial finding can be compared to the reassessment at the end. Then induce rotation of the sacrum on the lumbar spine and rotation of the lumbar spine on the sacrum until you find a point of balanced tension. Warmth, softening, increased motion, or a sensation that less force is needed to hold the joint in its treatment position might also be felt. Once this happens, subtle motions can be used to find the next point of balanced tension. Repeat this process until no further change is appreciated. Reassess by repeating your diagnostic assessment.", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Technique or Treatment. The patient is lying prone on the table. Stand on either side of the patient and face the table. Contact the sacrum with the cephalad hand, so the heel of the hand is at the sacral base. Be mindful that the fingertips are not contacting sensitive areas. Cross the other arm over and contact the lower lumbar segments with the caudad hand. Position the caudad hand perpendicular to the cephalad hand, so the hands form the letter \u201cT,\u201d or contact the lower lumbar segments with the palm of the caudad hand, so the fingertips point superiorly. To assess for restriction, have the patient take deep breaths and notice the motion of the sacrum and lumbar spine at the LS junction. With an inhalation, the sacrum should go into counternutation, and the lumbar lordosis should flatten. With an exhalation, the sacrum should go into nutation, and the lumbar lordosis should increase. To treat, keep the arms fairly straight with a slight bend at the elbows, and lean over the patient. The hands will naturally separate from each other and create a distraction at the LS junction. Notice the amount of restriction at the LS junction when distraction is applied at the joint, so the initial finding can be compared to the reassessment at the end. Then induce rotation of the sacrum on the lumbar spine and rotation of the lumbar spine on the sacrum until you find a point of balanced tension. Warmth, softening, increased motion, or a sensation that less force is needed to hold the joint in its treatment position might also be felt. Once this happens, subtle motions can be used to find the next point of balanced tension. Repeat this process until no further change is appreciated. Reassess by repeating your diagnostic assessment."}
+{"id": "article-102978_25", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Technique or Treatment", "content": "LS Decompression- Supine", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Technique or Treatment. LS Decompression- Supine"}
+{"id": "article-102978_26", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Technique or Treatment", "content": "The patient is lying supine on the table. Sit on either side of the patient-facing the patient\u2019s head. Contact the lower lumbar region with the cephalad hand, so the finger pads are on the contralateral paraspinal muscles, and the thenar/hypothenar eminences are on the ipsilateral paraspinal muscles. Have the patient bend one or both knees and lift their pelvis off the table. Position the arm closest to the patient in-between the patient\u2019s legs and contact the sacrum, so the fingertips are at the sacral base, and the hands are perpendicular to each other. Have the patient relax their pelvis back down on the table. They can either keep their knees bent or straighten them out. Keeping the hand and wrist relaxed will help with palpation of the tissues while it is under the weight of the patient and improve provider ergonomics. To assess the motion of the sacrum on the ilia, induce nutation/counternutation on its transverse axes by flexing and extending the wrist and right/left rotation on its vertical axes by pronating and supinating the wrist of the hand that is under the sacrum.", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Technique or Treatment. The patient is lying supine on the table. Sit on either side of the patient-facing the patient\u2019s head. Contact the lower lumbar region with the cephalad hand, so the finger pads are on the contralateral paraspinal muscles, and the thenar/hypothenar eminences are on the ipsilateral paraspinal muscles. Have the patient bend one or both knees and lift their pelvis off the table. Position the arm closest to the patient in-between the patient\u2019s legs and contact the sacrum, so the fingertips are at the sacral base, and the hands are perpendicular to each other. Have the patient relax their pelvis back down on the table. They can either keep their knees bent or straighten them out. Keeping the hand and wrist relaxed will help with palpation of the tissues while it is under the weight of the patient and improve provider ergonomics. To assess the motion of the sacrum on the ilia, induce nutation/counternutation on its transverse axes by flexing and extending the wrist and right/left rotation on its vertical axes by pronating and supinating the wrist of the hand that is under the sacrum."}
+{"id": "article-102978_27", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Technique or Treatment", "content": "To assess the motion of the sacrum with respect to the lumbar spine, induce lumbar rotation by flexing and extending the wrist of the hand that is under the lumbar spine. Assess the motion at the LS junction when the patient takes deep breaths. With an inhalation, the sacrum should go into counternutation, and the lumbar lordosis should flatten. With an exhalation, the sacrum should go into nutation, and the lumbar lordosis should increase. Assess whether adding compression or distraction to the LS junction creates more freedom of motion there. To add compression bring the caudad hand superiorly and the cephalad hand inferiorly. To add distraction, bring the caudad hand inferiorly and the cephalad hand superiorly. To treat, add compression or distraction, induce motion in all the planes tested in the sacrum, and add a rotation of the lumbar spine. Depending on whether direct or indirect BLT is used, the provider will first go into the direction of ease or restriction and then fine-tune to a point of balanced tension. Warmth, softening, increased motion, or a sensation that less force is needed to hold the joint in its treatment position might also be felt. Once this happens, subtle motions can be used to find the next point of balanced tension. Repeat this process until no further change is appreciated. Reassess by repeating your diagnostic assessment.", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Technique or Treatment. To assess the motion of the sacrum with respect to the lumbar spine, induce lumbar rotation by flexing and extending the wrist of the hand that is under the lumbar spine. Assess the motion at the LS junction when the patient takes deep breaths. With an inhalation, the sacrum should go into counternutation, and the lumbar lordosis should flatten. With an exhalation, the sacrum should go into nutation, and the lumbar lordosis should increase. Assess whether adding compression or distraction to the LS junction creates more freedom of motion there. To add compression bring the caudad hand superiorly and the cephalad hand inferiorly. To add distraction, bring the caudad hand inferiorly and the cephalad hand superiorly. To treat, add compression or distraction, induce motion in all the planes tested in the sacrum, and add a rotation of the lumbar spine. Depending on whether direct or indirect BLT is used, the provider will first go into the direction of ease or restriction and then fine-tune to a point of balanced tension. Warmth, softening, increased motion, or a sensation that less force is needed to hold the joint in its treatment position might also be felt. Once this happens, subtle motions can be used to find the next point of balanced tension. Repeat this process until no further change is appreciated. Reassess by repeating your diagnostic assessment."}
+{"id": "article-102978_28", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Complications", "content": "While BLT is one of the safest techniques, patients may still experience soreness for several days following treatment and are advised to drink plenty of water after the treatment to prevent or minimize soreness.", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Complications. While BLT is one of the safest techniques, patients may still experience soreness for several days following treatment and are advised to drink plenty of water after the treatment to prevent or minimize soreness."}
+{"id": "article-102978_29", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Clinical Significance", "content": "The philosophy of osteopathic medicine is to treat the patient as a whole. The answer to the question of when OMT should be used on the pelvis can be addressed when somatic dysfunction is found on an osteopathic structural exam and when treatment would benefit the patient. While BLT is one of many osteopathic treatment modalities, the decision to use one modality over another comes down to provider preference and the responsiveness of the patient\u2019s tissues. Here are a couple of specific examples of how OMT for pelvic dysfunction can be applied.", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Clinical Significance. The philosophy of osteopathic medicine is to treat the patient as a whole. The answer to the question of when OMT should be used on the pelvis can be addressed when somatic dysfunction is found on an osteopathic structural exam and when treatment would benefit the patient. While BLT is one of many osteopathic treatment modalities, the decision to use one modality over another comes down to provider preference and the responsiveness of the patient\u2019s tissues. Here are a couple of specific examples of how OMT for pelvic dysfunction can be applied."}
+{"id": "article-102978_30", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Clinical Significance", "content": "The pregnant patient:\u00a0There are many physiologic and biomechanical changes that happen to the body during pregnancy. These changes can lead to symptoms, including back pain, pelvic pain, stiffness, and lower extremity edema that have a large impact on a person\u2019s ability to function in daily life. Many medications normally prescribed to address these symptoms are not recommended during pregnancy, and osteopathic manipulative treatment is a nonpharmacologic option for pregnant patients looking for relief. In the Pregnancy Research on Osteopathic Manipulation Optimizing Treatment Effects (PROMOTE) study, there was not a higher conversion rate to high-risk status in third-trimester patients in the OMT group indicating that OMT is safe for this patient population. In addition to the pelvic region (pelvic diaphragm, innominate, and sacrum), attention should also be given to the occipitoatlantal joint, cervical vertebrae, clavicles, and Sibson fascia, thoracoabdominal diaphragm, ribs, hips, and cranium during the assessment and treatment with OMT in the pregnant patient. [6]", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Clinical Significance. The pregnant patient:\u00a0There are many physiologic and biomechanical changes that happen to the body during pregnancy. These changes can lead to symptoms, including back pain, pelvic pain, stiffness, and lower extremity edema that have a large impact on a person\u2019s ability to function in daily life. Many medications normally prescribed to address these symptoms are not recommended during pregnancy, and osteopathic manipulative treatment is a nonpharmacologic option for pregnant patients looking for relief. In the Pregnancy Research on Osteopathic Manipulation Optimizing Treatment Effects (PROMOTE) study, there was not a higher conversion rate to high-risk status in third-trimester patients in the OMT group indicating that OMT is safe for this patient population. In addition to the pelvic region (pelvic diaphragm, innominate, and sacrum), attention should also be given to the occipitoatlantal joint, cervical vertebrae, clavicles, and Sibson fascia, thoracoabdominal diaphragm, ribs, hips, and cranium during the assessment and treatment with OMT in the pregnant patient. [6]"}
+{"id": "article-102978_31", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Clinical Significance", "content": "The hospitalized patient: BLT is a useful modality in treating the hospitalized patient because active participation of the patient in the treatment is not required, and it can be adapted to use in any part of the body while the patient is supine. The Multicenter Osteopathic Pneumonia Study in the Elderly (MOPSE) randomized controlled trial showed shortened length-of-stay and decreased in-hospital mortality rates in certain subgroups, which supports the role of OMT as an adjunctive treatment to standard of care in patients hospitalized with pneumonia. [7]", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Clinical Significance. The hospitalized patient: BLT is a useful modality in treating the hospitalized patient because active participation of the patient in the treatment is not required, and it can be adapted to use in any part of the body while the patient is supine. The Multicenter Osteopathic Pneumonia Study in the Elderly (MOPSE) randomized controlled trial showed shortened length-of-stay and decreased in-hospital mortality rates in certain subgroups, which supports the role of OMT as an adjunctive treatment to standard of care in patients hospitalized with pneumonia. [7]"}
+{"id": "article-102978_32", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Clinical Significance", "content": "Another study looking at the effects of OMT on hospital length-of-stay and incidence of postoperative ileus in general surgical patients showed that OMT decreased time to flatus and decreased length-of-stay. [8] The anatomy that is targeted with OMT in the pelvis can be thought of in terms of autonomics, biomechanics, and circulation. Autonomic tone can be modulated through manipulation of the sacrum. The pelvic splanchnic nerves arise from S2-S4 nerve roots and carry afferent parasympathetic nerve fibers to the distal end of the transverse colon, descending colon, sigmoid colon, rectum, cervix, and upper vagina. [9]", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Clinical Significance. Another study looking at the effects of OMT on hospital length-of-stay and incidence of postoperative ileus in general surgical patients showed that OMT decreased time to flatus and decreased length-of-stay. [8] The anatomy that is targeted with OMT in the pelvis can be thought of in terms of autonomics, biomechanics, and circulation. Autonomic tone can be modulated through manipulation of the sacrum. The pelvic splanchnic nerves arise from S2-S4 nerve roots and carry afferent parasympathetic nerve fibers to the distal end of the transverse colon, descending colon, sigmoid colon, rectum, cervix, and upper vagina. [9]"}
+{"id": "article-102978_33", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Clinical Significance", "content": "Targeting the parasympathetic fibers innervating the colon could be useful in the postsurgical patient in trying to encourage the return of normal bowel function. Treating dysfunction at the lumbosacral junction and the sacroiliac joints could restore mobility and help in the process of getting the patient out of bed and walking again. Treatment of restriction in the pelvic diaphragm, which is recognized as a muscle of respiration, opens up the pathway for lymphatic and venous return and decreases any congestion in the area. A goal in treating a hospitalized patient with OMT is to help decrease the patient\u2019s allostatic load by correcting somatic dysfunction so that they put more of their body\u2019s energy towards healing.", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Clinical Significance. Targeting the parasympathetic fibers innervating the colon could be useful in the postsurgical patient in trying to encourage the return of normal bowel function. Treating dysfunction at the lumbosacral junction and the sacroiliac joints could restore mobility and help in the process of getting the patient out of bed and walking again. Treatment of restriction in the pelvic diaphragm, which is recognized as a muscle of respiration, opens up the pathway for lymphatic and venous return and decreases any congestion in the area. A goal in treating a hospitalized patient with OMT is to help decrease the patient\u2019s allostatic load by correcting somatic dysfunction so that they put more of their body\u2019s energy towards healing."}
+{"id": "article-102978_34", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Enhancing Healthcare Team Outcomes", "content": "The effectiveness of BLT primarily stems from an in-tune palpatory sense on the part of the provider. Since this is developed through hands-on practice, it is important that as a provider, one continues to hone these skills through repetition, as this will result in the highest likelihood of correctly diagnosing and treating patients with this particular modality. Practitioners are encouraged to attend workshops and meetings where they can further develop not only their palpatory skills with BLT but also many other treatment modalities within osteopathic manipulative medicine. Proper application of this technique can be very beneficial to nearly all patients as it is a gentle and very tolerable approach for even the most vulnerable patient populations. Further research into the efficacy of BLT in the treatment of ligamentous somatic dysfunctions could shed light on novel uses for this effective modality in the field of osteopathic manipulative treatment.", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Enhancing Healthcare Team Outcomes. The effectiveness of BLT primarily stems from an in-tune palpatory sense on the part of the provider. Since this is developed through hands-on practice, it is important that as a provider, one continues to hone these skills through repetition, as this will result in the highest likelihood of correctly diagnosing and treating patients with this particular modality. Practitioners are encouraged to attend workshops and meetings where they can further develop not only their palpatory skills with BLT but also many other treatment modalities within osteopathic manipulative medicine. Proper application of this technique can be very beneficial to nearly all patients as it is a gentle and very tolerable approach for even the most vulnerable patient populations. Further research into the efficacy of BLT in the treatment of ligamentous somatic dysfunctions could shed light on novel uses for this effective modality in the field of osteopathic manipulative treatment."}
+{"id": "article-102978_35", "title": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Osteopathic Manipulative Treatment: BLT/LAS Procedure - Pelvic Dysfunctions -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

statpearls/chunk/article-102980.jsonl

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+{"id": "article-102980_0", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Continuing Education Activity", "content": "Acromioclavicular (AC) and sternoclavicular (SC) joint injuries are most commonly seen in a contact sport setting (such as football, rugby, and ice hockey) or traumatic setting. The severity of these injuries can vary, the worst of which require surgical intervention. For those that do not require surgery, osteopathic manipulative treatment (such as muscle-energy) is a valuable option in the treatment of these injuries. This activity reviews the evaluation and treatment procedure of the AC and SC joints with muscle energy. It highlights the role of the healthcare team in treating patients with these injuries.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Continuing Education Activity. Acromioclavicular (AC) and sternoclavicular (SC) joint injuries are most commonly seen in a contact sport setting (such as football, rugby, and ice hockey) or traumatic setting. The severity of these injuries can vary, the worst of which require surgical intervention. For those that do not require surgery, osteopathic manipulative treatment (such as muscle-energy) is a valuable option in the treatment of these injuries. This activity reviews the evaluation and treatment procedure of the AC and SC joints with muscle energy. It highlights the role of the healthcare team in treating patients with these injuries."}
+{"id": "article-102980_1", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Continuing Education Activity", "content": "Objectives: Review the anatomy of the AC and SC joints. Describe the diagnostic steps to identify somatic dysfunctions of the AC and SC joints. Summarize the muscle energy procedure, along with its indications and contraindications, for the AC and SC joint. Outline the importance of communication amongst the interprofessional team to improve outcomes for patients receiving muscle energy treatment for the AC and SC joints. Access free multiple choice questions on this topic.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Continuing Education Activity. Objectives: Review the anatomy of the AC and SC joints. Describe the diagnostic steps to identify somatic dysfunctions of the AC and SC joints. Summarize the muscle energy procedure, along with its indications and contraindications, for the AC and SC joint. Outline the importance of communication amongst the interprofessional team to improve outcomes for patients receiving muscle energy treatment for the AC and SC joints. Access free multiple choice questions on this topic."}
+{"id": "article-102980_2", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Introduction", "content": "Acromioclavicular (AC) joint injuries are one of the more common injuries of the shoulder. A recent study by Nordin et al. found that AC Joint injuries have an incidence of 2 in every 10,000 people ages 18\u00a0to 75. Most of these injuries are in young men, with more severe AC joint injuries occurring in the elderly population. [1] AC joint injury severity is assessed radiographically. Images and patient characteristics provide indications for surgery. Damage to surrounding structures such as the AC ligament, coracoclavicular ligament, and muscle stabilizers of the shoulder are indicators of more severe damage to the AC Joint. [2]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Introduction. Acromioclavicular (AC) joint injuries are one of the more common injuries of the shoulder. A recent study by Nordin et al. found that AC Joint injuries have an incidence of 2 in every 10,000 people ages 18\u00a0to 75. Most of these injuries are in young men, with more severe AC joint injuries occurring in the elderly population. [1] AC joint injury severity is assessed radiographically. Images and patient characteristics provide indications for surgery. Damage to surrounding structures such as the AC ligament, coracoclavicular ligament, and muscle stabilizers of the shoulder are indicators of more severe damage to the AC Joint. [2]"}
+{"id": "article-102980_3", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Introduction", "content": "The Tossy and Rockwood classifications are two of the most commonly used radiographic systems in the evaluation of AC joint injury severity. Tossy has three categories: AC sprain, AC subluxation, and AC dislocation. [3] Rockwood has six more specific categories: Damage to AC ligament (I), rupture of AC ligament and damage to coracoclavicular ligament (II), rupture of both AC and Coracoclavicular ligament (III), posterior dislocation of AC joint (IV), high-grade superior dislocation with rupture of dynamic stabilization mechanism (V), and inferior dislocations of AC joint (VI). [2] Non-surgical treatments are recommended for types I and II, and surgery is indicated for types IV and VI. There is controversy surrounding the surgical vs. non-surgical approach in types III and V. [4]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Introduction. The Tossy and Rockwood classifications are two of the most commonly used radiographic systems in the evaluation of AC joint injury severity. Tossy has three categories: AC sprain, AC subluxation, and AC dislocation. [3] Rockwood has six more specific categories: Damage to AC ligament (I), rupture of AC ligament and damage to coracoclavicular ligament (II), rupture of both AC and Coracoclavicular ligament (III), posterior dislocation of AC joint (IV), high-grade superior dislocation with rupture of dynamic stabilization mechanism (V), and inferior dislocations of AC joint (VI). [2] Non-surgical treatments are recommended for types I and II, and surgery is indicated for types IV and VI. There is controversy surrounding the surgical vs. non-surgical approach in types III and V. [4]"}
+{"id": "article-102980_4", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Introduction", "content": "The sternoclavicular (SC) joint has its own variety of ligamentous injuries, similar to that of the AC joint. However, its anatomical position of dislocations is either anterior or posterior. Anterior dislocation can often be resolved with closed reduction versus posterior dislocation, which may need open reduction and is more severe due to the critical anatomy residing posterior to the clavicle. [5] Injury to the SC joint is much less common. One retrospective study found an incidence of just 0.9% of all shoulder girdle injuries seen at a level 1 trauma center over 19 years. [6]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Introduction. The sternoclavicular (SC) joint has its own variety of ligamentous injuries, similar to that of the AC joint. However, its anatomical position of dislocations is either anterior or posterior. Anterior dislocation can often be resolved with closed reduction versus posterior dislocation, which may need open reduction and is more severe due to the critical anatomy residing posterior to the clavicle. [5] Injury to the SC joint is much less common. One retrospective study found an incidence of just 0.9% of all shoulder girdle injuries seen at a level 1 trauma center over 19 years. [6]"}
+{"id": "article-102980_5", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Introduction", "content": "This review aims to look at the non-surgical treatment of AC and SC joint injuries. Specifically, muscle energy techniques that are utilized in osteopathic manipulative treatment. Muscle energy is a technique typically used to treat hypertonic muscles and restricted joints. It applies to structures throughout the body, especially the AC and SC joints. The isometric variation of the muscle energy technique is most commonly used, and includes the following steps [7] : Localization of the restrictive barrier of the muscle/joint under evaluation The patient actively contracts muscle/joint in a specific direction for a specific amount of time (usually 3 to 5 seconds) Counterforce is being applied by the provider during this 3\u00a0to 5-second interval. The patient relaxes after this 3\u00a0to 5-second interval. The provider takes the muscle/joint being treated further into the restrictive barrier. Steps #2\u00a0through 5 are repeated (typically done 3 to 5 times total)", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Introduction. This review aims to look at the non-surgical treatment of AC and SC joint injuries. Specifically, muscle energy techniques that are utilized in osteopathic manipulative treatment. Muscle energy is a technique typically used to treat hypertonic muscles and restricted joints. It applies to structures throughout the body, especially the AC and SC joints. The isometric variation of the muscle energy technique is most commonly used, and includes the following steps [7] : Localization of the restrictive barrier of the muscle/joint under evaluation The patient actively contracts muscle/joint in a specific direction for a specific amount of time (usually 3 to 5 seconds) Counterforce is being applied by the provider during this 3\u00a0to 5-second interval. The patient relaxes after this 3\u00a0to 5-second interval. The provider takes the muscle/joint being treated further into the restrictive barrier. Steps #2\u00a0through 5 are repeated (typically done 3 to 5 times total)"}
+{"id": "article-102980_6", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Anatomy and Physiology", "content": "The AC joint is just one of the complex structures that makes up the shoulder girdle. The acromion, which originates from the spine of the scapula, meets with the lateral aspect of the clavicle to form the AC joint.\u00a0The clavicle and the acromion of the scapula have a flat articular surface, with an oval contour; the clavicular facet turns outwards and downwards, the acromial facet looks medially and upwards. Between the articular surfaces, there is a fibrocartilaginous disc with variable development; it is rarely complete. It is stabilized with the deltoid and trapezius muscles, as well as the AC ligament and coracoclavicular ligaments. The coracoclavicular ligament consists of the conoid and trapezoid ligaments, which provides vertical stability, whereas the AC ligament provides horizontal stability. [8]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Anatomy and Physiology. The AC joint is just one of the complex structures that makes up the shoulder girdle. The acromion, which originates from the spine of the scapula, meets with the lateral aspect of the clavicle to form the AC joint.\u00a0The clavicle and the acromion of the scapula have a flat articular surface, with an oval contour; the clavicular facet turns outwards and downwards, the acromial facet looks medially and upwards. Between the articular surfaces, there is a fibrocartilaginous disc with variable development; it is rarely complete. It is stabilized with the deltoid and trapezius muscles, as well as the AC ligament and coracoclavicular ligaments. The coracoclavicular ligament consists of the conoid and trapezoid ligaments, which provides vertical stability, whereas the AC ligament provides horizontal stability. [8]"}
+{"id": "article-102980_7", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Anatomy and Physiology", "content": "The AC joint is a synovial joint (arthrodial joint) that only allows gliding motion. It assists in abduction and flexion of the shoulder. The AC joint receives blood supply from the suprascapular and thoracoacromial arteries, along with innervation from the suprascapular, axillary, and lateral thoracic nerves. [9] The acromioclavicular joint comes into play, simultaneously with the sternoclavicular joint and within the entire joint mechanism of the thoracic belt, to allow sliding movements through which the scapula changes its relationship with the chest. As a result of these behaviors of the scapula, the glenoid cavity is oriented to allow wider freedom of movement to the arm. In the mechanics of the acromioclavicular joint, the trapezoid and conoid ligaments, stretched between the coracoid process and the external third of the clavicle, is of great importance. They release the acromioclavicular joint of part of the weight exerted by the upper limb and, by limiting the motility of the joint itself, they help to fix the scapula.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Anatomy and Physiology. The AC joint is a synovial joint (arthrodial joint) that only allows gliding motion. It assists in abduction and flexion of the shoulder. The AC joint receives blood supply from the suprascapular and thoracoacromial arteries, along with innervation from the suprascapular, axillary, and lateral thoracic nerves. [9] The acromioclavicular joint comes into play, simultaneously with the sternoclavicular joint and within the entire joint mechanism of the thoracic belt, to allow sliding movements through which the scapula changes its relationship with the chest. As a result of these behaviors of the scapula, the glenoid cavity is oriented to allow wider freedom of movement to the arm. In the mechanics of the acromioclavicular joint, the trapezoid and conoid ligaments, stretched between the coracoid process and the external third of the clavicle, is of great importance. They release the acromioclavicular joint of part of the weight exerted by the upper limb and, by limiting the motility of the joint itself, they help to fix the scapula."}
+{"id": "article-102980_8", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Anatomy and Physiology", "content": "The SC joint is also a synovial joint that articulates with the manubrium of the sternum and the first costal cartilage. The SC joint is tough to injure due to the amount of stabilizing structures that surrounds it. These include the anterior and posterior sternoclavicular ligaments, interclavicular ligaments, costoclavicular ligaments, as well as the subclavius muscle. The SC joint is diarthrodial (saddle-shaped), and communication from the shoulder can dictate its movement. The SC joint functionally allows for motion of the shoulder in various planes, including horizontal, coronal, and anteroposterior planes. Blood supply to\u00a0this joint comes from the internal thoracic and suprascapular arteries, and it receives innervation from the medial supraclavicular and subclavius nerves. As mentioned, posterior dislocations of the SC joint can result in significant complications due to the crucial anatomy posterior to this joint. Structures such as the brachiocephalic trunk, internal jugular vein, common carotid artery, trachea, esophagus, and vagus nerve are all vulnerable to a posteriorly dislocated SC joint. [10]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Anatomy and Physiology. The SC joint is also a synovial joint that articulates with the manubrium of the sternum and the first costal cartilage. The SC joint is tough to injure due to the amount of stabilizing structures that surrounds it. These include the anterior and posterior sternoclavicular ligaments, interclavicular ligaments, costoclavicular ligaments, as well as the subclavius muscle. The SC joint is diarthrodial (saddle-shaped), and communication from the shoulder can dictate its movement. The SC joint functionally allows for motion of the shoulder in various planes, including horizontal, coronal, and anteroposterior planes. Blood supply to\u00a0this joint comes from the internal thoracic and suprascapular arteries, and it receives innervation from the medial supraclavicular and subclavius nerves. As mentioned, posterior dislocations of the SC joint can result in significant complications due to the crucial anatomy posterior to this joint. Structures such as the brachiocephalic trunk, internal jugular vein, common carotid artery, trachea, esophagus, and vagus nerve are all vulnerable to a posteriorly dislocated SC joint. [10]"}
+{"id": "article-102980_9", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Anatomy and Physiology", "content": "The physiology underlying the muscle energy technique is not fully understood. It appears to be due to neurophysiologic responses that cause inhibition of neural responses allowing muscular relaxation, as well as an alteration in pain modulation. [11]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Anatomy and Physiology. The physiology underlying the muscle energy technique is not fully understood. It appears to be due to neurophysiologic responses that cause inhibition of neural responses allowing muscular relaxation, as well as an alteration in pain modulation. [11]"}
+{"id": "article-102980_10", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Indications", "content": "Muscle energy techniques (METs) are attributed to an American osteopath, Fred Mitchell Senior. Employing complex neurological mechanisms, including the neuromuscular spindles and the Golgi tendon organs, following guided muscle contractions, a shortened muscle can be stretched until it reaches a new resting length.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Indications. Muscle energy techniques (METs) are attributed to an American osteopath, Fred Mitchell Senior. Employing complex neurological mechanisms, including the neuromuscular spindles and the Golgi tendon organs, following guided muscle contractions, a shortened muscle can be stretched until it reaches a new resting length."}
+{"id": "article-102980_11", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Indications", "content": "METs represent a manual treatment modality that involves the voluntary contraction of some muscles of the patient in a very precise direction, with different levels of intensity, carried out towards a counterforce exerted specifically by the operator.These techniques classify as active or direct techniques. Isometric and concentric isotonic contraction can be used in three different ways on the dysfunction: Isometric contraction opposed to the restriction. Isometric contraction towards the restriction Concentric isotonic contraction towards restriction Indications: Hypertonic\u00a0muscles Somatic dysfunction of muscle or joint Limited ROM of joint To decrease localized edema and reduce congestion (pumping of the venous and lymphatic systems)", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Indications. METs represent a manual treatment modality that involves the voluntary contraction of some muscles of the patient in a very precise direction, with different levels of intensity, carried out towards a counterforce exerted specifically by the operator.These techniques classify as active or direct techniques. Isometric and concentric isotonic contraction can be used in three different ways on the dysfunction: Isometric contraction opposed to the restriction. Isometric contraction towards the restriction Concentric isotonic contraction towards restriction Indications: Hypertonic\u00a0muscles Somatic dysfunction of muscle or joint Limited ROM of joint To decrease localized edema and reduce congestion (pumping of the venous and lymphatic systems)"}
+{"id": "article-102980_12", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Contraindications", "content": "Muscle energy is a very safe technique, and it can be utilized outside of medical emergencies or very severe injuries (such as the following examples): Broken bone Ruptured ligament/tendon/muscle Joint infection No somatic dysfunction present Patient\u00a0refusal", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Contraindications. Muscle energy is a very safe technique, and it can be utilized outside of medical emergencies or very severe injuries (such as the following examples): Broken bone Ruptured ligament/tendon/muscle Joint infection No somatic dysfunction present Patient\u00a0refusal"}
+{"id": "article-102980_13", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Equipment", "content": "Osteopathic manipulative treatment table Stool", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Equipment. Osteopathic manipulative treatment table Stool"}
+{"id": "article-102980_14", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Preparation", "content": "Evaluating the AC and SC joints is critical before beginning treatment. Visual assessment (bruising, erythema, edema), pain scale, the strength of surrounding musculature, and range of motion of the AC and SC joints should all be accounted for both before and after treatment. The following\u00a0will\u00a0explore two somatic dysfunctions\u00a0of the AC joint in this review that are treatable with muscle energy: Internally rotated AC joint, or Externally rotated AC joint", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Preparation. Evaluating the AC and SC joints is critical before beginning treatment. Visual assessment (bruising, erythema, edema), pain scale, the strength of surrounding musculature, and range of motion of the AC and SC joints should all be accounted for both before and after treatment. The following\u00a0will\u00a0explore two somatic dysfunctions\u00a0of the AC joint in this review that are treatable with muscle energy: Internally rotated AC joint, or Externally rotated AC joint"}
+{"id": "article-102980_15", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Preparation", "content": "Palpation of the AC joint can be done by \"walking\" on hand down the spine of the scapula to the acromion, while the other hand travels down the clavicle laterally. Where these two points meet will be the AC joint. Let the patient's arm hang by there side in sight abduction of the shoulder with minimal flexion of the elbow. With the patient in this position, palpate the AC joint with one hand, and manipulate their shoulder into internal rotation, followed by external rotation. We compare this movement of the AC joint bilaterally. The somatic dysfunction is named the\u00a0opposite of the restriction. For example, if the range of motion of the left and right AC joint is normal in internal rotation B/L, but the AC joint on the right\u00a0has a restriction in the external rotation when compared to the left. The right AC joint is said to be internally rotated. One could also look at naming the somatic dysfunction as where the joint is \"living.\" For example, if a patient has a left externally rotated AC joint, this means the AC joint allows for external rotation (AKA \"living\" in external rotation) and shows restriction in left internal rotation (when compared to the right AC joint).", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Preparation. Palpation of the AC joint can be done by \"walking\" on hand down the spine of the scapula to the acromion, while the other hand travels down the clavicle laterally. Where these two points meet will be the AC joint. Let the patient's arm hang by there side in sight abduction of the shoulder with minimal flexion of the elbow. With the patient in this position, palpate the AC joint with one hand, and manipulate their shoulder into internal rotation, followed by external rotation. We compare this movement of the AC joint bilaterally. The somatic dysfunction is named the\u00a0opposite of the restriction. For example, if the range of motion of the left and right AC joint is normal in internal rotation B/L, but the AC joint on the right\u00a0has a restriction in the external rotation when compared to the left. The right AC joint is said to be internally rotated. One could also look at naming the somatic dysfunction as where the joint is \"living.\" For example, if a patient has a left externally rotated AC joint, this means the AC joint allows for external rotation (AKA \"living\" in external rotation) and shows restriction in left internal rotation (when compared to the right AC joint)."}
+{"id": "article-102980_16", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Preparation", "content": "For the SC joint,\u00a0this text will\u00a0also explore two possible somatic dysfunctions: Adducted clavicle Horizontally extended clavicle", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Preparation. For the SC joint,\u00a0this text will\u00a0also explore two possible somatic dysfunctions: Adducted clavicle Horizontally extended clavicle"}
+{"id": "article-102980_17", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Preparation", "content": "Before getting into the evaluation of somatic dysfunction, it is imperative to understand the relationship between the shoulder and clavicle. The position of the clavicle is named for\u00a0the movement at the lateral aspect of the clavicle! Abduction of the shoulders causes the medial edge of the clavicle (closest to SC joint) to drop inferior, and the lateral edge to rise superior (as if it is abducting with the shoulder).", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Preparation. Before getting into the evaluation of somatic dysfunction, it is imperative to understand the relationship between the shoulder and clavicle. The position of the clavicle is named for\u00a0the movement at the lateral aspect of the clavicle! Abduction of the shoulders causes the medial edge of the clavicle (closest to SC joint) to drop inferior, and the lateral edge to rise superior (as if it is abducting with the shoulder)."}
+{"id": "article-102980_18", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Preparation", "content": "You can also think of the clavicle and its movement as a see-saw. Flexion of the shoulder brings the arm anterior, and we would say the lateral edge of the clavicle travels anterior (horizontal flexion) with it, and the medial edge travels posterior. As we extend the shoulder, the arm moves posterior, and the lateral edge of the clavicle also travels posterior (horizontal extension), while the medial portion of the clavicle travels anteriorly.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Preparation. You can also think of the clavicle and its movement as a see-saw. Flexion of the shoulder brings the arm anterior, and we would say the lateral edge of the clavicle travels anterior (horizontal flexion) with it, and the medial edge travels posterior. As we extend the shoulder, the arm moves posterior, and the lateral edge of the clavicle also travels posterior (horizontal extension), while the medial portion of the clavicle travels anteriorly."}
+{"id": "article-102980_19", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Preparation", "content": "The SC joint can be palpated by following the clavicle medially with one hand and traveling laterally off the manubrium with the other. Evaluation of this joint is best with the patient in the supine position. To evaluate for an\u00a0adducted clavicle:", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Preparation. The SC joint can be palpated by following the clavicle medially with one hand and traveling laterally off the manubrium with the other. Evaluation of this joint is best with the patient in the supine position. To evaluate for an\u00a0adducted clavicle:"}
+{"id": "article-102980_20", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Preparation", "content": "The provider should be at the head of the table, with the index finger on the superior portion of the SC joint. The patient (lying supine) will be instructed to shrug both shoulders to their ears simultaneously (this imitates the abduction of the shoulder) The provider will compare the SC joints at the peak of this shoulder shrug: whichever SC joint drops least inferior (or stays more cephalad in terms of the supine patient), is the adducted clavicle. To evaluate for a\u00a0horizontally extended clavicle: The provider\u00a0should be at the head of the table, with index fingers on the anterior portion of the SC joint. The patient (supine) is instructed to slowly move their shoulders into flexion. The provider compares the posterior movement at the SC joint, whichever SC joint does\u00a0NOT drop posteriorly is said to be a horizontally extended clavicle.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Preparation. The provider should be at the head of the table, with the index finger on the superior portion of the SC joint. The patient (lying supine) will be instructed to shrug both shoulders to their ears simultaneously (this imitates the abduction of the shoulder) The provider will compare the SC joints at the peak of this shoulder shrug: whichever SC joint drops least inferior (or stays more cephalad in terms of the supine patient), is the adducted clavicle. To evaluate for a\u00a0horizontally extended clavicle: The provider\u00a0should be at the head of the table, with index fingers on the anterior portion of the SC joint. The patient (supine) is instructed to slowly move their shoulders into flexion. The provider compares the posterior movement at the SC joint, whichever SC joint does\u00a0NOT drop posteriorly is said to be a horizontally extended clavicle."}
+{"id": "article-102980_21", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Technique or Treatment -- Muscle Energy Technique for an Internally Rotated AC Joint:", "content": "Have the patient in a seated position, with the arm in slight abduction and elbow slightly flexed While one hand monitors AC joint, use the other to \"shake hands\" with the patient and guide the AC joint into external rotation until the restrictive barrier is met The patient internally rotates their shoulder against isometric resistance from the provider for 3\u00a0to 5 seconds. The\u00a0provider instructs the patient to relax and takes shoulder further into the restrictive barrier (thus, further into external rotation) Repeat steps 3\u00a0and 4 multiple times (typically 3\u00a0to 5 times) Muscle Energy Technique for an Adducted Clavicle :", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Technique or Treatment -- Muscle Energy Technique for an Internally Rotated AC Joint:. Have the patient in a seated position, with the arm in slight abduction and elbow slightly flexed While one hand monitors AC joint, use the other to \"shake hands\" with the patient and guide the AC joint into external rotation until the restrictive barrier is met The patient internally rotates their shoulder against isometric resistance from the provider for 3\u00a0to 5 seconds. The\u00a0provider instructs the patient to relax and takes shoulder further into the restrictive barrier (thus, further into external rotation) Repeat steps 3\u00a0and 4 multiple times (typically 3\u00a0to 5 times) Muscle Energy Technique for an Adducted Clavicle :"}
+{"id": "article-102980_22", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Technique or Treatment", "content": "Provider standing on the side of the table/patient (on the side of the adducted clavicle) and facing cephalad relative to the patient The patient abducts arm on the side of dysfunction to 90 degrees with the thumb facing down. The provider positions his/her thigh against the patient's abducted arm. The hand closest to the patient contacts the superior part of the SC joint. Patient instructed to push arm into the provider's thigh, while the provider isometrically resists (for 3\u00a0to 5 seconds) The provider instructs the patient to relax. The provider abducts the shoulder further to the restrictive barrier while maintaining an inferior force on the SC joint. Repeat steps 4\u00a0to 6 multiple times (typically 3\u00a0to 5 times) Recheck", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Technique or Treatment. Provider standing on the side of the table/patient (on the side of the adducted clavicle) and facing cephalad relative to the patient The patient abducts arm on the side of dysfunction to 90 degrees with the thumb facing down. The provider positions his/her thigh against the patient's abducted arm. The hand closest to the patient contacts the superior part of the SC joint. Patient instructed to push arm into the provider's thigh, while the provider isometrically resists (for 3\u00a0to 5 seconds) The provider instructs the patient to relax. The provider abducts the shoulder further to the restrictive barrier while maintaining an inferior force on the SC joint. Repeat steps 4\u00a0to 6 multiple times (typically 3\u00a0to 5 times) Recheck"}
+{"id": "article-102980_23", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Technique or Treatment -- Muscle Energy Technique for a Horizontally Extended Clavicle:", "content": "Provider standing on the side of the table/patient (opposite the side of the dysfunction) Provider contacts the anterior surface of the dysfunctional SC joint with the palm of the hand Instruct patient to bring the hand to the ceiling (flexion of the shoulder) and wrap an arm around the provider's trapezius area The provider should then contact the scapular region with their free-hand. The patient is instructed to try to bring scapula down towards the table, while the provider resists (for 3 to 5 seconds) The provider instructs the patient to relax. While relaxed, provider further pushes SC joint posterior while simultaneously bringing the patient's shoulder/scapula region anterior Repeat steps 5\u00a0to 7 multiple times (typically 3\u00a0to 5 times) Recheck", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Technique or Treatment -- Muscle Energy Technique for a Horizontally Extended Clavicle:. Provider standing on the side of the table/patient (opposite the side of the dysfunction) Provider contacts the anterior surface of the dysfunctional SC joint with the palm of the hand Instruct patient to bring the hand to the ceiling (flexion of the shoulder) and wrap an arm around the provider's trapezius area The provider should then contact the scapular region with their free-hand. The patient is instructed to try to bring scapula down towards the table, while the provider resists (for 3 to 5 seconds) The provider instructs the patient to relax. While relaxed, provider further pushes SC joint posterior while simultaneously bringing the patient's shoulder/scapula region anterior Repeat steps 5\u00a0to 7 multiple times (typically 3\u00a0to 5 times) Recheck"}
+{"id": "article-102980_24", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Complications", "content": "As one study states, significant adverse events are not well described or correlated with manual therapy use. For instance, there is no correlation to a musculoskeletal treatment with resulting gastrointestinal complications that we are aware of, although they rarely\u00a0coincidentally occur. However, minor adverse events that require little to no follow-up are known to occur with manual therapy, such as headache, muscle soreness, and light-headedness. [12] Patients should refrain from strenuous activity\u00a0after treatment and drink ample amounts of water.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Complications. As one study states, significant adverse events are not well described or correlated with manual therapy use. For instance, there is no correlation to a musculoskeletal treatment with resulting gastrointestinal complications that we are aware of, although they rarely\u00a0coincidentally occur. However, minor adverse events that require little to no follow-up are known to occur with manual therapy, such as headache, muscle soreness, and light-headedness. [12] Patients should refrain from strenuous activity\u00a0after treatment and drink ample amounts of water."}
+{"id": "article-102980_25", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Clinical Significance", "content": "Osteopathic manipulative treatment is an underutilized non-surgical alternative that can provide significant benefits to patients with somatic dysfunctions of the AC and SC Joints. As mentioned before, non-surgical approaches are best for AC injuries type I and II, and there is still dispute over types III and V. All non-surgical approaches should be exhausted prior to surgery, and muscle energy is a viable option to treat these non-surgical injuries while benefiting\u00a0the surrounding stabilizing\u00a0structures as well.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Clinical Significance. Osteopathic manipulative treatment is an underutilized non-surgical alternative that can provide significant benefits to patients with somatic dysfunctions of the AC and SC Joints. As mentioned before, non-surgical approaches are best for AC injuries type I and II, and there is still dispute over types III and V. All non-surgical approaches should be exhausted prior to surgery, and muscle energy is a viable option to treat these non-surgical injuries while benefiting\u00a0the surrounding stabilizing\u00a0structures as well."}
+{"id": "article-102980_26", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Enhancing Healthcare Team Outcomes", "content": "Interprofessional communication is something that lacks in terms of osteopathic manipulative treatment. As an osteopathic treatment, only DOs are familiar with the process (unless an MD has taken a separate course). With a large number of patient\u00a0complaints stemming from the musculoskeletal origin, we need to educate physicians and mid-level practitioners about osteopathic manipulative treatment so patients can be directed to the proper physician to enhance patient care. [Level 5]", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Enhancing Healthcare Team Outcomes. Interprofessional communication is something that lacks in terms of osteopathic manipulative treatment. As an osteopathic treatment, only DOs are familiar with the process (unless an MD has taken a separate course). With a large number of patient\u00a0complaints stemming from the musculoskeletal origin, we need to educate physicians and mid-level practitioners about osteopathic manipulative treatment so patients can be directed to the proper physician to enhance patient care. [Level 5]"}
+{"id": "article-102980_27", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Nursing, Allied Health, and Interprofessional Team Interventions", "content": "Interprofessional education of osteopathic manipulative treatment and awareness of which physicians in their area utilize this treatment modality is critical. These are simple techniques that can be taught and utilized by health care professionals.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Nursing, Allied Health, and Interprofessional Team Interventions. Interprofessional education of osteopathic manipulative treatment and awareness of which physicians in their area utilize this treatment modality is critical. These are simple techniques that can be taught and utilized by health care professionals."}
+{"id": "article-102980_28", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Nursing, Allied Health, and Interprofessional Team Monitoring", "content": "Communication about patient progression is essential. Treatment by an osteopathic physician requires continual monitoring and progress communicated to the patient's primary physician or orthopedist.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Nursing, Allied Health, and Interprofessional Team Monitoring. Communication about patient progression is essential. Treatment by an osteopathic physician requires continual monitoring and progress communicated to the patient's primary physician or orthopedist."}
+{"id": "article-102980_29", "title": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Osteopathic Manipulative Treatment: Muscle Energy Procedure - AC Joint, Clavicle, SC Joint -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

statpearls/chunk/article-102982.jsonl

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+{"id": "article-102982_0", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Continuing Education Activity", "content": "The lymphatic system intimately connects to all body parts, yet its clinical significance is poorly understood.\u00a0Besides playing a role in the immune system, it has many other functions. This mesh of tissues and organs exports toxins, waste, and unnecessary materials out of the body via lymph fluid. Modern medical education today does not do full justice to the lymphatic system.\u00a0Understanding the lymphatic formation and removal process from the interstitium is a crucial physiologic principle to treat osteopathically.\u00a0Osteopathic manipulative treatment (OMT) may be used to affect and improve lymphatic flow. This activity outlines lymphatic osteopathic manipulation treatment and explains the role of the interprofessional team in improving care for patients who undergo lymphatic OMT.", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Continuing Education Activity. The lymphatic system intimately connects to all body parts, yet its clinical significance is poorly understood.\u00a0Besides playing a role in the immune system, it has many other functions. This mesh of tissues and organs exports toxins, waste, and unnecessary materials out of the body via lymph fluid. Modern medical education today does not do full justice to the lymphatic system.\u00a0Understanding the lymphatic formation and removal process from the interstitium is a crucial physiologic principle to treat osteopathically.\u00a0Osteopathic manipulative treatment (OMT) may be used to affect and improve lymphatic flow. This activity outlines lymphatic osteopathic manipulation treatment and explains the role of the interprofessional team in improving care for patients who undergo lymphatic OMT."}
+{"id": "article-102982_1", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Continuing Education Activity", "content": "Objectives: Identify patients with conditions or symptoms suggestive of lymphatic system involvement where lymphatic OMT may be beneficial. Screen patients for any medical conditions or factors that may affect the suitability of lymphatic OMT as a treatment option. Select appropriate lymphatic OMT techniques based on the patient's specific lymphatic system dysfunction and clinical presentation. Collaborate with other healthcare professionals, such as physical therapists and lymphedema specialists, to optimize patient outcomes through an interprofessional approach. Access free multiple choice questions on this topic.", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Continuing Education Activity. Objectives: Identify patients with conditions or symptoms suggestive of lymphatic system involvement where lymphatic OMT may be beneficial. Screen patients for any medical conditions or factors that may affect the suitability of lymphatic OMT as a treatment option. Select appropriate lymphatic OMT techniques based on the patient's specific lymphatic system dysfunction and clinical presentation. Collaborate with other healthcare professionals, such as physical therapists and lymphedema specialists, to optimize patient outcomes through an interprofessional approach. Access free multiple choice questions on this topic."}
+{"id": "article-102982_2", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Introduction", "content": "The lymphatic system can easily be overlooked but drastically impacts the immune system. This mesh of tissues and organs exports toxins, waste, and unnecessary materials out of the body via lymph fluid. Modern medical education today does not do full justice to the lymphatic system. This system removes fluids\u00a0and protein from the extracellular space and interstitium to maintain proper osmotic balance. In acute inflammation,\u00a0changes occur in the lymphatic system, so our body will try to maintain appropriate homeostasis. [1]", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Introduction. The lymphatic system can easily be overlooked but drastically impacts the immune system. This mesh of tissues and organs exports toxins, waste, and unnecessary materials out of the body via lymph fluid. Modern medical education today does not do full justice to the lymphatic system. This system removes fluids\u00a0and protein from the extracellular space and interstitium to maintain proper osmotic balance. In acute inflammation,\u00a0changes occur in the lymphatic system, so our body will try to maintain appropriate homeostasis. [1]"}
+{"id": "article-102982_3", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Introduction", "content": "Osteopathic manipulative treatment (OMT) is used to treat somatic dysfunctions. OMT focuses on enhancing the neuromuscular connection, improving biomechanical balance, decreasing pain, and increasing the range of motion. [2] In the historical context of osteopathy, Dr. Andrew Taylor Still placed a lot of importance on the lymphatic system during his development of the tenets of osteopathy. In the book The Philosophy and Mechanical Principles of Osteopathy by Andrew Taylor Still, he mentions that \"We suffer from two causes: want of supply and the burdens of dead deposits.\" Dr. Still understood the importance of the lymphatic system's role in clearing the \"debris\" that may cause disease. In modern medicine, we know more about the lymphatic vessels and how they may contribute to certain chronic conditions. [3] [4]", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Introduction. Osteopathic manipulative treatment (OMT) is used to treat somatic dysfunctions. OMT focuses on enhancing the neuromuscular connection, improving biomechanical balance, decreasing pain, and increasing the range of motion. [2] In the historical context of osteopathy, Dr. Andrew Taylor Still placed a lot of importance on the lymphatic system during his development of the tenets of osteopathy. In the book The Philosophy and Mechanical Principles of Osteopathy by Andrew Taylor Still, he mentions that \"We suffer from two causes: want of supply and the burdens of dead deposits.\" Dr. Still understood the importance of the lymphatic system's role in clearing the \"debris\" that may cause disease. In modern medicine, we know more about the lymphatic vessels and how they may contribute to certain chronic conditions. [3] [4]"}
+{"id": "article-102982_4", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Introduction", "content": "Inflammation is a normal homeostatic response to injury or infection; it is\u00a0the body's response to try to heal. During the process, significant amounts of different cytokines and other inflammatory mediators are released to signal the appropriate immune cells. Removing these markers through lymphatic drainage flow is essential to help resolve the inflammation. [5] [6]", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Introduction. Inflammation is a normal homeostatic response to injury or infection; it is\u00a0the body's response to try to heal. During the process, significant amounts of different cytokines and other inflammatory mediators are released to signal the appropriate immune cells. Removing these markers through lymphatic drainage flow is essential to help resolve the inflammation. [5] [6]"}
+{"id": "article-102982_5", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Introduction", "content": "Understanding the lymphatic formation and removal process from the interstitium is a crucial physiologic principle to treat osteopathically. Osteopaths believe\u00a0that lymphatic drainage plays a significant role in rheumatoid arthritis; immune complexes are formed in the disease, which cause substantial inflammatory exudates. These exudates cause pain and destroy joint tissue,\u00a0and it has been shown that there is increased lymph production and drainage from these patients. [7]", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Introduction. Understanding the lymphatic formation and removal process from the interstitium is a crucial physiologic principle to treat osteopathically. Osteopaths believe\u00a0that lymphatic drainage plays a significant role in rheumatoid arthritis; immune complexes are formed in the disease, which cause substantial inflammatory exudates. These exudates cause pain and destroy joint tissue,\u00a0and it has been shown that there is increased lymph production and drainage from these patients. [7]"}
+{"id": "article-102982_6", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Introduction", "content": "Some osteopathic techniques are similar to those implemented by chiropractors, physical therapists, and massage therapists, and other methods are solely used by osteopathic physicians. However, one main difference is that these physicians are trained to apply these techniques with their extensive knowledge of physiology and anatomy. This allows osteopathic physicians to tailor their treatment to each patient. [8] This will enable OMT to be applied to more than just spinal alignment to treat many physiologic conditions. [8]", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Introduction. Some osteopathic techniques are similar to those implemented by chiropractors, physical therapists, and massage therapists, and other methods are solely used by osteopathic physicians. However, one main difference is that these physicians are trained to apply these techniques with their extensive knowledge of physiology and anatomy. This allows osteopathic physicians to tailor their treatment to each patient. [8] This will enable OMT to be applied to more than just spinal alignment to treat many physiologic conditions. [8]"}
+{"id": "article-102982_7", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Introduction", "content": "Some techniques were\u00a0designed to be used to help increase lymphatic flow. Some other techniques were not designed to be lymphatic, but they can be used in its treatment by understanding the complexity of the human anatomy. When treating lymphatic techniques, it is essential to be mindful of structures that may impinge the lymphatic vessels, such as fascia, muscles, ligaments, and other somatic dysfunctions. Many techniques comprise OMT, which can treat many ailments, including the lymphatic system. Problems within this system lead to the accumulation of lymph, decreased immune responses, fat build-up, tissue swelling, and connective tissue accumulation. [9]", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Introduction. Some techniques were\u00a0designed to be used to help increase lymphatic flow. Some other techniques were not designed to be lymphatic, but they can be used in its treatment by understanding the complexity of the human anatomy. When treating lymphatic techniques, it is essential to be mindful of structures that may impinge the lymphatic vessels, such as fascia, muscles, ligaments, and other somatic dysfunctions. Many techniques comprise OMT, which can treat many ailments, including the lymphatic system. Problems within this system lead to the accumulation of lymph, decreased immune responses, fat build-up, tissue swelling, and connective tissue accumulation. [9]"}
+{"id": "article-102982_8", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Anatomy and Physiology", "content": "Lymphatic vessels can be found all over the body. They are very closely located in arterial and venous blood vessels. The lymphatic system begins in the interstitium of tissues with lymph capillaries, and they drain into larger collecting channels, which further drain into lymph nodes. The lymphatic vessels from the lower extremity left thorax, left upper extremity, and left head and neck drain into the thoracic duct. Meanwhile, the right thorax, right upper extremity, right head, neck, and heart drain into the right lymphatic duct. [10]", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Anatomy and Physiology. Lymphatic vessels can be found all over the body. They are very closely located in arterial and venous blood vessels. The lymphatic system begins in the interstitium of tissues with lymph capillaries, and they drain into larger collecting channels, which further drain into lymph nodes. The lymphatic vessels from the lower extremity left thorax, left upper extremity, and left head and neck drain into the thoracic duct. Meanwhile, the right thorax, right upper extremity, right head, neck, and heart drain into the right lymphatic duct. [10]"}
+{"id": "article-102982_9", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Anatomy and Physiology", "content": "The lymphatic capillaries are single-layered endothelial cells without any tight junctions anchoring filaments from the\u00a0basal side of the cell to the interstitial matrix. These filaments change the shape of the vessels depending on the motion of the tissues. [11] [12] [13] Due to the lack of adhesion molecules at the endothelial cells, the basement membrane acts as a one-way flow valve for the lymphatic fluids [14] [15] [6]", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Anatomy and Physiology. The lymphatic capillaries are single-layered endothelial cells without any tight junctions anchoring filaments from the\u00a0basal side of the cell to the interstitial matrix. These filaments change the shape of the vessels depending on the motion of the tissues. [11] [12] [13] Due to the lack of adhesion molecules at the endothelial cells, the basement membrane acts as a one-way flow valve for the lymphatic fluids [14] [15] [6]"}
+{"id": "article-102982_10", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Anatomy and Physiology", "content": "The presence of a bicuspid valve is the start of the lymph-collecting vessels, which are comprised of smooth muscles near the valves, which thicken as they become more proximal. The segments between the valves are called lymphangions. The smooth muscles around the vessels contain sympathetic innervation. [16] There is a hypothesis that the role of sympathetic innervation is to modify the immune response rather than to increase flow through the vessels. [17] The collecting vessels near skeletal muscles have fewer smooth muscles;\u00a0this finding suggests that skeletal muscle contraction is essential in moving lymphatic fluids along the vessels. [18]", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Anatomy and Physiology. The presence of a bicuspid valve is the start of the lymph-collecting vessels, which are comprised of smooth muscles near the valves, which thicken as they become more proximal. The segments between the valves are called lymphangions. The smooth muscles around the vessels contain sympathetic innervation. [16] There is a hypothesis that the role of sympathetic innervation is to modify the immune response rather than to increase flow through the vessels. [17] The collecting vessels near skeletal muscles have fewer smooth muscles;\u00a0this finding suggests that skeletal muscle contraction is essential in moving lymphatic fluids along the vessels. [18]"}
+{"id": "article-102982_11", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Anatomy and Physiology", "content": "When lymphatic fluid from the lower extremity flow towards the thoracic duct, intrathoracic pressure is essential. A change in the intrathoracic pressure during respiration may increase lymphatic flow up the thoracic duct. [19] The lymphatic system comprises the spleen, lymph nodes, thymus, lymph channels, adenoids, tonsils, and thymus. Lymph nodes \u2013 The average adult has roughly 700 lymph nodes. These nodules produce and store white blood cells and function to filter lymph fluid. Tonsils and adenoids \u2013 Closely packed lymphatic cells in the posterior of the oropharynx and posterior to the soft palate, respectively Thymus \u2013 The site of T-cell maturation sits just posterior to the manubrium. This organ is most active in the early stages of life. Spleen \u2013 Largest of the organs involved in the lymphatic system, the spleen holds white blood cells to fight infection and filters the blood.", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Anatomy and Physiology. When lymphatic fluid from the lower extremity flow towards the thoracic duct, intrathoracic pressure is essential. A change in the intrathoracic pressure during respiration may increase lymphatic flow up the thoracic duct. [19] The lymphatic system comprises the spleen, lymph nodes, thymus, lymph channels, adenoids, tonsils, and thymus. Lymph nodes \u2013 The average adult has roughly 700 lymph nodes. These nodules produce and store white blood cells and function to filter lymph fluid. Tonsils and adenoids \u2013 Closely packed lymphatic cells in the posterior of the oropharynx and posterior to the soft palate, respectively Thymus \u2013 The site of T-cell maturation sits just posterior to the manubrium. This organ is most active in the early stages of life. Spleen \u2013 Largest of the organs involved in the lymphatic system, the spleen holds white blood cells to fight infection and filters the blood."}
+{"id": "article-102982_12", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Anatomy and Physiology", "content": "A few areas in the body where lymphatic vessels may be hindered due to somatic dysfunctions are the thoracic outlet, thoracic diaphragm, femoral triangle, and the popliteal fossa. When treating the thoracic diaphragm, it is essential to be aware of the thoracic duct, which crosses the diaphragm at the level of T12 and is between the vertebral body and the aorta. Underneath the diaphragm and slightly to the right of the vertebral column is the cisterna chili, where most lymph from below the diaphragm drains before ascending towards the thoracic duct.", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Anatomy and Physiology. A few areas in the body where lymphatic vessels may be hindered due to somatic dysfunctions are the thoracic outlet, thoracic diaphragm, femoral triangle, and the popliteal fossa. When treating the thoracic diaphragm, it is essential to be aware of the thoracic duct, which crosses the diaphragm at the level of T12 and is between the vertebral body and the aorta. Underneath the diaphragm and slightly to the right of the vertebral column is the cisterna chili, where most lymph from below the diaphragm drains before ascending towards the thoracic duct."}
+{"id": "article-102982_13", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Indications", "content": "A foundational principle in osteopathic medicine is to help remove obstructions to circulatory flow. Lymphatic vessels are included in Dr. Still's concept of circulation. As mentioned in the introduction of this activity, Dr. Still\u00a0emphasized the lymphatic system as a way for the body to remove \"debris.\" Modern medicine understands the role of inflammation, injury, and disease; therefore, osteopathic physicians should understand its implications for the lymphatic system. Lymphatic congestion can lead to significant worsening of conditions based on being unable to remove the inflammatory mediators from the body. Therefore, proper lymphatic flow is essential in many chronic, autoimmune, and inflammatory diseases.", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Indications. A foundational principle in osteopathic medicine is to help remove obstructions to circulatory flow. Lymphatic vessels are included in Dr. Still's concept of circulation. As mentioned in the introduction of this activity, Dr. Still\u00a0emphasized the lymphatic system as a way for the body to remove \"debris.\" Modern medicine understands the role of inflammation, injury, and disease; therefore, osteopathic physicians should understand its implications for the lymphatic system. Lymphatic congestion can lead to significant worsening of conditions based on being unable to remove the inflammatory mediators from the body. Therefore, proper lymphatic flow is essential in many chronic, autoimmune, and inflammatory diseases."}
+{"id": "article-102982_14", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Indications", "content": "Examples of common conditions treated with lymphatic techniques can be autoimmune, such as rheumatoid arthritis, inflammatory bowel disease, and psoriasis. In addition, inflammatory conditions such as pharyngitis, pericarditis, myocarditis, mastitis, colitis, and pancreatitis are a few conditions that can benefit from lymphatic treatments. Lymphatic treatment may also be an adjunct to antibiotic use in an infectious process by helping the flow of immune cells to the area of infection. [20] [21] However,\u00a0osteopathic practitioners must not only rely on lymphatic techniques\u00a0but also understand the physiology and anatomy of the patient to apply effective treatments.", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Indications. Examples of common conditions treated with lymphatic techniques can be autoimmune, such as rheumatoid arthritis, inflammatory bowel disease, and psoriasis. In addition, inflammatory conditions such as pharyngitis, pericarditis, myocarditis, mastitis, colitis, and pancreatitis are a few conditions that can benefit from lymphatic treatments. Lymphatic treatment may also be an adjunct to antibiotic use in an infectious process by helping the flow of immune cells to the area of infection. [20] [21] However,\u00a0osteopathic practitioners must not only rely on lymphatic techniques\u00a0but also understand the physiology and anatomy of the patient to apply effective treatments."}
+{"id": "article-102982_15", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Indications", "content": "Lymphatic treatment is a great adjunctive approach for treating infectious diseases like pneumonia. The MOPSE trial even showed that it could reduce hospital length stays. [22] Osteopathic treatment for infection can increase immune cells' flow and efficient delivery of antibiotics to the source of infection.", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Indications. Lymphatic treatment is a great adjunctive approach for treating infectious diseases like pneumonia. The MOPSE trial even showed that it could reduce hospital length stays. [22] Osteopathic treatment for infection can increase immune cells' flow and efficient delivery of antibiotics to the source of infection."}
+{"id": "article-102982_16", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Contraindications", "content": "There are relative contraindications (eg, pain) and absolute contraindications (no consent from the patient). However, these can be more difficult to discern with lymphatic techniques as any technique can become lymphatic treatment with the right intention.", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Contraindications. There are relative contraindications (eg, pain) and absolute contraindications (no consent from the patient). However, these can be more difficult to discern with lymphatic techniques as any technique can become lymphatic treatment with the right intention."}
+{"id": "article-102982_17", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Contraindications", "content": "There are a few absolute contraindications to lymphatic treatments. Any lymphatic pumping techniques should be avoided in areas with acute injuries, such as bone fractures. Leukemia or lymphoma may be a relative contraindication as there is a hypothetical risk that lymphatic techniques may spread the condition further. Another\u00a0contraindication to lymphatic techniques, commonly taught in school, is that they should be avoided in patients with metastatic cancer due to the hypothetical risk of further metastasis. However, even in the osteopathic community, there is some movement away from avoiding lymphatic techniques in patients with metastases.\u00a0There are questions regarding the validity of\u00a0the hypothesis that metastases can be spread using lymphatic techniques. [23] One argument is that even walking is a form of lymphatic treatment.", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Contraindications. There are a few absolute contraindications to lymphatic treatments. Any lymphatic pumping techniques should be avoided in areas with acute injuries, such as bone fractures. Leukemia or lymphoma may be a relative contraindication as there is a hypothetical risk that lymphatic techniques may spread the condition further. Another\u00a0contraindication to lymphatic techniques, commonly taught in school, is that they should be avoided in patients with metastatic cancer due to the hypothetical risk of further metastasis. However, even in the osteopathic community, there is some movement away from avoiding lymphatic techniques in patients with metastases.\u00a0There are questions regarding the validity of\u00a0the hypothesis that metastases can be spread using lymphatic techniques. [23] One argument is that even walking is a form of lymphatic treatment."}
+{"id": "article-102982_18", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Contraindications", "content": "The practitioner should also be mindful when doing lymphatic treatments during certain infections. For example, there is a hypothetical risk that lymphatic treatments may further disseminate diseases in the case of bacteremia or an abscess about to burst.", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Contraindications. The practitioner should also be mindful when doing lymphatic treatments during certain infections. For example, there is a hypothetical risk that lymphatic treatments may further disseminate diseases in the case of bacteremia or an abscess about to burst."}
+{"id": "article-102982_19", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Contraindications", "content": "Another contraindication is lymphatic techniques in acute heart failure exacerbation. Many physicians may want to apply lymphatic pump techniques when seeing lymphedema in the legs. However, in acute heart failure, lymphatic pumping techniques may hypothetically increase the heart's afterload by pushing more fluid into the circulatory system. Therefore, treating any somatic dysfunctions obstructing lymphatic flow will be more advisable than pumping techniques. However, lymphatic techniques are beneficial overall in cardiac conditions. [24] [25]", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Contraindications. Another contraindication is lymphatic techniques in acute heart failure exacerbation. Many physicians may want to apply lymphatic pump techniques when seeing lymphedema in the legs. However, in acute heart failure, lymphatic pumping techniques may hypothetically increase the heart's afterload by pushing more fluid into the circulatory system. Therefore, treating any somatic dysfunctions obstructing lymphatic flow will be more advisable than pumping techniques. However, lymphatic techniques are beneficial overall in cardiac conditions. [24] [25]"}
+{"id": "article-102982_20", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Contraindications", "content": "Lymphatic\u00a0pumping techniques in the lower extremities should be avoided if there are any concerns of possible deep vein thrombosis. Likewise, lymphatic pumping techniques such as the liver pump and the splenic pump should be avoided if there are concerns of acute liver injury or splenomegaly.", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Contraindications. Lymphatic\u00a0pumping techniques in the lower extremities should be avoided if there are any concerns of possible deep vein thrombosis. Likewise, lymphatic pumping techniques such as the liver pump and the splenic pump should be avoided if there are concerns of acute liver injury or splenomegaly."}
+{"id": "article-102982_21", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Equipment", "content": "A comfortable place for the patient to sit and lay, typically an exam table, OMT table, or massage table. A pillow for patient comfort.", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Equipment. A comfortable place for the patient to sit and lay, typically an exam table, OMT table, or massage table. A pillow for patient comfort."}
+{"id": "article-102982_22", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Preparation", "content": "Consent is necessary before any procedure, including OMT. The patient must understand the risks, benefits, and alternative options to provide informed consent.\u00a0Patients also appreciate the provider warming their hands before the treatment begins.", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Preparation. Consent is necessary before any procedure, including OMT. The patient must understand the risks, benefits, and alternative options to provide informed consent.\u00a0Patients also appreciate the provider warming their hands before the treatment begins."}
+{"id": "article-102982_23", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Technique or Treatment -- Chapman Reflexes", "content": "There are roughly 100 documented Chapman points. These are areas of gangliform contraction, which, when in certain areas, are associated with specific organs that have dysfunctions. Treating these points will decrease sympathetic tone, increase myofascial motion, and improve lymphatic return to visceral dysfunction. [26] Chapman points have been documented in chronic hepatitis patients on physical exams. They can help physicians narrow their differential, validate a diagnosis, and increase treatment options. [27]", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Technique or Treatment -- Chapman Reflexes. There are roughly 100 documented Chapman points. These are areas of gangliform contraction, which, when in certain areas, are associated with specific organs that have dysfunctions. Treating these points will decrease sympathetic tone, increase myofascial motion, and improve lymphatic return to visceral dysfunction. [26] Chapman points have been documented in chronic hepatitis patients on physical exams. They can help physicians narrow their differential, validate a diagnosis, and increase treatment options. [27]"}
+{"id": "article-102982_24", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Technique or Treatment -- Thoracic (Miller) Pump", "content": "Increases mobilization of all lymphatic fluid movement and increases rib case mobility. The patient is supine on the table, and the physician is at the head of the table facing the patient. The physician's hands are placed on either side of the chest, and the patient is asked to take deep breaths. The physician will follow the ribs' motion while applying a gentle oscillatory force during exhalation.", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Technique or Treatment -- Thoracic (Miller) Pump. Increases mobilization of all lymphatic fluid movement and increases rib case mobility. The patient is supine on the table, and the physician is at the head of the table facing the patient. The physician's hands are placed on either side of the chest, and the patient is asked to take deep breaths. The physician will follow the ribs' motion while applying a gentle oscillatory force during exhalation."}
+{"id": "article-102982_25", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Technique or Treatment -- Pedal (Dalrymple) Pump", "content": "Increases mobilization of all lymphatic fluid movement. This technique is beneficial in pediatric patients or lymphedema. The patient is supine on the table, and the physician is at the feet of the table facing the patient. The physician gently dorsiflexes the feet to \"pick up the slack\" in the tissue. Gentle oscillatory force is applied cephalad while maintaining dorsiflexion. Amplitude should be enough to visualize the motion of the oscillation in the nose. [28]", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Technique or Treatment -- Pedal (Dalrymple) Pump. Increases mobilization of all lymphatic fluid movement. This technique is beneficial in pediatric patients or lymphedema. The patient is supine on the table, and the physician is at the feet of the table facing the patient. The physician gently dorsiflexes the feet to \"pick up the slack\" in the tissue. Gentle oscillatory force is applied cephalad while maintaining dorsiflexion. Amplitude should be enough to visualize the motion of the oscillation in the nose. [28]"}
+{"id": "article-102982_26", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Technique or Treatment -- Thoracic Inlet Release", "content": "Sibson's fascia mentioned above is the fascial layer comprised of the connective tissues of the longus coli and scalene muscles and attaches to the transverse process of C7. The right and left thoracic ducts travel through this fascia once and twice. Using techniques to release Sibson's fascia will better allow all lymph to return to the circulatory system. This treatment should be done before most lymphatic treatments. The patient starts supine. The physician is stated at the head of the table facing the patient. The physician places their hands on the shoulder. Motion test the shoulders in flexion/extension, side bending, rotations, and compression. If treating indirectly, stack up the tissue in the direction of ease. If treating directly, stack up the tissue toward the barrier. Hold the fascia until a release can be palpated.", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Technique or Treatment -- Thoracic Inlet Release. Sibson's fascia mentioned above is the fascial layer comprised of the connective tissues of the longus coli and scalene muscles and attaches to the transverse process of C7. The right and left thoracic ducts travel through this fascia once and twice. Using techniques to release Sibson's fascia will better allow all lymph to return to the circulatory system. This treatment should be done before most lymphatic treatments. The patient starts supine. The physician is stated at the head of the table facing the patient. The physician places their hands on the shoulder. Motion test the shoulders in flexion/extension, side bending, rotations, and compression. If treating indirectly, stack up the tissue in the direction of ease. If treating directly, stack up the tissue toward the barrier. Hold the fascia until a release can be palpated."}
+{"id": "article-102982_27", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Technique or Treatment -- Rib Raising", "content": "Rib raising\u00a0is not a strict lymphatic technique, but it can be used to increase compliance with costal motion, allowing for deeper intrathoracic pressure changes to increase lymphatic flow. The patient is supine on the table, and the physician is on the ipsilateral side, facing the patient. The physician's hands slide underneath that patient and contact the rib angle. Gentle, rhythmic motion to translate the ribs anteriorly to articulate the costovertebral joints. [29]", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Technique or Treatment -- Rib Raising. Rib raising\u00a0is not a strict lymphatic technique, but it can be used to increase compliance with costal motion, allowing for deeper intrathoracic pressure changes to increase lymphatic flow. The patient is supine on the table, and the physician is on the ipsilateral side, facing the patient. The physician's hands slide underneath that patient and contact the rib angle. Gentle, rhythmic motion to translate the ribs anteriorly to articulate the costovertebral joints. [29]"}
+{"id": "article-102982_28", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Technique or Treatment -- Splenic/Liver Pump", "content": "This procedure facilitates the flow of lymph to the liver and spleen. In the liver, this increases the ability of the Kupffer cells to interact with antigens and toxins in the lymph. The spleen's ability to screen and remove damaged cells from the system is also enhanced. Rhythmic external compression of the costal margin on either side to \"pump\" the spleen or liver", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Technique or Treatment -- Splenic/Liver Pump. This procedure facilitates the flow of lymph to the liver and spleen. In the liver, this increases the ability of the Kupffer cells to interact with antigens and toxins in the lymph. The spleen's ability to screen and remove damaged cells from the system is also enhanced. Rhythmic external compression of the costal margin on either side to \"pump\" the spleen or liver"}
+{"id": "article-102982_29", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Technique or Treatment -- Facial Sinus Pressure Techniques (Facial Effleurage)", "content": "It improves sinus congestion and otitis media; it involves direct strokes applied to the sinuses, zygomatic bones, and the temporal mandibular joints bilaterally to enhance lymph movement towards the right and left lymphatic ducts. There are multiple ways and different sequences of doing facial effleurage. [30] The following\u00a0are some examples: Over the eyebrows for frontal sinus Under the maxillary protuberance for the maxillary sinus On the anterior surface of the mandible Under the mandible Sternocleidomastoid", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Technique or Treatment -- Facial Sinus Pressure Techniques (Facial Effleurage). It improves sinus congestion and otitis media; it involves direct strokes applied to the sinuses, zygomatic bones, and the temporal mandibular joints bilaterally to enhance lymph movement towards the right and left lymphatic ducts. There are multiple ways and different sequences of doing facial effleurage. [30] The following\u00a0are some examples: Over the eyebrows for frontal sinus Under the maxillary protuberance for the maxillary sinus On the anterior surface of the mandible Under the mandible Sternocleidomastoid"}
+{"id": "article-102982_30", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Technique or Treatment -- Galbreath Technique", "content": "This maneuver\u00a0facilitates the opening of the eustachian tubes and allows lymph flow distally from the ears. The patient is supine, and the physician stands on the contralateral side. The cephalad hand is placed on the forehead to stabilize the patient. The caudad hand is placed on the angle of the mandible and pulls the jaw inferio-medially. The technique also pulls the medial pterygoid muscle, stimulating the jugulodigastric lymph nodes. [31]", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Technique or Treatment -- Galbreath Technique. This maneuver\u00a0facilitates the opening of the eustachian tubes and allows lymph flow distally from the ears. The patient is supine, and the physician stands on the contralateral side. The cephalad hand is placed on the forehead to stabilize the patient. The caudad hand is placed on the angle of the mandible and pulls the jaw inferio-medially. The technique also pulls the medial pterygoid muscle, stimulating the jugulodigastric lymph nodes. [31]"}
+{"id": "article-102982_31", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Technique or Treatment -- Doming the Diaphragm", "content": "Increases mobilization of lymphatic fluid from the lower extremities and increases diaphragm motion Somatic\u00a0dysfunction in the diaphragm can restrict the thoracic duct as it passes the diaphragm at the level of T12 between the vertebral body and the aorta. The patient starts supine, and the physician is on either side of the patient. Both hands are placed on either inferior costal margin. Follow the motion of the ribs with inhalation, and gently resist during exhalation. Repeat three times. This technique may\u00a0cause some discomfort for patients. [32]", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Technique or Treatment -- Doming the Diaphragm. Increases mobilization of lymphatic fluid from the lower extremities and increases diaphragm motion Somatic\u00a0dysfunction in the diaphragm can restrict the thoracic duct as it passes the diaphragm at the level of T12 between the vertebral body and the aorta. The patient starts supine, and the physician is on either side of the patient. Both hands are placed on either inferior costal margin. Follow the motion of the ribs with inhalation, and gently resist during exhalation. Repeat three times. This technique may\u00a0cause some discomfort for patients. [32]"}
+{"id": "article-102982_32", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Complications", "content": "OMT is relatively safe, and lymphatic treatments are some of the safest. Some transient effects may include headache, tiredness, and fatigue. [8] Adverse effects may be avoided if the patient drinks plenty of fluids. There is a hypothetical risk of causing a transient decrease in ejection fraction if too much aggressive lymphatic technique is done by suddenly increasing the afterload. There is also a risk of damaging the liver or spleen if an aggressive splenic/liver pump is done during organomegaly.", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Complications. OMT is relatively safe, and lymphatic treatments are some of the safest. Some transient effects may include headache, tiredness, and fatigue. [8] Adverse effects may be avoided if the patient drinks plenty of fluids. There is a hypothetical risk of causing a transient decrease in ejection fraction if too much aggressive lymphatic technique is done by suddenly increasing the afterload. There is also a risk of damaging the liver or spleen if an aggressive splenic/liver pump is done during organomegaly."}
+{"id": "article-102982_33", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Clinical Significance", "content": "Due to the vast relationship of the lymphatic system to all body organs, lymphatic treatment can have substantial clinical significance. During the Spanish flu of 1918, there was a 33% mortality rate for patients who received care. However, patients who also received treatment with OMT had a mortality rate of 10%. The techniques improved lymphatic flow, immune defense, and respiratory function. [20]", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Clinical Significance. Due to the vast relationship of the lymphatic system to all body organs, lymphatic treatment can have substantial clinical significance. During the Spanish flu of 1918, there was a 33% mortality rate for patients who received care. However, patients who also received treatment with OMT had a mortality rate of 10%. The techniques improved lymphatic flow, immune defense, and respiratory function. [20]"}
+{"id": "article-102982_34", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Clinical Significance", "content": "In 2010, a randomized controlled trial of over 400 elderly patients with pneumonia found that OMT as an adjunctive treatment to the standard of care lowered costs, decreased hospital length of stay, duration of intravenous antibiotics, and incidence of respiratory failure or death. [20] In essence, lymphatic treatment may be a powerful adjunct to conventional medicine when treating many medical conditions.", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Clinical Significance. In 2010, a randomized controlled trial of over 400 elderly patients with pneumonia found that OMT as an adjunctive treatment to the standard of care lowered costs, decreased hospital length of stay, duration of intravenous antibiotics, and incidence of respiratory failure or death. [20] In essence, lymphatic treatment may be a powerful adjunct to conventional medicine when treating many medical conditions."}
+{"id": "article-102982_35", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Enhancing Healthcare Team Outcomes", "content": "For the last 130 years, osteopathic physicians have been practicing medicine. [8] Although the understanding of osteopathic medicine has dramatically increased, it is still poorly understood by many healthcare workers and patients. Interprofessional team members, including nursing staff, must\u00a0understand OMT and what it can provide to patients. Osteopathic practitioners should document all OMT interventions in the patient's permanent medical record so all team members know the overall treatment plan. This will also allow the patients to know what options are available and may receive increased relief for their ailments in addition to allopathic medicine. Outcomes and patient satisfaction will improve. OMT is also very safe; if some issues are treatable with\u00a0OMT alone, it will also increase patient safety.", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Enhancing Healthcare Team Outcomes. For the last 130 years, osteopathic physicians have been practicing medicine. [8] Although the understanding of osteopathic medicine has dramatically increased, it is still poorly understood by many healthcare workers and patients. Interprofessional team members, including nursing staff, must\u00a0understand OMT and what it can provide to patients. Osteopathic practitioners should document all OMT interventions in the patient's permanent medical record so all team members know the overall treatment plan. This will also allow the patients to know what options are available and may receive increased relief for their ailments in addition to allopathic medicine. Outcomes and patient satisfaction will improve. OMT is also very safe; if some issues are treatable with\u00a0OMT alone, it will also increase patient safety."}
+{"id": "article-102982_36", "title": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Osteopathic Manipulative Treatment: Lymphatic Procedures -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

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+{"id": "article-102984_0", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Continuing Education Activity", "content": "High-velocity low amplitude (HVLA) techniques employ a rapid use of force over a short duration, distance, and/or rotational area within the anatomical range of motion of a joint to engage the restrictive barrier in one or more planes of motion to elicit the release of restriction. This activity outlines high-velocity low amplitude manipulation techniques and explains the role of the healthcare team in improving care for patients who undergo HVLA manipulation.", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Continuing Education Activity. High-velocity low amplitude (HVLA) techniques employ a rapid use of force over a short duration, distance, and/or rotational area within the anatomical range of motion of a joint to engage the restrictive barrier in one or more planes of motion to elicit the release of restriction. This activity outlines high-velocity low amplitude manipulation techniques and explains the role of the healthcare team in improving care for patients who undergo HVLA manipulation."}
+{"id": "article-102984_1", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Continuing Education Activity", "content": "Objectives: Describe the common terminology associated with HVLA. Identify the common complications of HVLA procedures. Summarize the proper procedural considerations for HVLA manipulation. Outline the prevalence of HVLA procedures. Access free multiple choice questions on this topic.", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Continuing Education Activity. Objectives: Describe the common terminology associated with HVLA. Identify the common complications of HVLA procedures. Summarize the proper procedural considerations for HVLA manipulation. Outline the prevalence of HVLA procedures. Access free multiple choice questions on this topic."}
+{"id": "article-102984_2", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Introduction", "content": "Dr. Kirkaldy-Willis first conceptualized and published theories regarding the Biomechanics and Biology of the Spinal Degenerative Cascade. He defined the HVLA technique as \"a skilled, passive manual therapeutic maneuver during which a synovial joint is beyond the normal physiological range of movement (in the direction of the restriction) without exceeding the boundaries of anatomical integrity.\" [1]", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Introduction. Dr. Kirkaldy-Willis first conceptualized and published theories regarding the Biomechanics and Biology of the Spinal Degenerative Cascade. He defined the HVLA technique as \"a skilled, passive manual therapeutic maneuver during which a synovial joint is beyond the normal physiological range of movement (in the direction of the restriction) without exceeding the boundaries of anatomical integrity.\" [1]"}
+{"id": "article-102984_3", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Introduction", "content": "High-velocity low amplitude techniques employ a rapid use of force over a short duration, distance, and/or rotational area within the anatomical range of motion of a joint to engage the restrictive barrier in one or more planes of motion to elicit the release of restriction. This manipulation technique uses high velocity and low amplitude thrusts to manipulate joints. Osteopathic physicians, chiropractors, and physical therapists are trained in HVLA and commonly perform these techniques.", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Introduction. High-velocity low amplitude techniques employ a rapid use of force over a short duration, distance, and/or rotational area within the anatomical range of motion of a joint to engage the restrictive barrier in one or more planes of motion to elicit the release of restriction. This manipulation technique uses high velocity and low amplitude thrusts to manipulate joints. Osteopathic physicians, chiropractors, and physical therapists are trained in HVLA and commonly perform these techniques."}
+{"id": "article-102984_4", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Introduction", "content": "Both therapies are used in cases of acute musculoskeletal back pain. The physician positions the person at the barrier of limited movement and then gives a rapid thrust in the isolated barrier's direction to resolve the restriction and improve motion. This method is among the oldest and most frequently used, and it is among the most common types of complementary medicine for children.\u00a0Most clinical research has focused on evaluating the efficacy of this form of manipulation, particularly for low back, mid-back, and neck pain. Purpose \u2014 restore motion to a restricted joint and improve function.", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Introduction. Both therapies are used in cases of acute musculoskeletal back pain. The physician positions the person at the barrier of limited movement and then gives a rapid thrust in the isolated barrier's direction to resolve the restriction and improve motion. This method is among the oldest and most frequently used, and it is among the most common types of complementary medicine for children.\u00a0Most clinical research has focused on evaluating the efficacy of this form of manipulation, particularly for low back, mid-back, and neck pain. Purpose \u2014 restore motion to a restricted joint and improve function."}
+{"id": "article-102984_5", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Introduction -- Terminology", "content": "High-velocity low amplitude is interchangeable with manipulation and thrust because of the different biomechanics. Nevertheless, these all unify in describing the process of increasing the range of motion.", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Introduction -- Terminology. High-velocity low amplitude is interchangeable with manipulation and thrust because of the different biomechanics. Nevertheless, these all unify in describing the process of increasing the range of motion."}
+{"id": "article-102984_6", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Introduction -- Terminology", "content": "Abbreviations \u2014  (AOA) American Osteopathic Association; (DO) Doctor of Osteopathic Medicine; (HLVA) High-velocity low amplitude; (HVLA-SM) High-velocity low amplitude spinal manipulation; (L) Lumbar; (ms) milliseconds; (N) newtons; (OMT) Osteopathic Manipulative Treatment; (RCT) randomized controlled trials", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Introduction -- Terminology. Abbreviations \u2014  (AOA) American Osteopathic Association; (DO) Doctor of Osteopathic Medicine; (HLVA) High-velocity low amplitude; (HVLA-SM) High-velocity low amplitude spinal manipulation; (L) Lumbar; (ms) milliseconds; (N) newtons; (OMT) Osteopathic Manipulative Treatment; (RCT) randomized controlled trials"}
+{"id": "article-102984_7", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Introduction -- Terminology", "content": "Adverse Event \u2014  Stroke, headache, joint pain, and vertebral artery dissection are possible adverse events associated with an HVLA OMT technique.", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Introduction -- Terminology. Adverse Event \u2014  Stroke, headache, joint pain, and vertebral artery dissection are possible adverse events associated with an HVLA OMT technique."}
+{"id": "article-102984_8", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Introduction -- Terminology", "content": "Amplitude \u2014  The thrust's distance attempts to create a movement of about 1/8th inch at the joint treated.", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Introduction -- Terminology. Amplitude \u2014  The thrust's distance attempts to create a movement of about 1/8th inch at the joint treated."}
+{"id": "article-102984_9", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Introduction -- Terminology", "content": "Cavitation \u2014 The process of using a mechanical force to precipitate a gas bubble in a joint space.", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Introduction -- Terminology. Cavitation \u2014 The process of using a mechanical force to precipitate a gas bubble in a joint space."}
+{"id": "article-102984_10", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Introduction -- Terminology", "content": "Fulcrum \u2014  This describes when a hand or body localizes a thrust's force into the segment or joint that is restricted.", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Introduction -- Terminology. Fulcrum \u2014  This describes when a hand or body localizes a thrust's force into the segment or joint that is restricted."}
+{"id": "article-102984_11", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Introduction -- Terminology", "content": "Long Lever \u2014  The extremities or multiple segments of the vertebral column.", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Introduction -- Terminology. Long Lever \u2014  The extremities or multiple segments of the vertebral column."}
+{"id": "article-102984_12", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Introduction -- Terminology", "content": "Manipulation \u2014 Synonym for a high-velocity low amplitude technique. Manipulation occurs at the end of and often beyond the available motion of the joint to break adhesions that disrupt or prevent joint movement.", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Introduction -- Terminology. Manipulation \u2014 Synonym for a high-velocity low amplitude technique. Manipulation occurs at the end of and often beyond the available motion of the joint to break adhesions that disrupt or prevent joint movement."}
+{"id": "article-102984_13", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Introduction -- Terminology", "content": "Short Lever \u2014 Any portion of the vertebra held while force is applied to the adjacent vertebra's bony prominence.", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Introduction -- Terminology. Short Lever \u2014 Any portion of the vertebra held while force is applied to the adjacent vertebra's bony prominence."}
+{"id": "article-102984_14", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Introduction -- Terminology", "content": "Thrust \u2014 Synonym for a high-velocity low amplitude technique. Thrust may refer to cracking or popping sounds.", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Introduction -- Terminology. Thrust \u2014 Synonym for a high-velocity low amplitude technique. Thrust may refer to cracking or popping sounds."}
+{"id": "article-102984_15", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Introduction -- Statistics", "content": "Prevalence Of Use Amongst The Pediatric Population: 2\u00a0to 3% [2] Approximately Incidence Adverse Event Per OMT Procedure: 1/50,000 [2] Approximate Number of Adverse Events Which Are Operator-Induced: 1/5 [2] Approximate Number of Adverse Events In Cervical Manipulation: 1/400,000\u00a0to 1,000,000, 1 every 177.5 weeks [2]", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Introduction -- Statistics. Prevalence Of Use Amongst The Pediatric Population: 2\u00a0to 3% [2] Approximately Incidence Adverse Event Per OMT Procedure: 1/50,000 [2] Approximate Number of Adverse Events Which Are Operator-Induced: 1/5 [2] Approximate Number of Adverse Events In Cervical Manipulation: 1/400,000\u00a0to 1,000,000, 1 every 177.5 weeks [2]"}
+{"id": "article-102984_16", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Anatomy and Physiology -- Spine\u00a0and Vertebra", "content": "Five vertebral segments and their respective nerve roots exit under the respective vertebrae in the lumbar spine.\u00a0For instance, the L3 nerve leaves the foramen of L3 and L4. When a patient experiences pain radiating down a given dermatome, therapies focused on nerve fibers, including associated spinal segments, might be viable to adjust to that area.", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Anatomy and Physiology -- Spine\u00a0and Vertebra. Five vertebral segments and their respective nerve roots exit under the respective vertebrae in the lumbar spine.\u00a0For instance, the L3 nerve leaves the foramen of L3 and L4. When a patient experiences pain radiating down a given dermatome, therapies focused on nerve fibers, including associated spinal segments, might be viable to adjust to that area."}
+{"id": "article-102984_17", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Anatomy and Physiology -- Spine\u00a0and Vertebra", "content": "Small joints, such as zygapophyseal joints, have synovial joints\u00a0on the upper and lower surfaces of the vertebrae. The upper facets are centered on the back and medial joint surface and interface with the contiguous vertebras' related joint surface. This structure results in flexion and contraction in contrast with\u00a0rotation or horizontal bending of the vertebral motion's remainder. This reduced flexibility for lateral stretching guides the vertebrae to be manipulated in lumbar HVLA. Spinal therapy is the most common method of manual care used to correct musculoskeletal disease.", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Anatomy and Physiology -- Spine\u00a0and Vertebra. Small joints, such as zygapophyseal joints, have synovial joints\u00a0on the upper and lower surfaces of the vertebrae. The upper facets are centered on the back and medial joint surface and interface with the contiguous vertebras' related joint surface. This structure results in flexion and contraction in contrast with\u00a0rotation or horizontal bending of the vertebral motion's remainder. This reduced flexibility for lateral stretching guides the vertebrae to be manipulated in lumbar HVLA. Spinal therapy is the most common method of manual care used to correct musculoskeletal disease."}
+{"id": "article-102984_18", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Anatomy and Physiology -- Spine\u00a0and Vertebra", "content": "This process\u00a0is very clearly separated from spinal mobilization by an external thrust. Hence, it is fair to assume that these two modes of therapy can have an equal impact and should thus be investigated separately, either clinically or through their modes of action. Usage results show that comparatively high speed and low amplitude\u00a0manual procedure occurs for most patients who undergo spinal manipulation. The health care worker immediately transmits a thrust to the target vertebra by a small lever arm following preloading of the vertebra tissues by physically touching the skin that is overlaid by the lamina, spiny, transverse, or laminar\u00a0mechanism to move the vertebra, gap its facet joints and produce mechanical, physiological, biological results.", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Anatomy and Physiology -- Spine\u00a0and Vertebra. This process\u00a0is very clearly separated from spinal mobilization by an external thrust. Hence, it is fair to assume that these two modes of therapy can have an equal impact and should thus be investigated separately, either clinically or through their modes of action. Usage results show that comparatively high speed and low amplitude\u00a0manual procedure occurs for most patients who undergo spinal manipulation. The health care worker immediately transmits a thrust to the target vertebra by a small lever arm following preloading of the vertebra tissues by physically touching the skin that is overlaid by the lamina, spiny, transverse, or laminar\u00a0mechanism to move the vertebra, gap its facet joints and produce mechanical, physiological, biological results."}
+{"id": "article-102984_19", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Anatomy and Physiology -- Spine\u00a0and Vertebra", "content": "An analysis of clinical evidence showed that spinal manipulation could help respond to back pain,\u00a0migraine, pain in the spine, upper and lower extremities, and whiplash-related disorders for many conditions. In specific adaptations, the whole spine or significant parts of it are controlled as a unit; others are small motions intended to impact a particular joint. [3] [4]", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Anatomy and Physiology -- Spine\u00a0and Vertebra. An analysis of clinical evidence showed that spinal manipulation could help respond to back pain,\u00a0migraine, pain in the spine, upper and lower extremities, and whiplash-related disorders for many conditions. In specific adaptations, the whole spine or significant parts of it are controlled as a unit; others are small motions intended to impact a particular joint. [3] [4]"}
+{"id": "article-102984_20", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Anatomy and Physiology -- Biomechanics", "content": "HVLA strategies aim to re-establish normal joint operations. They use a thrust force that hits a height from 220 to 889 N in a range of 75 to 225 mm that moves the vertebral, separates the facet joints, and causes mechanical, neurological, and biological effects. Up to 10 mm from the initially planned location is the initial point of contact. However, it is uncertain what significance these improvements have on the pathways underlying the efficacy of HVLA. [5] [6]", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Anatomy and Physiology -- Biomechanics. HVLA strategies aim to re-establish normal joint operations. They use a thrust force that hits a height from 220 to 889 N in a range of 75 to 225 mm that moves the vertebral, separates the facet joints, and causes mechanical, neurological, and biological effects. Up to 10 mm from the initially planned location is the initial point of contact. However, it is uncertain what significance these improvements have on the pathways underlying the efficacy of HVLA. [5] [6]"}
+{"id": "article-102984_21", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Anatomy and Physiology -- Neurophysiology", "content": "A\u00a0physiological barrier is a point at which soft tissue stress restricts the voluntary range of movement in an articulation. If the joint crosses a physiological barrier, it may cause additional movement to the anatomical barrier.\u00a0The anatomical barrier is when the bone curvature or body tissues (notably cartilage) become restricted to the passive range of motion.\u00a0The anatomical barrier is the final limit of motion in the joint.\u00a0Tissue damage can result from movement outside the anatomical barrier. [2]", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Anatomy and Physiology -- Neurophysiology. A\u00a0physiological barrier is a point at which soft tissue stress restricts the voluntary range of movement in an articulation. If the joint crosses a physiological barrier, it may cause additional movement to the anatomical barrier.\u00a0The anatomical barrier is when the bone curvature or body tissues (notably cartilage) become restricted to the passive range of motion.\u00a0The anatomical barrier is the final limit of motion in the joint.\u00a0Tissue damage can result from movement outside the anatomical barrier. [2]"}
+{"id": "article-102984_22", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Anatomy and Physiology -- Neurophysiology", "content": "An increasing body of reviewed literature indicates that neurophysiological changes occur after spinal stimulation, including neural plastic changes, motor neuron excitability alteration, and cortical drive increase.\u00a0One hypothesis is that the dispersion of carbon dioxide and nitrogen restores mutual function. In its liquid form, carbon dioxide\u00a0displaces a joint from its regular location. During a manipulative motion, the velocity created a guided force-the absorption of nitrogen, turning them from a liquid into a gaseous state and allowing the joint to return to normal articulation; this indicates that the range of motion is increased by cavitation. [7]", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Anatomy and Physiology -- Neurophysiology. An increasing body of reviewed literature indicates that neurophysiological changes occur after spinal stimulation, including neural plastic changes, motor neuron excitability alteration, and cortical drive increase.\u00a0One hypothesis is that the dispersion of carbon dioxide and nitrogen restores mutual function. In its liquid form, carbon dioxide\u00a0displaces a joint from its regular location. During a manipulative motion, the velocity created a guided force-the absorption of nitrogen, turning them from a liquid into a gaseous state and allowing the joint to return to normal articulation; this indicates that the range of motion is increased by cavitation. [7]"}
+{"id": "article-102984_23", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Anatomy and Physiology -- Neurophysiology", "content": "Carbon dioxide is dispersed by cavitation, which leads to audible joint pop. The vasodilatory effects of carbon dioxide promote increased blood flow, chemotaxis, and cell-attaining nutrients.\u00a0The joint's popping often follows a manipulative motion.\u00a0Crack noise or joint cavitation results from a gaseous bubble in the synovial fluid producing or collapsing.\u00a0Cineradiographic studies have documented increased joint space and production/breakdown of carbon dioxide gas after thrust manipulation.\u00a0Since carbon dioxide is the gas with the highest miscibility in the synovial fluid, this rise in carbon dioxide levels has been suggested as the mechanism for raising the range of motion after manipulation in the joint.", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Anatomy and Physiology -- Neurophysiology. Carbon dioxide is dispersed by cavitation, which leads to audible joint pop. The vasodilatory effects of carbon dioxide promote increased blood flow, chemotaxis, and cell-attaining nutrients.\u00a0The joint's popping often follows a manipulative motion.\u00a0Crack noise or joint cavitation results from a gaseous bubble in the synovial fluid producing or collapsing.\u00a0Cineradiographic studies have documented increased joint space and production/breakdown of carbon dioxide gas after thrust manipulation.\u00a0Since carbon dioxide is the gas with the highest miscibility in the synovial fluid, this rise in carbon dioxide levels has been suggested as the mechanism for raising the range of motion after manipulation in the joint."}
+{"id": "article-102984_24", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Anatomy and Physiology -- Neurophysiology", "content": "It has also been hypothesized that any reflex relaxation of the periarticular musculature will initiate the cavitation. After the manipulation, the joint takes about 15 minutes to rearrange the gas particles and make another cavitation sound.\u00a0Some people believe that nothing has changed because there is no noise; this assumption is often incorrect. Recent findings indicate no correlation between the presence of an audible pop in patients with non-radicular low back pain during joint manipulation and improvement in pain, ROM, and impairment. [5]", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Anatomy and Physiology -- Neurophysiology. It has also been hypothesized that any reflex relaxation of the periarticular musculature will initiate the cavitation. After the manipulation, the joint takes about 15 minutes to rearrange the gas particles and make another cavitation sound.\u00a0Some people believe that nothing has changed because there is no noise; this assumption is often incorrect. Recent findings indicate no correlation between the presence of an audible pop in patients with non-radicular low back pain during joint manipulation and improvement in pain, ROM, and impairment. [5]"}
+{"id": "article-102984_25", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Anatomy and Physiology -- Neurophysiology", "content": "There are several hypotheses from a physiological perspective as to why HVLA is an efficient method of care.\u00a0First, an HVLA thrust tends to stretch a contracted muscle, which, in turn, creates many afferent impulses to the central nervous system from the muscle spindles.\u00a0The central nervous system then reflexively sends an inhibitory impulsion to the muscle spindle to relax the muscle.\u00a0An alternative hypothesis suggests that the Golgi tendon receptors become activated instead of the muscle spindle, eventually relaxing the muscle. [1]", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Anatomy and Physiology -- Neurophysiology. There are several hypotheses from a physiological perspective as to why HVLA is an efficient method of care.\u00a0First, an HVLA thrust tends to stretch a contracted muscle, which, in turn, creates many afferent impulses to the central nervous system from the muscle spindles.\u00a0The central nervous system then reflexively sends an inhibitory impulsion to the muscle spindle to relax the muscle.\u00a0An alternative hypothesis suggests that the Golgi tendon receptors become activated instead of the muscle spindle, eventually relaxing the muscle. [1]"}
+{"id": "article-102984_26", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Indications -- Findings That Suggest An Individual Might Recieve Therapeutic Benefit From HVLA", "content": "Low back pain for 16 days or less/ more recent onset of low back pain. Hypomobility of the lumbar spine. All joints showing hypo-mobility", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Indications -- Findings That Suggest An Individual Might Recieve Therapeutic Benefit From HVLA. Low back pain for 16 days or less/ more recent onset of low back pain. Hypomobility of the lumbar spine. All joints showing hypo-mobility"}
+{"id": "article-102984_27", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Indications -- Findings That Suggest An Individual Might Not Receive Therapeutic Benefit From HVLA", "content": "Symptoms behind the knee Low back pain episodes increasing frequency High back pain is recurring or chronic. Just low back pain (no distal symptoms); no knee pain Peripheralization of action knee pain High scoring questionnaire values based on the presence of conditions such as, for example, the use of anticoagulant drugs, chronic osteoarticular pathologies, or traumas that alter the morphology of the joint, unspecified pain, recent surgery, and all conditions of clinical instability No spring test pain.", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Indications -- Findings That Suggest An Individual Might Not Receive Therapeutic Benefit From HVLA. Symptoms behind the knee Low back pain episodes increasing frequency High back pain is recurring or chronic. Just low back pain (no distal symptoms); no knee pain Peripheralization of action knee pain High scoring questionnaire values based on the presence of conditions such as, for example, the use of anticoagulant drugs, chronic osteoarticular pathologies, or traumas that alter the morphology of the joint, unspecified pain, recent surgery, and all conditions of clinical instability No spring test pain."}
+{"id": "article-102984_28", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Indications -- Eligibility", "content": "Not to\u00a0render manipulations: If osteoarthritis or osteoporosis is severely present in the spine If tumors or malignancies arise in the area If blood flow deficiency occurs inside the vertebral artery in the cervical field If a joint is bloodied If the joint has a loose body Max mutual substitutions Joints close a forum for the development Where a degenerative joint is present To reach a complete diagnosis", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Indications -- Eligibility. Not to\u00a0render manipulations: If osteoarthritis or osteoporosis is severely present in the spine If tumors or malignancies arise in the area If blood flow deficiency occurs inside the vertebral artery in the cervical field If a joint is bloodied If the joint has a loose body Max mutual substitutions Joints close a forum for the development Where a degenerative joint is present To reach a complete diagnosis"}
+{"id": "article-102984_29", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Contraindications", "content": "A contraindication is if the chance of damage to the patient exceeds its potential benefit. Indirect methods result in less risk for patients with acute injuries, serious diseases, undiagnosed disorders, or vulnerable conditions. The body is pushed away from the restriction into a tissue laxity position.\u00a0In these conditions, direct strategies wherein the transition occurs towards a restriction are far less applicable but are adequate and appropriate in many chronic diseases. Absolute Contraindications with Clinical Instability", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Contraindications. A contraindication is if the chance of damage to the patient exceeds its potential benefit. Indirect methods result in less risk for patients with acute injuries, serious diseases, undiagnosed disorders, or vulnerable conditions. The body is pushed away from the restriction into a tissue laxity position.\u00a0In these conditions, direct strategies wherein the transition occurs towards a restriction are far less applicable but are adequate and appropriate in many chronic diseases. Absolute Contraindications with Clinical Instability"}
+{"id": "article-102984_30", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Contraindications", "content": "Meningitis; dislocations; bone disease; cancer; cardiac diseases; rejection by patients, for example, thrombosis; nerve-damaged neurological disorders, damage to the spinal cord, and serious intervertebral disc-prolapse. [8] [9]", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Contraindications. Meningitis; dislocations; bone disease; cancer; cardiac diseases; rejection by patients, for example, thrombosis; nerve-damaged neurological disorders, damage to the spinal cord, and serious intervertebral disc-prolapse. [8] [9]"}
+{"id": "article-102984_31", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Contraindications -- Relative Contraindications", "content": "Ankylosing spondylitis, anticoagulant treatment, atherosclerosis, aspirin, warfarin, bone fracturing disorders, Down syndrome, heparin, herniated disk, hypochondriasis, hysteria, eptifibatide, Malingering, nerve root compression, osteoarthritis, osteoporosis, Patient hesitation, clopidogrel, extreme discomfort, ticlopidine, vertigo, extreme sprains, and strains. [8] [9]", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Contraindications -- Relative Contraindications. Ankylosing spondylitis, anticoagulant treatment, atherosclerosis, aspirin, warfarin, bone fracturing disorders, Down syndrome, heparin, herniated disk, hypochondriasis, hysteria, eptifibatide, Malingering, nerve root compression, osteoarthritis, osteoporosis, Patient hesitation, clopidogrel, extreme discomfort, ticlopidine, vertigo, extreme sprains, and strains. [8] [9]"}
+{"id": "article-102984_32", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Contraindications -- Relative Contraindications", "content": "The HVLA technique is not allowed by students due to the possible danger of regularly treating a uniform patient with a thrusting process to the same section on a given day. A 2010 analysis found that HVLA used less than 0.01\u00a0percent of cases out of 24,202 OMT documented instances. [10]", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Contraindications -- Relative Contraindications. The HVLA technique is not allowed by students due to the possible danger of regularly treating a uniform patient with a thrusting process to the same section on a given day. A 2010 analysis found that HVLA used less than 0.01\u00a0percent of cases out of 24,202 OMT documented instances. [10]"}
+{"id": "article-102984_33", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Equipment", "content": "The patient can be put on a cushioned bench specifically built to help therapists maintain the proper care configurations.\u00a0Although the hands are normally used, certain therapists might employ a tool to help with the adjustment.\u00a0Specially designed chairs and tables may be used to position the patient. [5]", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Equipment. The patient can be put on a cushioned bench specifically built to help therapists maintain the proper care configurations.\u00a0Although the hands are normally used, certain therapists might employ a tool to help with the adjustment.\u00a0Specially designed chairs and tables may be used to position the patient. [5]"}
+{"id": "article-102984_34", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Equipment -- Electromyography", "content": "This device\u00a0can be used\u00a0to ensure a regulated, recurring, quantifiable\u00a0HVLA technique. Studies have\u00a0shown that a rise in thrust intensity produces\u00a0linear changes in the magnitude of electromyography\u00a0responses evoked before and after the deceptive thrust. [11]", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Equipment -- Electromyography. This device\u00a0can be used\u00a0to ensure a regulated, recurring, quantifiable\u00a0HVLA technique. Studies have\u00a0shown that a rise in thrust intensity produces\u00a0linear changes in the magnitude of electromyography\u00a0responses evoked before and after the deceptive thrust. [11]"}
+{"id": "article-102984_35", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Personnel", "content": "The staff who apply this manual approach must have a previous internship process.", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Personnel. The staff who apply this manual approach must have a previous internship process."}
+{"id": "article-102984_36", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Preparation", "content": "Staff preparation includes a thorough theoretical and practical study of manual methodology. Patient preparation is linked to the description of the procedure and the patient's consent.", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Preparation. Staff preparation includes a thorough theoretical and practical study of manual methodology. Patient preparation is linked to the description of the procedure and the patient's consent."}
+{"id": "article-102984_37", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Technique or Treatment -- Methods", "content": "Identify restricted joint movement for all possible planes of motion Move the joint into its restriction for all planes Apply a short quick thrust through one of the restricted joint planes Retest motion", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Technique or Treatment -- Methods. Identify restricted joint movement for all possible planes of motion Move the joint into its restriction for all planes Apply a short quick thrust through one of the restricted joint planes Retest motion"}
+{"id": "article-102984_38", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Technique or Treatment -- Techniques", "content": "Diversified \u2014 This method is the high-speed, low-amplitude route typically synonymous with manual physiotherapy corrections. For this procedure, therapists use a fast torque (low amplitude) throughout varying joints to recover the flexibility and mobility range throughout the joint. The body of the patient is put in particular forms to maximize the spinal change. [5]", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Technique or Treatment -- Techniques. Diversified \u2014 This method is the high-speed, low-amplitude route typically synonymous with manual physiotherapy corrections. For this procedure, therapists use a fast torque (low amplitude) throughout varying joints to recover the flexibility and mobility range throughout the joint. The body of the patient is put in particular forms to maximize the spinal change. [5]"}
+{"id": "article-102984_39", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Technique or Treatment -- Techniques", "content": "Palmer Gonstead Adjustment \u2014\u00a0Although the Gonstead adaptation is an HVLA adaptation, close to the\u00a0previous technique, it varies in the assessment (localization) of the target joint and joint localization parameters.\u00a0To position the patient, devices such as the cervix chair\u00a0or the chest-knee table, specially built chairs, and tables can be used. [12]", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Technique or Treatment -- Techniques. Palmer Gonstead Adjustment \u2014\u00a0Although the Gonstead adaptation is an HVLA adaptation, close to the\u00a0previous technique, it varies in the assessment (localization) of the target joint and joint localization parameters.\u00a0To position the patient, devices such as the cervix chair\u00a0or the chest-knee table, specially built chairs, and tables can be used. [12]"}
+{"id": "article-102984_40", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Technique or Treatment -- Techniques", "content": "Thompson Terminal Point \u2014This technique involves physiotherapy treatment tables with areas that fall short distances through an\u00a0HVLA threshold, thus\u00a0promoting mobility by minimizing the table's component. This modification strategy is also used in preference or for a combination of more conventional diversified HVLA modifications. This\u00a0may or may not have the typical \"cracking tone,\" so this coercion method may also be viewed as a form of mobilization or gentle adaptation. [12]", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Technique or Treatment -- Techniques. Thompson Terminal Point \u2014This technique involves physiotherapy treatment tables with areas that fall short distances through an\u00a0HVLA threshold, thus\u00a0promoting mobility by minimizing the table's component. This modification strategy is also used in preference or for a combination of more conventional diversified HVLA modifications. This\u00a0may or may not have the typical \"cracking tone,\" so this coercion method may also be viewed as a form of mobilization or gentle adaptation. [12]"}
+{"id": "article-102984_41", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Technique or Treatment -- Techniques", "content": "Alternative Lumbar Manipulation \u2014\u00a0Other HVLA techniques\u00a0do\u00a0not explicitly\u00a0fall into\u00a0a direct or indirect model. Some techniques include soft tissue manipulation, which is\u00a0essentially a massage technique that reduces muscle tension.\u00a0For illustration, to make HVLA convenient, we\u00a0typically make the area with soft tissue techniques before conducting HVLA. [13]", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Technique or Treatment -- Techniques. Alternative Lumbar Manipulation \u2014\u00a0Other HVLA techniques\u00a0do\u00a0not explicitly\u00a0fall into\u00a0a direct or indirect model. Some techniques include soft tissue manipulation, which is\u00a0essentially a massage technique that reduces muscle tension.\u00a0For illustration, to make HVLA convenient, we\u00a0typically make the area with soft tissue techniques before conducting HVLA. [13]"}
+{"id": "article-102984_42", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Technique or Treatment -- Techniques", "content": "Balance\u00a0and Control \u2014\u00a0The practitioner and patient must have\u00a0a reasonably relaxed, comfortably controlled, and secure posture in their body.\u00a0For optimum placement,\u00a0the table should be at the appropriate height.\u00a0The patient has to be\u00a0put on the table properly.\u00a0While conducting the\u00a0thrust, the patient should be calm.\u00a0The thrust is better applied with (1) leverage used to change the joint with\u00a0the hand and/or forearms and (2) to position and focus the thrust into a particular joint. [5]", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Technique or Treatment -- Techniques. Balance\u00a0and Control \u2014\u00a0The practitioner and patient must have\u00a0a reasonably relaxed, comfortably controlled, and secure posture in their body.\u00a0For optimum placement,\u00a0the table should be at the appropriate height.\u00a0The patient has to be\u00a0put on the table properly.\u00a0While conducting the\u00a0thrust, the patient should be calm.\u00a0The thrust is better applied with (1) leverage used to change the joint with\u00a0the hand and/or forearms and (2) to position and focus the thrust into a particular joint. [5]"}
+{"id": "article-102984_43", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Complications", "content": "Patients' temporary side effects from manipulation\u00a0can persist undetected if nonspecific guidance to\u00a0patients is provided aftercare. Prospective research has\u00a0estimated that approximately 30\u00a0to 61%\u00a0\u00a0of patients encounter typical side effects arising from spinal stimulation. [14] [15] [16]", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Complications. Patients' temporary side effects from manipulation\u00a0can persist undetected if nonspecific guidance to\u00a0patients is provided aftercare. Prospective research has\u00a0estimated that approximately 30\u00a0to 61%\u00a0\u00a0of patients encounter typical side effects arising from spinal stimulation. [14] [15] [16]"}
+{"id": "article-102984_44", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Complications", "content": "Most often, localized tightness, headaches, weakness, soreness radiating, numbness, dizziness, exhaustion, rigidity, body warmth, and consciousness loss. Premature or severe menstruation, gastrointestinal\u00a0discomfort, twitching, dysrhythmia, and sweating\u00a0are the least frequent. [17] These intermittent side effects generally occur about 4 hours\u00a0after therapy and then improve throughout\u00a0the following 24 hours. [16]", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Complications. Most often, localized tightness, headaches, weakness, soreness radiating, numbness, dizziness, exhaustion, rigidity, body warmth, and consciousness loss. Premature or severe menstruation, gastrointestinal\u00a0discomfort, twitching, dysrhythmia, and sweating\u00a0are the least frequent. [17] These intermittent side effects generally occur about 4 hours\u00a0after therapy and then improve throughout\u00a0the following 24 hours. [16]"}
+{"id": "article-102984_45", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Complications", "content": "A\u00a0few individuals may develop a slight headache after cervical manipulation\u00a0or soreness after back stimulation.\u00a0In persons with delicate skin,\u00a0some erythema\u00a0and petechiae may\u00a0occur, which may persist for\u00a0hours.\u00a0As therapy progresses, some problems can resurface, and when treatment is\u00a0interrupted, effects can worsen.", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Complications. A\u00a0few individuals may develop a slight headache after cervical manipulation\u00a0or soreness after back stimulation.\u00a0In persons with delicate skin,\u00a0some erythema\u00a0and petechiae may\u00a0occur, which may persist for\u00a0hours.\u00a0As therapy progresses, some problems can resurface, and when treatment is\u00a0interrupted, effects can worsen."}
+{"id": "article-102984_46", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Clinical Significance -- Clinical Goals", "content": "Increase the movement capacity of a confined joint Realignment of skeletal components to recover natural joint receptor function at the treated level Reduce the hypertonicity of muscles and/or spasms to restore equilibrium to the joint-related muscles Extension of the joint-related reduced connective tissue", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Clinical Significance -- Clinical Goals. Increase the movement capacity of a confined joint Realignment of skeletal components to recover natural joint receptor function at the treated level Reduce the hypertonicity of muscles and/or spasms to restore equilibrium to the joint-related muscles Extension of the joint-related reduced connective tissue"}
+{"id": "article-102984_47", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Clinical Significance", "content": "Research \u2014 HVLA thrust techniques are commonly considered potentially riskier than other techniques because of their accelerated thrust and force operation. \u00a0As a result, the bulk of research\u00a0focuses\u00a0on the\u00a0adverse HVLA effects. \u00a0The most important side effects associated with\u00a0HVLA are those that combine\u00a0high-velocity thrusts with rotational techniques or anesthesia. Self-rotation or involuntary turning of the head has also been associated with\u00a0sudden and unintended injuries. In a\u00a0study that looked at\u00a0283 reviews, only 118\u00a0produced\u00a0adverse results.\u00a0Strokes, headaches, and vertebral artery dissection were\u00a0the most commonly described adverse effects. Of the 118 investigated,\u00a046%\u00a0indicated that HVLA\u00a0is safe, 13% indicated that HVLA was harmful, and\u00a042%\u00a0were\u00a0neutral or unknown to the effects of HVLA. [11]", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Clinical Significance. Research \u2014 HVLA thrust techniques are commonly considered potentially riskier than other techniques because of their accelerated thrust and force operation. \u00a0As a result, the bulk of research\u00a0focuses\u00a0on the\u00a0adverse HVLA effects. \u00a0The most important side effects associated with\u00a0HVLA are those that combine\u00a0high-velocity thrusts with rotational techniques or anesthesia. Self-rotation or involuntary turning of the head has also been associated with\u00a0sudden and unintended injuries. In a\u00a0study that looked at\u00a0283 reviews, only 118\u00a0produced\u00a0adverse results.\u00a0Strokes, headaches, and vertebral artery dissection were\u00a0the most commonly described adverse effects. Of the 118 investigated,\u00a046%\u00a0indicated that HVLA\u00a0is safe, 13% indicated that HVLA was harmful, and\u00a042%\u00a0were\u00a0neutral or unknown to the effects of HVLA. [11]"}
+{"id": "article-102984_48", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Clinical Significance", "content": "The American Osteopathic Healthcare Association focuses on the continual investigation of patient treatment, hospital visits, chronic pain,\u00a0women's chlamydia infection, deep venous thrombosis, and elderly fall prevention, in addition to the many above conditions. [11]", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Clinical Significance. The American Osteopathic Healthcare Association focuses on the continual investigation of patient treatment, hospital visits, chronic pain,\u00a0women's chlamydia infection, deep venous thrombosis, and elderly fall prevention, in addition to the many above conditions. [11]"}
+{"id": "article-102984_49", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Enhancing Healthcare Team Outcomes -- Skills", "content": "Teaching aids improve skill-based outcomes, patient safety, and overall team performance among physicians, nurses, pharmacists, and other health professionals. Studies have shown that teaching aids can improve the rate of skill acquisition. Additionally, it appears that mentoring, coaching, and feedback, in addition to training aids, are the most efficacious. [18] [19] [Level 4]", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Enhancing Healthcare Team Outcomes -- Skills. Teaching aids improve skill-based outcomes, patient safety, and overall team performance among physicians, nurses, pharmacists, and other health professionals. Studies have shown that teaching aids can improve the rate of skill acquisition. Additionally, it appears that mentoring, coaching, and feedback, in addition to training aids, are the most efficacious. [18] [19] [Level 4]"}
+{"id": "article-102984_50", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Enhancing Healthcare Team Outcomes -- Strategy", "content": "A cost-benefit-based approach to HVLA training amongst physicians, nurses, pharmacists, and other health professionals appears to be best. There is a significant gap in the cost-to-benefit ratio, such that teaching aids might be most effective within a defined curriculum structure. Studies seem to suggest that early implementation leads to longer-lasting consistency. At the same time, downstream implementation enhances more technical aspects of manipulation. Timing is an important consideration when designing curricula for training programs. Using lower ratios of\u00a0contact hours and teaching aids to augment practice may result in better performance gains when introduced later than if added early in the curriculum. Teaching aids and a hands-on approach may result in better performance gains when introduced later in the curriculum than earlier for programs with lower contact hours. [1] [20] [Level 4]", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Enhancing Healthcare Team Outcomes -- Strategy. A cost-benefit-based approach to HVLA training amongst physicians, nurses, pharmacists, and other health professionals appears to be best. There is a significant gap in the cost-to-benefit ratio, such that teaching aids might be most effective within a defined curriculum structure. Studies seem to suggest that early implementation leads to longer-lasting consistency. At the same time, downstream implementation enhances more technical aspects of manipulation. Timing is an important consideration when designing curricula for training programs. Using lower ratios of\u00a0contact hours and teaching aids to augment practice may result in better performance gains when introduced later than if added early in the curriculum. Teaching aids and a hands-on approach may result in better performance gains when introduced later in the curriculum than earlier for programs with lower contact hours. [1] [20] [Level 4]"}
+{"id": "article-102984_51", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Enhancing Healthcare Team Outcomes -- Ethics", "content": "To enhance the ethical aspects of HVLA in patient-centered care, clinicians, nurses, pharmacists, and other health professionals should consider the legality of HVLA techniques.\u00a0One study summarized the various legal\u00a0challenges. A survey of\u00a0California disciplinary data showed a case rate of 4.5 per 1000 chiropractors a year compared to 2.27 per year for physicians, with fraud incidents nine times higher among chiropractors (1.99 per 1000) than among physicians. [21] [22] [Level 5]", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Enhancing Healthcare Team Outcomes -- Ethics. To enhance the ethical aspects of HVLA in patient-centered care, clinicians, nurses, pharmacists, and other health professionals should consider the legality of HVLA techniques.\u00a0One study summarized the various legal\u00a0challenges. A survey of\u00a0California disciplinary data showed a case rate of 4.5 per 1000 chiropractors a year compared to 2.27 per year for physicians, with fraud incidents nine times higher among chiropractors (1.99 per 1000) than among physicians. [21] [22] [Level 5]"}
+{"id": "article-102984_52", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Enhancing Healthcare Team Outcomes -- Responsibilities", "content": "To enhance the role HVLA has in patient-centered care, physicians, nurses, pharmacists, and other health professionals must strive for uniformity.\u00a0A study investigated the significance of uniform standards. One\u00a0study looked at the Gonstead technique in\u00a081 simulated adjustments on a mannequin force plate.\u00a0Analysis of over 800 thrusts showed wide variations in peak loads.\u00a0Thrust rates are most\u00a0consistent\u00a0amongst clinicians. To improve the role HVLA has in outcomes, patient safety, and overall team performance, physicians, nurses, pharmacists, and other health professionals should therefore\u00a0focus on reproducibility. While reliability is relatively\u00a0high for manual rotational HVLA thrust on C1-C2, reliability for flexion-extension and lateral bending remains\u00a0low. [23] [24] [25] [Level 4]", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Enhancing Healthcare Team Outcomes -- Responsibilities. To enhance the role HVLA has in patient-centered care, physicians, nurses, pharmacists, and other health professionals must strive for uniformity.\u00a0A study investigated the significance of uniform standards. One\u00a0study looked at the Gonstead technique in\u00a081 simulated adjustments on a mannequin force plate.\u00a0Analysis of over 800 thrusts showed wide variations in peak loads.\u00a0Thrust rates are most\u00a0consistent\u00a0amongst clinicians. To improve the role HVLA has in outcomes, patient safety, and overall team performance, physicians, nurses, pharmacists, and other health professionals should therefore\u00a0focus on reproducibility. While reliability is relatively\u00a0high for manual rotational HVLA thrust on C1-C2, reliability for flexion-extension and lateral bending remains\u00a0low. [23] [24] [25] [Level 4]"}
+{"id": "article-102984_53", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Enhancing Healthcare Team Outcomes -- Interprofessional Communication", "content": "Clinicians, nurses, pharmacists, and other health professionals must also consider how the general public views manipulation and HVLA techniques. A paper described some of the\u00a0views concerning cervical spine manipulation.\u00a0HVLA is viewed unfavorably by mainstream medicine. Approximately 36% of respondents considered HVLA favorably. [26] [27] [Level 5]", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Enhancing Healthcare Team Outcomes -- Interprofessional Communication. Clinicians, nurses, pharmacists, and other health professionals must also consider how the general public views manipulation and HVLA techniques. A paper described some of the\u00a0views concerning cervical spine manipulation.\u00a0HVLA is viewed unfavorably by mainstream medicine. Approximately 36% of respondents considered HVLA favorably. [26] [27] [Level 5]"}
+{"id": "article-102984_54", "title": "High-Velocity Low-Amplitude Manipulation Techniques -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "High-Velocity Low-Amplitude Manipulation Techniques -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

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+{"id": "article-102985_0", "title": "Physiology, Muscle Energy -- Introduction", "content": "Muscle energy technique (MET) is a type of osteopathic manipulative medicine (OMM) developed by Fred Mitchell, Sr, DO. In 1948, Dr. Mitchell first described the kinematic motion of the pelvis. From this concept, and inspired by the work of the neurophysiologist Charles Sherrington, Dr. Mitchell developed a modality to treat muscular action dysfunction using the patient's muscle action. Sherrington's observation was that the contraction of an antagonistic muscle would help relax the agonistic muscle. [1] [2] [3] He named the modality Muscle Energy, which was designed to improve musculoskeletal function by mobilizing joints and stretching tight muscles and fascia; this reduced pain and improved circulation and lymphatic flow.", "contents": "Physiology, Muscle Energy -- Introduction. Muscle energy technique (MET) is a type of osteopathic manipulative medicine (OMM) developed by Fred Mitchell, Sr, DO. In 1948, Dr. Mitchell first described the kinematic motion of the pelvis. From this concept, and inspired by the work of the neurophysiologist Charles Sherrington, Dr. Mitchell developed a modality to treat muscular action dysfunction using the patient's muscle action. Sherrington's observation was that the contraction of an antagonistic muscle would help relax the agonistic muscle. [1] [2] [3] He named the modality Muscle Energy, which was designed to improve musculoskeletal function by mobilizing joints and stretching tight muscles and fascia; this reduced pain and improved circulation and lymphatic flow."}
+{"id": "article-102985_1", "title": "Physiology, Muscle Energy -- Introduction", "content": "MET can be applied in all body joints except the cranium. [1] [4] MET is a nontraumatic modality, and its application helps treat key lesions that are the root cause of many dysfunctions in the body. Understanding the intricacies of MET involves understanding the biomechanics of the human body; this knowledge can help make treatments with other modalities easier. For example, those with an in-depth understanding of human biomechanics can treat lesions of high velocity using less force and more precision. Though Dr. Mitchell's initial concept of MET involved muscle activation with post-isometric relaxation, many other physiological principles for MET have been developed. In today's MET, there are a total of 9 different physiological principles: crossed, extensor reflex, isolytic lengthening, isokinetic strengthening, joint mobilization using muscle force, respiratory assistance, oculocephalogyric reflex, reciprocal inhibition, muscle force in one region of the body to achieve movement in another and post-isometric relaxation. Of the 9 approaches, the most utilized is post-isometric relaxation. We will delve further into these principles in later chapters.", "contents": "Physiology, Muscle Energy -- Introduction. MET can be applied in all body joints except the cranium. [1] [4] MET is a nontraumatic modality, and its application helps treat key lesions that are the root cause of many dysfunctions in the body. Understanding the intricacies of MET involves understanding the biomechanics of the human body; this knowledge can help make treatments with other modalities easier. For example, those with an in-depth understanding of human biomechanics can treat lesions of high velocity using less force and more precision. Though Dr. Mitchell's initial concept of MET involved muscle activation with post-isometric relaxation, many other physiological principles for MET have been developed. In today's MET, there are a total of 9 different physiological principles: crossed, extensor reflex, isolytic lengthening, isokinetic strengthening, joint mobilization using muscle force, respiratory assistance, oculocephalogyric reflex, reciprocal inhibition, muscle force in one region of the body to achieve movement in another and post-isometric relaxation. Of the 9 approaches, the most utilized is post-isometric relaxation. We will delve further into these principles in later chapters."}
+{"id": "article-102985_2", "title": "Physiology, Muscle Energy -- Introduction", "content": "MET is a safe technique and can be used with inpatients to help decrease hospital stays. [5] [6] [7] [8] MET with post-isometric relaxation is generally contraindicated in patients with low vitality, certain post-surgical patients, or those in the ICU. They would benefit from MET using reciprocal inhibition, respiratory assist, or the oculocephlogyric reflex.", "contents": "Physiology, Muscle Energy -- Introduction. MET is a safe technique and can be used with inpatients to help decrease hospital stays. [5] [6] [7] [8] MET with post-isometric relaxation is generally contraindicated in patients with low vitality, certain post-surgical patients, or those in the ICU. They would benefit from MET using reciprocal inhibition, respiratory assist, or the oculocephlogyric reflex."}
+{"id": "article-102985_3", "title": "Physiology, Muscle Energy -- Introduction", "content": "Patients with a history of eye surgery are contraindicated for MET with oculocephalogyric reflex. As the treatment requires patient cooperation, patients should be able to understand and communicate easily with the clinician. Complications can be avoided if the clinicians correctly diagnose, localize the lesions, and use appropriate force.", "contents": "Physiology, Muscle Energy -- Introduction. Patients with a history of eye surgery are contraindicated for MET with oculocephalogyric reflex. As the treatment requires patient cooperation, patients should be able to understand and communicate easily with the clinician. Complications can be avoided if the clinicians correctly diagnose, localize the lesions, and use appropriate force."}
+{"id": "article-102985_4", "title": "Physiology, Muscle Energy -- Introduction", "content": "Understanding muscle physiology is essential for MET. There are 4 types of muscle contraction: isometric, concentric, eccentric, and isolytic. Isometric contraction is when the muscles contract without having the origin and insertion of the muscles approach each other. Concentric contraction is when the muscles shorten with contraction. Eccentric contraction is when the muscle lengthens with contraction, and isolytic contraction is when an external force lengthens muscle contraction. [9] The physiology of muscle contractions best explains the mechanism of action in MET.", "contents": "Physiology, Muscle Energy -- Introduction. Understanding muscle physiology is essential for MET. There are 4 types of muscle contraction: isometric, concentric, eccentric, and isolytic. Isometric contraction is when the muscles contract without having the origin and insertion of the muscles approach each other. Concentric contraction is when the muscles shorten with contraction. Eccentric contraction is when the muscle lengthens with contraction, and isolytic contraction is when an external force lengthens muscle contraction. [9] The physiology of muscle contractions best explains the mechanism of action in MET."}
+{"id": "article-102985_5", "title": "Physiology, Muscle Energy -- Issues of Concern", "content": "MET has clinical benefits, but there have been some anecdotal injuries using this technique. An inappropriate amount of force can cause tendon avulsion in geriatric patients. Rib fractures are also possible in those with osteoporosis. There have been stories of intraocular hemorrhage in a postcataract removal patient who had MET with oculocephalogyric reflex. Prioritizing precise diagnosis and localization and applying the appropriate force when using this technique is highly important.", "contents": "Physiology, Muscle Energy -- Issues of Concern. MET has clinical benefits, but there have been some anecdotal injuries using this technique. An inappropriate amount of force can cause tendon avulsion in geriatric patients. Rib fractures are also possible in those with osteoporosis. There have been stories of intraocular hemorrhage in a postcataract removal patient who had MET with oculocephalogyric reflex. Prioritizing precise diagnosis and localization and applying the appropriate force when using this technique is highly important."}
+{"id": "article-102985_6", "title": "Physiology, Muscle Energy -- Cellular Level", "content": "Understanding muscle anatomy and physiology is essential in MET. A muscle includes many spindles; each spindle comprises 3 to 12 intrafusal muscle fibers surrounded by a large extrafusal fiber. Each spindle has an efferent and an afferent neural component. Motor nerve fibers innervate the extrafusal fibers through the alpha motor neurons, and the gamma motor neurons innervate the intrafusal fibers. The Ia and II fibers innervate the muscle spindles' afferent (sensory) portions. The central portion of a muscle spindle does not have myofibrils and does not have contracting capabilities; however, the ends of these spindles do contract in response to gamma motor neurons. The Ib fibers innervate the Golgi tendon organs (GTO) in the myotendinous junctions. [10]", "contents": "Physiology, Muscle Energy -- Cellular Level. Understanding muscle anatomy and physiology is essential in MET. A muscle includes many spindles; each spindle comprises 3 to 12 intrafusal muscle fibers surrounded by a large extrafusal fiber. Each spindle has an efferent and an afferent neural component. Motor nerve fibers innervate the extrafusal fibers through the alpha motor neurons, and the gamma motor neurons innervate the intrafusal fibers. The Ia and II fibers innervate the muscle spindles' afferent (sensory) portions. The central portion of a muscle spindle does not have myofibrils and does not have contracting capabilities; however, the ends of these spindles do contract in response to gamma motor neurons. The Ib fibers innervate the Golgi tendon organs (GTO) in the myotendinous junctions. [10]"}
+{"id": "article-102985_7", "title": "Physiology, Muscle Energy -- Cellular Level", "content": "GTO is an encapsulated sensory receptor associated with 10 to 15 muscle fibers. They are stimulated to inhibit the muscle when exposed to contraction or stretching; this stimulation occurs by a negative feedback loop through the alpha neuron. When the tension on a muscle is too great, the GTO will contract to relax the entire muscle via the Ia fibers. [11] Dr. Mitchell initially hypothesized that the muscle is refractory after an isometric contraction, where it may be passively stretched without a reflexive contraction. In MET with post-isometric relaxation, the GTO is activated by increasing tension on the muscle fibers when the patient is asked to contract against a barrier. Once activated, there is a reflexive inhibition and relaxation of the muscle through the Ia fibers, and the clinician may further passively stretch the muscle due to the refractory state. Two reflex systems within a muscle unit play a role in MET: intrinsic and extrinsic reflex systems.", "contents": "Physiology, Muscle Energy -- Cellular Level. GTO is an encapsulated sensory receptor associated with 10 to 15 muscle fibers. They are stimulated to inhibit the muscle when exposed to contraction or stretching; this stimulation occurs by a negative feedback loop through the alpha neuron. When the tension on a muscle is too great, the GTO will contract to relax the entire muscle via the Ia fibers. [11] Dr. Mitchell initially hypothesized that the muscle is refractory after an isometric contraction, where it may be passively stretched without a reflexive contraction. In MET with post-isometric relaxation, the GTO is activated by increasing tension on the muscle fibers when the patient is asked to contract against a barrier. Once activated, there is a reflexive inhibition and relaxation of the muscle through the Ia fibers, and the clinician may further passively stretch the muscle due to the refractory state. Two reflex systems within a muscle unit play a role in MET: intrinsic and extrinsic reflex systems."}
+{"id": "article-102985_8", "title": "Physiology, Muscle Energy -- Cellular Level -- Intrinsic Reflex System", "content": "The basic functional unit in muscle physiology is called a myotactic unit, which includes a motor unit and the intrinsic sensory system from the muscle fibers. These sensory receptors comprise 2 types of intrafusal fibers: nuclear bag and nuclear chain (bundles together). The nuclear bag fibers extend beyond the capsule to attach to the endomysium, and the nuclear chain attaches to the inside of the capsule. [12] Nuclear bag receptors adapt to muscle length, velocity, and acceleration of contractions. The nuclear chain fibers slowly adapt to tension. There is a hypothesis that the alpha motor neuron is firing to contract the muscle to reduce the tension on the nuclear chain fibers in a somatic dysfunction. During MET with post-isometric relaxation, contracting the extrafusal muscles while the length of the muscle remains constant engages the nuclear bag fibers. This contracting reduces the nuclear chain, and the nuclear bag fibers quickly adapt to the stretch. The post-isometric stretch is complete without further elongating the bag fibers due to the refractory period from the decrease in gamma efferent discharge to the spindles.", "contents": "Physiology, Muscle Energy -- Cellular Level -- Intrinsic Reflex System. The basic functional unit in muscle physiology is called a myotactic unit, which includes a motor unit and the intrinsic sensory system from the muscle fibers. These sensory receptors comprise 2 types of intrafusal fibers: nuclear bag and nuclear chain (bundles together). The nuclear bag fibers extend beyond the capsule to attach to the endomysium, and the nuclear chain attaches to the inside of the capsule. [12] Nuclear bag receptors adapt to muscle length, velocity, and acceleration of contractions. The nuclear chain fibers slowly adapt to tension. There is a hypothesis that the alpha motor neuron is firing to contract the muscle to reduce the tension on the nuclear chain fibers in a somatic dysfunction. During MET with post-isometric relaxation, contracting the extrafusal muscles while the length of the muscle remains constant engages the nuclear bag fibers. This contracting reduces the nuclear chain, and the nuclear bag fibers quickly adapt to the stretch. The post-isometric stretch is complete without further elongating the bag fibers due to the refractory period from the decrease in gamma efferent discharge to the spindles."}
+{"id": "article-102985_9", "title": "Physiology, Muscle Energy -- Cellular Level -- Extrinsic Reflex System", "content": "In the extrinsic system, the alpha and gamma efferents of the muscle receive synaptic information from sensory nerves from other organs or muscles. This system includes reciprocal inhibition of antagonist muscles, pain avoidance, conditioned reflex, viscerosomatic reflexes, and muscle spasms. [13]", "contents": "Physiology, Muscle Energy -- Cellular Level -- Extrinsic Reflex System. In the extrinsic system, the alpha and gamma efferents of the muscle receive synaptic information from sensory nerves from other organs or muscles. This system includes reciprocal inhibition of antagonist muscles, pain avoidance, conditioned reflex, viscerosomatic reflexes, and muscle spasms. [13]"}
+{"id": "article-102985_10", "title": "Physiology, Muscle Energy -- Development", "content": "Before birth, the first evidence of GTOs is observable in aponeurosis, where Ib axons terminate within islets of collagen bundles and myotubules. [14] In the first postnatal week, the innervated core elongates as collagen bundles and Schwann cells proliferate. Within the capsule completed by day 2, collagen fibrils are placed between the Schwann cells and the terminal nerve ends. These collagen bundles link the muscle fiber tips to the aponeurosis, establishing the relationship of muscle tension to GTO activation. Muscular contraction applies force to the collagen bundles, stimulating the nerve endings within the GTO. [15] [16]", "contents": "Physiology, Muscle Energy -- Development. Before birth, the first evidence of GTOs is observable in aponeurosis, where Ib axons terminate within islets of collagen bundles and myotubules. [14] In the first postnatal week, the innervated core elongates as collagen bundles and Schwann cells proliferate. Within the capsule completed by day 2, collagen fibrils are placed between the Schwann cells and the terminal nerve ends. These collagen bundles link the muscle fiber tips to the aponeurosis, establishing the relationship of muscle tension to GTO activation. Muscular contraction applies force to the collagen bundles, stimulating the nerve endings within the GTO. [15] [16]"}
+{"id": "article-102985_11", "title": "Physiology, Muscle Energy -- Development", "content": "Muscle spindle differentiation starts around 11 weeks of gestation when the intrafusal and extrafusal fibers differentiate. The Ia afferent axon communicates to the spindle, prompting the formation of the nuclear bag, a term given to intrafusal fibers with multiple equatorial nuclei. [17] [18] Subsequently, the motor nerve supply reaches the spindle. [17] [19] The spindle matures between 24 to 31 weeks and increases in length after birth. [19]", "contents": "Physiology, Muscle Energy -- Development. Muscle spindle differentiation starts around 11 weeks of gestation when the intrafusal and extrafusal fibers differentiate. The Ia afferent axon communicates to the spindle, prompting the formation of the nuclear bag, a term given to intrafusal fibers with multiple equatorial nuclei. [17] [18] Subsequently, the motor nerve supply reaches the spindle. [17] [19] The spindle matures between 24 to 31 weeks and increases in length after birth. [19]"}
+{"id": "article-102985_12", "title": "Physiology, Muscle Energy -- Organ Systems Involved", "content": "The MET cannot directly affect organ systems, as this technique is used to treat the musculoskeletal system. However, it may affect and change certain organ system's functioning through viscerosomatic reflexes. [20] [21] Each organ system in the body has sympathetic and parasympathetic innervations dependent on where the nervous innervation arises in the spinal cord: sympathetic in the thoracolumbar region and parasympathetic in the sacral and cervical regions. Autonomic formation of the viscerosomatic reflex is beyond the scope of this topic. There is speculation that problems in specific viscera will present with somatic changes due to the innervation at that level called spinal facilitation. This facilitation sends increased output from the spinal cord, leading to changes in the alpha motor neuron and sympathetic outflow, causing increased pain. This facilitation can be treated using specific MET. [20]", "contents": "Physiology, Muscle Energy -- Organ Systems Involved. The MET cannot directly affect organ systems, as this technique is used to treat the musculoskeletal system. However, it may affect and change certain organ system's functioning through viscerosomatic reflexes. [20] [21] Each organ system in the body has sympathetic and parasympathetic innervations dependent on where the nervous innervation arises in the spinal cord: sympathetic in the thoracolumbar region and parasympathetic in the sacral and cervical regions. Autonomic formation of the viscerosomatic reflex is beyond the scope of this topic. There is speculation that problems in specific viscera will present with somatic changes due to the innervation at that level called spinal facilitation. This facilitation sends increased output from the spinal cord, leading to changes in the alpha motor neuron and sympathetic outflow, causing increased pain. This facilitation can be treated using specific MET. [20]"}
+{"id": "article-102985_13", "title": "Physiology, Muscle Energy -- Function", "content": "MET assumes that a shortened or contracted muscle maintains a somatic dysfunction. There are several hypotheses to the behaviors of such muscles: neuroreflexive (most likely), fibrosis, and congestion of muscle tissue (a cause of myofascial trigger points). MET approaches and treats the muscles using physiological principles and is not used to treat subluxations. There is currently no evidence to support the clinical benefit of treating subluxations. [22] [23] Another commonly believed restriction mechanism follows the Meniscoid Theory proposed by Emminger in 1967; this theory is more prevalent in Europe than North America and states that meniscoid between the facets causes restrictions in joint movement. [24]", "contents": "Physiology, Muscle Energy -- Function. MET assumes that a shortened or contracted muscle maintains a somatic dysfunction. There are several hypotheses to the behaviors of such muscles: neuroreflexive (most likely), fibrosis, and congestion of muscle tissue (a cause of myofascial trigger points). MET approaches and treats the muscles using physiological principles and is not used to treat subluxations. There is currently no evidence to support the clinical benefit of treating subluxations. [22] [23] Another commonly believed restriction mechanism follows the Meniscoid Theory proposed by Emminger in 1967; this theory is more prevalent in Europe than North America and states that meniscoid between the facets causes restrictions in joint movement. [24]"}
+{"id": "article-102985_14", "title": "Physiology, Muscle Energy -- Mechanism", "content": "As mentioned in the introduction, METs take advantage of the physiologic mechanisms of post-isometric relaxation and reciprocal inhibition, primarily to improve musculoskeletal function and reduce pain. MET is \"direct\" or \"indirect\" for a given joint based on the indication. [1]", "contents": "Physiology, Muscle Energy -- Mechanism. As mentioned in the introduction, METs take advantage of the physiologic mechanisms of post-isometric relaxation and reciprocal inhibition, primarily to improve musculoskeletal function and reduce pain. MET is \"direct\" or \"indirect\" for a given joint based on the indication. [1]"}
+{"id": "article-102985_15", "title": "Physiology, Muscle Energy -- Mechanism -- Post-isometric Relaxation", "content": "Golgi tendon organs (GTOs) are mechanoreceptors in most skeletal muscles. They are sensitive to muscular contractile force, and in contrast to muscle spindles, muscle stretches rarely and inconsistently activate GTOs. These encapsulated bundles of collagen are innervated by fast-conducting type Ib afferent fibers and are present at muscle-tendon or muscle-aponeurosis junctions; they attach to an individual muscle fascicle tendon on one end, and the whole muscle-tendon or aponeurosis of the other. This positioning, described as \"in-series,\" means the receptor is part of the functional unit and stands in contrast to the muscle spindle that operates adjacent to the functional unit \"in parallel.\" [15] [16] GTOs are activated at high levels of force and hypothetically inhibit muscle activity, preventing musculoskeletal injury. [25]", "contents": "Physiology, Muscle Energy -- Mechanism -- Post-isometric Relaxation. Golgi tendon organs (GTOs) are mechanoreceptors in most skeletal muscles. They are sensitive to muscular contractile force, and in contrast to muscle spindles, muscle stretches rarely and inconsistently activate GTOs. These encapsulated bundles of collagen are innervated by fast-conducting type Ib afferent fibers and are present at muscle-tendon or muscle-aponeurosis junctions; they attach to an individual muscle fascicle tendon on one end, and the whole muscle-tendon or aponeurosis of the other. This positioning, described as \"in-series,\" means the receptor is part of the functional unit and stands in contrast to the muscle spindle that operates adjacent to the functional unit \"in parallel.\" [15] [16] GTOs are activated at high levels of force and hypothetically inhibit muscle activity, preventing musculoskeletal injury. [25]"}
+{"id": "article-102985_16", "title": "Physiology, Muscle Energy -- Mechanism -- Post-isometric Relaxation", "content": "Physiologically, increased tension to the GTO prompts the activation of the type Ib afferent fibers that project to the spine, where they provide positive input on inhibitory interneurons that, in turn, add negative or inhibitory input on the efferent \u03b1-motor neurons that receive input from the cortex to the homonymous muscle. [26] In effect, sufficient GTO stimulation can override the efferent output from the brain, leading to relaxation. This phenomenon is known as the \"inverse stretch\" or the \"autogenic\" reflex. [27] [28] Dr. Mitchell Jr further postulated that there is a refractory state after an isometric contraction where passive stretching may be performed without a myostatic reflex opposition.", "contents": "Physiology, Muscle Energy -- Mechanism -- Post-isometric Relaxation. Physiologically, increased tension to the GTO prompts the activation of the type Ib afferent fibers that project to the spine, where they provide positive input on inhibitory interneurons that, in turn, add negative or inhibitory input on the efferent \u03b1-motor neurons that receive input from the cortex to the homonymous muscle. [26] In effect, sufficient GTO stimulation can override the efferent output from the brain, leading to relaxation. This phenomenon is known as the \"inverse stretch\" or the \"autogenic\" reflex. [27] [28] Dr. Mitchell Jr further postulated that there is a refractory state after an isometric contraction where passive stretching may be performed without a myostatic reflex opposition."}
+{"id": "article-102985_17", "title": "Physiology, Muscle Energy -- Mechanism -- Post-isometric Relaxation", "content": "The patients are usually placed into the barrier and asked to contract against the clinician. They are then asked to relax. This phase is refractory, where a new barrier can be reached, and the process is repeated.", "contents": "Physiology, Muscle Energy -- Mechanism -- Post-isometric Relaxation. The patients are usually placed into the barrier and asked to contract against the clinician. They are then asked to relax. This phase is refractory, where a new barrier can be reached, and the process is repeated."}
+{"id": "article-102985_18", "title": "Physiology, Muscle Energy -- Mechanism -- Joint Mobilization Using Muscle Force", "content": "This principle works off the Meniscoid theory as described above. A distortion of articulation and motion loss leads to reflexive hypertonicity of the muscles crossing the joint. The reflexive hypertonicity further compresses the dysfunctional joint surface and leads to the thinning of the synovial fluid layers and adherence of both joint surfaces. Treating the segment requires the maximum force the clinician can tolerate to \"reseat\" the joint and reflexively relax the hypertonic muscle.", "contents": "Physiology, Muscle Energy -- Mechanism -- Joint Mobilization Using Muscle Force. This principle works off the Meniscoid theory as described above. A distortion of articulation and motion loss leads to reflexive hypertonicity of the muscles crossing the joint. The reflexive hypertonicity further compresses the dysfunctional joint surface and leads to the thinning of the synovial fluid layers and adherence of both joint surfaces. Treating the segment requires the maximum force the clinician can tolerate to \"reseat\" the joint and reflexively relax the hypertonic muscle."}
+{"id": "article-102985_19", "title": "Physiology, Muscle Energy -- Mechanism -- Respiratory Assists", "content": "The clinician holds a fulcrum using the motion of the ribs or the subtle movement of the spine/pelvis during respiration, allowing the respiratory forces to work. This technique frequently treats somatic dysfunctions in the ribs and sacrum.", "contents": "Physiology, Muscle Energy -- Mechanism -- Respiratory Assists. The clinician holds a fulcrum using the motion of the ribs or the subtle movement of the spine/pelvis during respiration, allowing the respiratory forces to work. This technique frequently treats somatic dysfunctions in the ribs and sacrum."}
+{"id": "article-102985_20", "title": "Physiology, Muscle Energy -- Mechanism -- Reciprocal Inhibition", "content": "Muscle spindles are stretch-sensitive mechanoreceptors found in skeletal muscle. A muscle spindle is a bundle of striated, intrafusal muscle fibers within the fascicles of force-producing, extrafusal muscle fibers. \"Fusal\" derives from the term \"fusiform,\" meaning spindle-shaped. Any stretch or change in the length of the extrafusal fibers results in a stretch of the intrafusal fibers, which is then detected in the equatorial and polar regions of the muscle spindle. This physiology stands in contrast to GTOs, which are relatively insensate to passive changes in length but respond to an increase in muscle force. Two afferents, primary (type Ia) and secondary (type II), measure the stretch sensation. A single Ia fiber is present, along with between 0 to 5 II fibers per spindle. [29]", "contents": "Physiology, Muscle Energy -- Mechanism -- Reciprocal Inhibition. Muscle spindles are stretch-sensitive mechanoreceptors found in skeletal muscle. A muscle spindle is a bundle of striated, intrafusal muscle fibers within the fascicles of force-producing, extrafusal muscle fibers. \"Fusal\" derives from the term \"fusiform,\" meaning spindle-shaped. Any stretch or change in the length of the extrafusal fibers results in a stretch of the intrafusal fibers, which is then detected in the equatorial and polar regions of the muscle spindle. This physiology stands in contrast to GTOs, which are relatively insensate to passive changes in length but respond to an increase in muscle force. Two afferents, primary (type Ia) and secondary (type II), measure the stretch sensation. A single Ia fiber is present, along with between 0 to 5 II fibers per spindle. [29]"}
+{"id": "article-102985_21", "title": "Physiology, Muscle Energy -- Mechanism -- Reciprocal Inhibition", "content": "The Ia fiber is comparable in size and speed of transmission to the previously mentioned Ib fibers and supplies all intrafusal fibers in the spindle at the equatorial region. [15] The exact function of type II fibers is less understood; however, these smaller fibers terminate on the polar ends of the spindle. Muscle spindles are unique among proprioceptors in that efferent fibers innervate them. These myelinated \u03b3-motor neurons derive from the same efferents that supply the extrafusal muscle. Excitation of these \u03b3-motor neurons does not affect overall muscle tension but appears to maintain tension on the muscle spindles to track the length of the extrafusal fibers effectively. Lastly, spindle afferents are tonically active, with an increased firing rate in response to passive stretch in a velocity-dependent manner. [29]", "contents": "Physiology, Muscle Energy -- Mechanism -- Reciprocal Inhibition. The Ia fiber is comparable in size and speed of transmission to the previously mentioned Ib fibers and supplies all intrafusal fibers in the spindle at the equatorial region. [15] The exact function of type II fibers is less understood; however, these smaller fibers terminate on the polar ends of the spindle. Muscle spindles are unique among proprioceptors in that efferent fibers innervate them. These myelinated \u03b3-motor neurons derive from the same efferents that supply the extrafusal muscle. Excitation of these \u03b3-motor neurons does not affect overall muscle tension but appears to maintain tension on the muscle spindles to track the length of the extrafusal fibers effectively. Lastly, spindle afferents are tonically active, with an increased firing rate in response to passive stretch in a velocity-dependent manner. [29]"}
+{"id": "article-102985_22", "title": "Physiology, Muscle Energy -- Mechanism -- Reciprocal Inhibition", "content": "Physiologically, stretch to a muscle fiber produces activation of Ia muscle spindle afferents that project to the spine and activate the efferent \u03b1-motor neurons and, subsequently, the \u03b3-motor neurons of the homonymous muscle, leading to contraction of the intra- and extrafusal fibers. Simultaneously, the Ia fibers activate inhibitory interneurons in the spine to inhibit the \u03b1-motor neurons of the antagonist's\u00a0muscle. This circuit is called\u00a0the stretch reflex, believed to prevent muscle strain and support bipedal walking and posture. [30] [31] [32] [33] [34] This principle is used when contracting the antagonist to relax the dysfunctional agonist muscle.", "contents": "Physiology, Muscle Energy -- Mechanism -- Reciprocal Inhibition. Physiologically, stretch to a muscle fiber produces activation of Ia muscle spindle afferents that project to the spine and activate the efferent \u03b1-motor neurons and, subsequently, the \u03b3-motor neurons of the homonymous muscle, leading to contraction of the intra- and extrafusal fibers. Simultaneously, the Ia fibers activate inhibitory interneurons in the spine to inhibit the \u03b1-motor neurons of the antagonist's\u00a0muscle. This circuit is called\u00a0the stretch reflex, believed to prevent muscle strain and support bipedal walking and posture. [30] [31] [32] [33] [34] This principle is used when contracting the antagonist to relax the dysfunctional agonist muscle."}
+{"id": "article-102985_23", "title": "Physiology, Muscle Energy -- Mechanism -- Oculocephalogyric Reflex", "content": "The oculocephalogyric reflex approach to MET can gently treat an unstable segment in the upper cervical spine using eye motion. This reflex is not fully understood but is related to the doll's eye and vestibulo-ocular reflex. [35] [36] Nerves for the extraocular muscles are sent to the vestibular nuclei via the ophthalmic division of the trigeminal nerve. Information from the vestibular nuclei then travels down the medial and lateral vestibulospinal tract. The medial tract specifically goes to C1, which may branch into the suboccipital muscles, allowing motion within the suboccipital muscles. [37] This approach is useful if the patient has severe pain in the upper cervical spine or if upper cervical instability is suspected. The patient is set up to look toward a stimulus to test the reflex.", "contents": "Physiology, Muscle Energy -- Mechanism -- Oculocephalogyric Reflex. The oculocephalogyric reflex approach to MET can gently treat an unstable segment in the upper cervical spine using eye motion. This reflex is not fully understood but is related to the doll's eye and vestibulo-ocular reflex. [35] [36] Nerves for the extraocular muscles are sent to the vestibular nuclei via the ophthalmic division of the trigeminal nerve. Information from the vestibular nuclei then travels down the medial and lateral vestibulospinal tract. The medial tract specifically goes to C1, which may branch into the suboccipital muscles, allowing motion within the suboccipital muscles. [37] This approach is useful if the patient has severe pain in the upper cervical spine or if upper cervical instability is suspected. The patient is set up to look toward a stimulus to test the reflex."}
+{"id": "article-102985_24", "title": "Physiology, Muscle Energy -- Mechanism -- Crossed Extensor Reflex", "content": "MET uses the concept of crossed extensor reflex in the extremities when muscle damage occurs. Voluntary contraction will inhibit the same contralateral muscle and activate the contralateral antagonist muscle. [38] An example of the reflex is if one flexes their quads to lift their legs due to stepping on a nail, and the contralateral hamstring muscle contracts to help stabilize. During the signaling pathway, the efferent nerves will communicate with multiple interneurons at the level of the spinal cord, where one will relay the message to the contralateral agonist muscle to relax.", "contents": "Physiology, Muscle Energy -- Mechanism -- Crossed Extensor Reflex. MET uses the concept of crossed extensor reflex in the extremities when muscle damage occurs. Voluntary contraction will inhibit the same contralateral muscle and activate the contralateral antagonist muscle. [38] An example of the reflex is if one flexes their quads to lift their legs due to stepping on a nail, and the contralateral hamstring muscle contracts to help stabilize. During the signaling pathway, the efferent nerves will communicate with multiple interneurons at the level of the spinal cord, where one will relay the message to the contralateral agonist muscle to relax."}
+{"id": "article-102985_25", "title": "Physiology, Muscle Energy -- Mechanism -- Isokinetic Strengthening", "content": "This approach to MET is to help strengthen the muscle. A concentric contraction is utilized, and the muscle can shorten at a controlled rate. It is advised to first treat any shortening of an antagonistic muscle before performing strengthening treatments. For example, the quadriceps may be weakened due to hypertonic/shortened hamstrings; treatment would begin with treating the shortened hamstring muscles followed by isokinetic quadriceps strengthening.", "contents": "Physiology, Muscle Energy -- Mechanism -- Isokinetic Strengthening. This approach to MET is to help strengthen the muscle. A concentric contraction is utilized, and the muscle can shorten at a controlled rate. It is advised to first treat any shortening of an antagonistic muscle before performing strengthening treatments. For example, the quadriceps may be weakened due to hypertonic/shortened hamstrings; treatment would begin with treating the shortened hamstring muscles followed by isokinetic quadriceps strengthening."}
+{"id": "article-102985_26", "title": "Physiology, Muscle Energy -- Mechanism -- Isolytic Lengthening", "content": "This approach is used to lengthen a muscle shortened by contracture of fibrosis. An isolytic contraction occurs because the clinician's force overcomes the contracture of the patient. The clinician applies a vibratory motion while performing the technique, as there is anecdotal evidence that it can help break up fibrosis and circulation.", "contents": "Physiology, Muscle Energy -- Mechanism -- Isolytic Lengthening. This approach is used to lengthen a muscle shortened by contracture of fibrosis. An isolytic contraction occurs because the clinician's force overcomes the contracture of the patient. The clinician applies a vibratory motion while performing the technique, as there is anecdotal evidence that it can help break up fibrosis and circulation."}
+{"id": "article-102985_27", "title": "Physiology, Muscle Energy -- Mechanism -- Coordinated Motor Movement", "content": "This approach to MET involves moving adjacent body parts to treat the somatic dysfunction. It is thought that muscle contraction during the motion of the adjacent regions will also affect the area of dysfunction. An example is the treatment of a bilaterally extended sacrum; the patient is asked to push the pelvis and leg to help treat the sacral dysfunction.", "contents": "Physiology, Muscle Energy -- Mechanism -- Coordinated Motor Movement. This approach to MET involves moving adjacent body parts to treat the somatic dysfunction. It is thought that muscle contraction during the motion of the adjacent regions will also affect the area of dysfunction. An example is the treatment of a bilaterally extended sacrum; the patient is asked to push the pelvis and leg to help treat the sacral dysfunction."}
+{"id": "article-102985_28", "title": "Physiology, Muscle Energy -- Related Testing", "content": "To successfully perform MET, it is imperative to have the correct diagnosis. Often, Fryette's laws of spinal mechanics are used to diagnose MET; there are 3 laws of spinal mechanics, according to Fryette: In a neutral position, the segments will side bend and rotate to the opposite side In a non-neutral spinal position, the segments will side-bend\u00a0and rotate in the same direction A motion in one plane will reduce the motions in the other two planes of the spinal segment [39]", "contents": "Physiology, Muscle Energy -- Related Testing. To successfully perform MET, it is imperative to have the correct diagnosis. Often, Fryette's laws of spinal mechanics are used to diagnose MET; there are 3 laws of spinal mechanics, according to Fryette: In a neutral position, the segments will side bend and rotate to the opposite side In a non-neutral spinal position, the segments will side-bend\u00a0and rotate in the same direction A motion in one plane will reduce the motions in the other two planes of the spinal segment [39]"}
+{"id": "article-102985_29", "title": "Physiology, Muscle Energy -- Pathophysiology", "content": "The increased muscle tone purportedly treated by MET is comparable to that of the hypertonicity or spasticity that presents in upper motor neuron disease. [1] [40] Increased activity of the extrafusal muscle fibers is secondary to either increased activity of the muscle spindle or abnormal sensory processing in the spinal cord. In the former, increased activity of \u03b3-motor neurons leads to abnormally shortened muscle spindles, resulting in a hyperexcitable state such that movement within the physiologic range of motion produces reflexive muscular contraction. Similarly, type II fibers are hypothesized to contribute to spasticity through direct \u03b1-motor neuron activation. [40]", "contents": "Physiology, Muscle Energy -- Pathophysiology. The increased muscle tone purportedly treated by MET is comparable to that of the hypertonicity or spasticity that presents in upper motor neuron disease. [1] [40] Increased activity of the extrafusal muscle fibers is secondary to either increased activity of the muscle spindle or abnormal sensory processing in the spinal cord. In the former, increased activity of \u03b3-motor neurons leads to abnormally shortened muscle spindles, resulting in a hyperexcitable state such that movement within the physiologic range of motion produces reflexive muscular contraction. Similarly, type II fibers are hypothesized to contribute to spasticity through direct \u03b1-motor neuron activation. [40]"}
+{"id": "article-102985_30", "title": "Physiology, Muscle Energy -- Clinical Significance", "content": "As mentioned in the introduction, MET primarily serves to improve the range of motion and reduce pain. [1] [4] These techniques are used by physicians (osteopathic and allopathic) as well as physical therapists and chiropractors for primary or adjunctive therapy. [41] In the case of the former, MET is commonly used to reduce pain secondary to hypertonicity in the back, neck, and other major joints. However, this modality may hypothetically treat nearly any joint in the body. [42] [43] As for the latter, MET, in addition to standard-of-care treatment and other osteopathic techniques, has been demonstrated to improve outcomes in conditions such as pneumonia and fibromyalgia. In these cases, the complementary effects are attributed to fascial stretching, which is proposed to improve lymphatic and hemodynamic function. [44] [45]", "contents": "Physiology, Muscle Energy -- Clinical Significance. As mentioned in the introduction, MET primarily serves to improve the range of motion and reduce pain. [1] [4] These techniques are used by physicians (osteopathic and allopathic) as well as physical therapists and chiropractors for primary or adjunctive therapy. [41] In the case of the former, MET is commonly used to reduce pain secondary to hypertonicity in the back, neck, and other major joints. However, this modality may hypothetically treat nearly any joint in the body. [42] [43] As for the latter, MET, in addition to standard-of-care treatment and other osteopathic techniques, has been demonstrated to improve outcomes in conditions such as pneumonia and fibromyalgia. In these cases, the complementary effects are attributed to fascial stretching, which is proposed to improve lymphatic and hemodynamic function. [44] [45]"}
+{"id": "article-102985_31", "title": "Physiology, Muscle Energy -- Clinical Significance", "content": "A handful of metanalyses have been performed to assess MET's effectiveness in treating various conditions, particularly low back pain. While some yielded mixed results, there is an apparent consensus on the positive effects of MET on low back pain, with insufficient and inconsistent evidence to support its use in other circumstances. [1] [42] [46] [41] Additional research has demonstrated decreased motor excitability in the lumbar spine, leading to enhanced function. [47]", "contents": "Physiology, Muscle Energy -- Clinical Significance. A handful of metanalyses have been performed to assess MET's effectiveness in treating various conditions, particularly low back pain. While some yielded mixed results, there is an apparent consensus on the positive effects of MET on low back pain, with insufficient and inconsistent evidence to support its use in other circumstances. [1] [42] [46] [41] Additional research has demonstrated decreased motor excitability in the lumbar spine, leading to enhanced function. [47]"}
+{"id": "article-102985_32", "title": "Physiology, Muscle Energy -- Clinical Significance", "content": "The effectiveness of MET is dependent on diagnosis, localization, and the amount of force used. Differentiating between a key lesion and a compensatory change in diagnosis is important. An example is when a somatic dysfunction at the L5 often causes a compensatory change at the sacral base. [48] Treating the compensation will not correct the patient's presenting symptoms. Awareness of one lesion's fascial factors on another is also critical. Although a segmental diagnosis is identified, significant side bending restriction in the segment above actively causes fascial strain, potentially leading to treatment difficulty in the identified segmental somatic dysfunction. As in all aspects of osteopathy, diagnosing the patient accurately and considering the broader clinical context is essential.", "contents": "Physiology, Muscle Energy -- Clinical Significance. The effectiveness of MET is dependent on diagnosis, localization, and the amount of force used. Differentiating between a key lesion and a compensatory change in diagnosis is important. An example is when a somatic dysfunction at the L5 often causes a compensatory change at the sacral base. [48] Treating the compensation will not correct the patient's presenting symptoms. Awareness of one lesion's fascial factors on another is also critical. Although a segmental diagnosis is identified, significant side bending restriction in the segment above actively causes fascial strain, potentially leading to treatment difficulty in the identified segmental somatic dysfunction. As in all aspects of osteopathy, diagnosing the patient accurately and considering the broader clinical context is essential."}
+{"id": "article-102985_33", "title": "Physiology, Muscle Energy -- Clinical Significance", "content": "Using an excessive amount of force is a common mistake that is made by those new to MET. When using excessive force, a larger group of muscles is engaged to help stabilize the segment being treated. Further stability in the treated segment will negate the effects of muscle energy. Using 5 to 10 pounds of force during MET is commonly taught. However, experienced clinicians use enough force to observe a change in the relevant segment without recruiting surrounding muscles.", "contents": "Physiology, Muscle Energy -- Clinical Significance. Using an excessive amount of force is a common mistake that is made by those new to MET. When using excessive force, a larger group of muscles is engaged to help stabilize the segment being treated. Further stability in the treated segment will negate the effects of muscle energy. Using 5 to 10 pounds of force during MET is commonly taught. However, experienced clinicians use enough force to observe a change in the relevant segment without recruiting surrounding muscles."}
+{"id": "article-102985_34", "title": "Physiology, Muscle Energy -- Clinical Significance", "content": "Lastly, the localization of the force is more important than the amount of force. Position the body so the force applied is on the treated segmental joint. Clinicians should make subtle changes depending on the anatomic variability between individual patients. For example, the sacrum is known to have 3 transverse axes and 2 oblique axes. The middle transverse axis is where the sacrum moves about the innominate, and the inferior transverse axis is where the innominate moves against the sacrum. A clinician treating an anterior innominate would want to flex the hip until the inferior transverse axis is engaged. Flexing too much or too little will not engage the proper joint segment and decrease the chance of successful treatment. MET with post-isometric relaxation is the most commonly used modality and entails the following steps:", "contents": "Physiology, Muscle Energy -- Clinical Significance. Lastly, the localization of the force is more important than the amount of force. Position the body so the force applied is on the treated segmental joint. Clinicians should make subtle changes depending on the anatomic variability between individual patients. For example, the sacrum is known to have 3 transverse axes and 2 oblique axes. The middle transverse axis is where the sacrum moves about the innominate, and the inferior transverse axis is where the innominate moves against the sacrum. A clinician treating an anterior innominate would want to flex the hip until the inferior transverse axis is engaged. Flexing too much or too little will not engage the proper joint segment and decrease the chance of successful treatment. MET with post-isometric relaxation is the most commonly used modality and entails the following steps:"}
+{"id": "article-102985_35", "title": "Physiology, Muscle Energy -- Clinical Significance", "content": "The target joint or muscle barrier is isolated through joint positioning, generally to a pathologic barrier. Follow with active muscle contraction by the patient in a specific direction, generally away from the restriction, for a specified period against clinician-applied counterforce. Conventionally, the amount of force generated by the patient should be the maximum amount comfortably tolerated by both the patient and the clinician. Have the patient relaxation of the contracted muscle. Use passive movement of the patient's anatomy toward a new pathologic barrier. Repeat steps 1 to 4 as tolerated until physiologic pain is sufficiently relieved, or the patient achieves the desired range of motion. [41]", "contents": "Physiology, Muscle Energy -- Clinical Significance. The target joint or muscle barrier is isolated through joint positioning, generally to a pathologic barrier. Follow with active muscle contraction by the patient in a specific direction, generally away from the restriction, for a specified period against clinician-applied counterforce. Conventionally, the amount of force generated by the patient should be the maximum amount comfortably tolerated by both the patient and the clinician. Have the patient relaxation of the contracted muscle. Use passive movement of the patient's anatomy toward a new pathologic barrier. Repeat steps 1 to 4 as tolerated until physiologic pain is sufficiently relieved, or the patient achieves the desired range of motion. [41]"}
+{"id": "article-102985_36", "title": "Physiology, Muscle Energy -- Clinical Significance", "content": "Different protocols have been developed for each step within this framework, including duration and strength of contraction, duration of rest, and the number of repetitions. [1] [49] [50] [51] For example, the Greenman method proposes a 5- to 7-second\u00a0relaxation step and 3 to 5 repetitions overall. [1]", "contents": "Physiology, Muscle Energy -- Clinical Significance. Different protocols have been developed for each step within this framework, including duration and strength of contraction, duration of rest, and the number of repetitions. [1] [49] [50] [51] For example, the Greenman method proposes a 5- to 7-second\u00a0relaxation step and 3 to 5 repetitions overall. [1]"}
+{"id": "article-102985_37", "title": "Physiology, Muscle Energy -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Physiology, Muscle Energy -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

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+{"id": "article-102987_0", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Introduction", "content": "Osteopathic manipulative techniques can be classified as direct or indirect. A direct technique\u00a0requires positioning the patient\u00a0against a barrier. In contrast, an indirect technique\u00a0entails placing the patient\u00a0in\u00a0a position of ease. [1] Strain-counterstrain\u00a0(SCS), aka Counterstrain\u00a0(CS), and Facilitated Positional Release (FPR) are two commonly used indirect oseomanipulative techniques.\u00a0SCS\u00a0is a soft tissue technique\u00a0that passively treats musculoskeletal pain,\u00a0impaired range of motion, and somatic dysfunction by\u00a0influencing the cellular function of the tissues being treated. [2] [3]", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Introduction. Osteopathic manipulative techniques can be classified as direct or indirect. A direct technique\u00a0requires positioning the patient\u00a0against a barrier. In contrast, an indirect technique\u00a0entails placing the patient\u00a0in\u00a0a position of ease. [1] Strain-counterstrain\u00a0(SCS), aka Counterstrain\u00a0(CS), and Facilitated Positional Release (FPR) are two commonly used indirect oseomanipulative techniques.\u00a0SCS\u00a0is a soft tissue technique\u00a0that passively treats musculoskeletal pain,\u00a0impaired range of motion, and somatic dysfunction by\u00a0influencing the cellular function of the tissues being treated. [2] [3]"}
+{"id": "article-102987_1", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Introduction", "content": "Dr. Lawrence Jones developed SCS in 1955 when he encountered a particularly challenging back pain case at his clinic. The patient improved after remaining for some time in a position of ease where Dr. Jones put him. The same technique produced\u00a0similar results in other patients. These encounters helped Dr. Jones discover \"tenderpoints,\"\u00a0or\u00a0areas where pain is most pronounced in a muscle group. Tenderpoints have concomitant soft tissue textural changes at sites that would not usually cause pain. Proper management rests on identifying these areas.", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Introduction. Dr. Lawrence Jones developed SCS in 1955 when he encountered a particularly challenging back pain case at his clinic. The patient improved after remaining for some time in a position of ease where Dr. Jones put him. The same technique produced\u00a0similar results in other patients. These encounters helped Dr. Jones discover \"tenderpoints,\"\u00a0or\u00a0areas where pain is most pronounced in a muscle group. Tenderpoints have concomitant soft tissue textural changes at sites that would not usually cause pain. Proper management rests on identifying these areas."}
+{"id": "article-102987_2", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Introduction", "content": "SCS uses palpation and physician feedback to manipulate the soft tissues or joints into a position of ease, away from the restrictive barrier. Compressing or shortening the area of dysfunction relaxes the guarded muscles. [4]", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Introduction. SCS uses palpation and physician feedback to manipulate the soft tissues or joints into a position of ease, away from the restrictive barrier. Compressing or shortening the area of dysfunction relaxes the guarded muscles. [4]"}
+{"id": "article-102987_3", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Introduction", "content": "FPR is similar to SCS\u00a0in that the physician places the patient\u00a0in a position of comfort after identifying a sore area.\u00a0However, an additional activating force is applied to relax the affected muscle faster.\u00a0Stanley Schiowitz developed this technique in 1990. [5]", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Introduction. FPR is similar to SCS\u00a0in that the physician places the patient\u00a0in a position of comfort after identifying a sore area.\u00a0However, an additional activating force is applied to relax the affected muscle faster.\u00a0Stanley Schiowitz developed this technique in 1990. [5]"}
+{"id": "article-102987_4", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Issues of Concern", "content": "Clinical research on\u00a0the physiologic basis of\u00a0SCS and FPR is currently limited. [6] Much of the\u00a0information\u00a0about these techniques has been obtained from\u00a0animal models and in-vitro studies. [7] Consequently,\u00a0questions about their effectiveness remain.\u00a0However, many studies investigating the value of\u00a0SCS and FPR in treating specific dysfunctions show promising results, suggesting that\u00a0these\u00a0techniques may have a\u00a0positive impact on medical practice. [8] [9] [10]", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Issues of Concern. Clinical research on\u00a0the physiologic basis of\u00a0SCS and FPR is currently limited. [6] Much of the\u00a0information\u00a0about these techniques has been obtained from\u00a0animal models and in-vitro studies. [7] Consequently,\u00a0questions about their effectiveness remain.\u00a0However, many studies investigating the value of\u00a0SCS and FPR in treating specific dysfunctions show promising results, suggesting that\u00a0these\u00a0techniques may have a\u00a0positive impact on medical practice. [8] [9] [10]"}
+{"id": "article-102987_5", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Cellular Level", "content": "SCS\u00a0and FPR work on a cellular level to relieve pain, somatic dysfunction, and range-of-motion limitations.\u00a0Both techniques\u00a0act on the\u00a0muscle spindles, Golgi tendon organs, and inflammatory pathways.", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Cellular Level. SCS\u00a0and FPR work on a cellular level to relieve pain, somatic dysfunction, and range-of-motion limitations.\u00a0Both techniques\u00a0act on the\u00a0muscle spindles, Golgi tendon organs, and inflammatory pathways."}
+{"id": "article-102987_6", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Cellular Level", "content": "Proprioceptors are end organs that sense physical changes in musculoskeletal tissues, muscle length, joint position, and tendon tension. [11] These receptors contribute greatly\u00a0to somatic dysfunction, mobility limitation, and tenderpoints.", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Cellular Level. Proprioceptors are end organs that sense physical changes in musculoskeletal tissues, muscle length, joint position, and tendon tension. [11] These receptors contribute greatly\u00a0to somatic dysfunction, mobility limitation, and tenderpoints."}
+{"id": "article-102987_7", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Cellular Level", "content": "Aberrant spindle fiber and nociceptor activity are implicated in the development of tenderpoints and muscle pain. [12] Muscle spindles,\u00a0which are\u00a0mechanosensors, send muscle contraction information to the central nervous system (CNS). [13] [14] Each spindle contains several thin muscle fibers (intrafusal fibers), primarily type 1a\u00a0and type II sensory fibers.\u00a0Fusimotor neurons, made up of \u03b3- and \u03b2-motor neurons, are also found in muscle spindles.\u00a0The\u00a0mechanosensor is encapsulated\u00a0in a connective tissue sheath and is oriented parallel to the muscle fibers within the muscle. [15]", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Cellular Level. Aberrant spindle fiber and nociceptor activity are implicated in the development of tenderpoints and muscle pain. [12] Muscle spindles,\u00a0which are\u00a0mechanosensors, send muscle contraction information to the central nervous system (CNS). [13] [14] Each spindle contains several thin muscle fibers (intrafusal fibers), primarily type 1a\u00a0and type II sensory fibers.\u00a0Fusimotor neurons, made up of \u03b3- and \u03b2-motor neurons, are also found in muscle spindles.\u00a0The\u00a0mechanosensor is encapsulated\u00a0in a connective tissue sheath and is oriented parallel to the muscle fibers within the muscle. [15]"}
+{"id": "article-102987_8", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Cellular Level", "content": "The stretch reflex begins\u00a0at the level of the sensory fibers in the muscle spindles.\u00a0Type 1a sensory fibers send velocity information to nerve afferents, while\u00a0type II sensory fibers send information about muscle length. [16] These fibers fire rapidly when a muscle stretches. The signals\u00a0reach the dorsal root ganglion of the spinal cord and then monosynaptically\u00a0travel\u00a0back to the \u03b1-motor neurons in the same muscle spindle as the sensory fibers. [17] [18] Muscle spindle firing slows down when muscle contracts, eventually diminishing because fewer reflexive impulses excite the \u03b1-motor neurons.", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Cellular Level. The stretch reflex begins\u00a0at the level of the sensory fibers in the muscle spindles.\u00a0Type 1a sensory fibers send velocity information to nerve afferents, while\u00a0type II sensory fibers send information about muscle length. [16] These fibers fire rapidly when a muscle stretches. The signals\u00a0reach the dorsal root ganglion of the spinal cord and then monosynaptically\u00a0travel\u00a0back to the \u03b1-motor neurons in the same muscle spindle as the sensory fibers. [17] [18] Muscle spindle firing slows down when muscle contracts, eventually diminishing because fewer reflexive impulses excite the \u03b1-motor neurons."}
+{"id": "article-102987_9", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Cellular Level", "content": "Contracted intrafusal fibers can intensify the\u00a0stretched muscles' afferent signals. The CNS can alter intrafusal fiber tonicity and fine-tune the stretch reflex,\u00a0modifying\u00a0muscle\u00a0contraction\u00a0intensity\u00a0at a given length. \"Automatic gain control\" is achieved when\u00a0\u03b3-motor neurons constantly change intrafusal fiber length. A\u00a0\u03b3-motor neuron is a lower motor neuron that regulates intrafusal fiber contraction and tonicity, which\u00a0impact the stretch reflex.", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Cellular Level. Contracted intrafusal fibers can intensify the\u00a0stretched muscles' afferent signals. The CNS can alter intrafusal fiber tonicity and fine-tune the stretch reflex,\u00a0modifying\u00a0muscle\u00a0contraction\u00a0intensity\u00a0at a given length. \"Automatic gain control\" is achieved when\u00a0\u03b3-motor neurons constantly change intrafusal fiber length. A\u00a0\u03b3-motor neuron is a lower motor neuron that regulates intrafusal fiber contraction and tonicity, which\u00a0impact the stretch reflex."}
+{"id": "article-102987_10", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Cellular Level", "content": "Golgi tendon organs (GTOs) are proprioceptors found in tendons and joint capsules. These sensory structures send the CNS information about the tension created by muscle contraction.\u00a0Fast-conducting type Ib afferent fibers innervate GTOs. These fibers transmit signals directly to the dorsal horn and synapse directly with interneurons that\u00a0will send inhibitory signals back to the muscle-tendon complex. [19] This circuit initiated by the GTOs is the Golgi-tendon reflex, aka\u00a0autogenic inhibition or\u00a0inverse stretch reflex. [20]", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Cellular Level. Golgi tendon organs (GTOs) are proprioceptors found in tendons and joint capsules. These sensory structures send the CNS information about the tension created by muscle contraction.\u00a0Fast-conducting type Ib afferent fibers innervate GTOs. These fibers transmit signals directly to the dorsal horn and synapse directly with interneurons that\u00a0will send inhibitory signals back to the muscle-tendon complex. [19] This circuit initiated by the GTOs is the Golgi-tendon reflex, aka\u00a0autogenic inhibition or\u00a0inverse stretch reflex. [20]"}
+{"id": "article-102987_11", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Cellular Level", "content": "Muscle stress or strain causes\u00a0fibroblasts to release IL-1\u03b1, IL-1\u03b2, IL-2, IL-3, IL-6, and IL-16. These proinflammatory cytokines activate the immune system by recruiting and activating neutrophils, macrophages, and eosinophils. They also promote increased tissue perfusion, swelling, and temperature. [21] [22] Muscle injury leads to the leakage of cellular ATP. Extracellular pH decreases while bradykinin, E2 prostaglandins, and endogenous neuropeptides increase at the injury site. All these events produce an inflammatory cascade that activates nociceptors and\u00a0releases the neuropeptides substance P and calcitonin gene-related\u00a0peptide (CGRP).", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Cellular Level. Muscle stress or strain causes\u00a0fibroblasts to release IL-1\u03b1, IL-1\u03b2, IL-2, IL-3, IL-6, and IL-16. These proinflammatory cytokines activate the immune system by recruiting and activating neutrophils, macrophages, and eosinophils. They also promote increased tissue perfusion, swelling, and temperature. [21] [22] Muscle injury leads to the leakage of cellular ATP. Extracellular pH decreases while bradykinin, E2 prostaglandins, and endogenous neuropeptides increase at the injury site. All these events produce an inflammatory cascade that activates nociceptors and\u00a0releases the neuropeptides substance P and calcitonin gene-related\u00a0peptide (CGRP)."}
+{"id": "article-102987_12", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Cellular Level", "content": "Substance P and CGRP dilate blood vessels and increase their permeability.\u00a0The proposed pathophysiology of tenderpoints on a cellular level starts with the musculoskeletal changes and ends with the inflammatory cascade.", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Cellular Level. Substance P and CGRP dilate blood vessels and increase their permeability.\u00a0The proposed pathophysiology of tenderpoints on a cellular level starts with the musculoskeletal changes and ends with the inflammatory cascade."}
+{"id": "article-102987_13", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Development", "content": "Skeletal muscle fibers and myofibers\u00a0arise from\u00a0mesenchymal stem cells during primary (weeks 8-10) and secondary (weeks 16-18) myogenesis. [23] [24] Around week 11, muscle spindles begin to develop from flat mesenchymal cells near nervous tissue fibers. [25] [26]", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Development. Skeletal muscle fibers and myofibers\u00a0arise from\u00a0mesenchymal stem cells during primary (weeks 8-10) and secondary (weeks 16-18) myogenesis. [23] [24] Around week 11, muscle spindles begin to develop from flat mesenchymal cells near nervous tissue fibers. [25] [26]"}
+{"id": "article-102987_14", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Development", "content": "Muscle spindles become definitive structures by week 20 and continue to grow after birth.\u00a0From birth and into adulthood, muscle development mostly leads to an increase in\u00a0muscle fiber size. The muscles rely on muscle satellite cells to heal when injured. [27] GTOs develop in the late stage of fetal development, with thin collagen bundles forming myotendinous junctions at the tips of the myotubules.\u00a0GTOs continue to develop until a few weeks after birth when the subcapsular space divides, and the 1b fibers are myelinated. [28]", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Development. Muscle spindles become definitive structures by week 20 and continue to grow after birth.\u00a0From birth and into adulthood, muscle development mostly leads to an increase in\u00a0muscle fiber size. The muscles rely on muscle satellite cells to heal when injured. [27] GTOs develop in the late stage of fetal development, with thin collagen bundles forming myotendinous junctions at the tips of the myotubules.\u00a0GTOs continue to develop until a few weeks after birth when the subcapsular space divides, and the 1b fibers are myelinated. [28]"}
+{"id": "article-102987_15", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Organ Systems Involved", "content": "The musculoskeletal and nervous systems are the major organ systems involved in SCS and FPR. Tenderpoints arise from musculoskeletal injury and inflammation. The receptors and nerve pathways involved are essential to properly executing the SCS and FPR techniques.", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Organ Systems Involved. The musculoskeletal and nervous systems are the major organ systems involved in SCS and FPR. Tenderpoints arise from musculoskeletal injury and inflammation. The receptors and nerve pathways involved are essential to properly executing the SCS and FPR techniques."}
+{"id": "article-102987_16", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Function", "content": "SCS\u00a0corrects somatic dysfunction, pain, and tissue texture changes\u00a0that produce tenderpoints. This indirect technique is useful in patients\u00a0who require a gentler osteopathic technique or patients who have not responded to other osteopathic techniques. FPR\u00a0treats\u00a0tender areas faster than SCS, as it\u00a0uses\u00a0an additional compressive force\u00a0that\u00a0initiates a quicker cellular response.", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Function. SCS\u00a0corrects somatic dysfunction, pain, and tissue texture changes\u00a0that produce tenderpoints. This indirect technique is useful in patients\u00a0who require a gentler osteopathic technique or patients who have not responded to other osteopathic techniques. FPR\u00a0treats\u00a0tender areas faster than SCS, as it\u00a0uses\u00a0an additional compressive force\u00a0that\u00a0initiates a quicker cellular response."}
+{"id": "article-102987_17", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Mechanism", "content": "SCS begins\u00a0with the practitioner identifying tenderpoints. These areas will be monitored during and after the treatment. No standard pain scale measurement\u00a0can reliably\u00a0help identify tenderpoints, but the following may be used: Visual analog scale Dichotomous approach, meaning if pain\u00a0is present or absent \"Jump-sign\" or sudden physical withdrawal from palpation Additionally, dysfunction must be established by testing for range of motion, joint mobility, and strength.", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Mechanism. SCS begins\u00a0with the practitioner identifying tenderpoints. These areas will be monitored during and after the treatment. No standard pain scale measurement\u00a0can reliably\u00a0help identify tenderpoints, but the following may be used: Visual analog scale Dichotomous approach, meaning if pain\u00a0is present or absent \"Jump-sign\" or sudden physical withdrawal from palpation Additionally, dysfunction must be established by testing for range of motion, joint mobility, and strength."}
+{"id": "article-102987_18", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Mechanism", "content": "After identifying the tenderpoint, the practitioner moves the patient into a position of comfort\u00a0so that the tenderpoint is at least 70% less tender. The ideal position\u00a0is one without tenderness and with the fascia\u00a0relaxed. The practitioner\u00a0can find this position by bending the joints around the tenderpoint, thus contracting the\u00a0affected\u00a0muscle. Once found, the patient is maintained in this position for about 90 seconds. The practitioner monitors the muscle for tenderness and fascial tightness by palpation. Once improvement is observed, the patient returns to a neutral resting position and is reassessed.", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Mechanism. After identifying the tenderpoint, the practitioner moves the patient into a position of comfort\u00a0so that the tenderpoint is at least 70% less tender. The ideal position\u00a0is one without tenderness and with the fascia\u00a0relaxed. The practitioner\u00a0can find this position by bending the joints around the tenderpoint, thus contracting the\u00a0affected\u00a0muscle. Once found, the patient is maintained in this position for about 90 seconds. The practitioner monitors the muscle for tenderness and fascial tightness by palpation. Once improvement is observed, the patient returns to a neutral resting position and is reassessed."}
+{"id": "article-102987_19", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Mechanism", "content": "In FPR, the practitioner applies a compressive or distracting force to the affected tissues when the patient is in a position of ease. This technique can shorten the 90-second treatment interval to only about 5 seconds. However, FPR requires a 3-plane diagnosis instead of tenderpoint identification.", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Mechanism. In FPR, the practitioner applies a compressive or distracting force to the affected tissues when the patient is in a position of ease. This technique can shorten the 90-second treatment interval to only about 5 seconds. However, FPR requires a 3-plane diagnosis instead of tenderpoint identification."}
+{"id": "article-102987_20", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Mechanism", "content": "The clinician first places the patient in a neutral position to\u00a0unload any pressure on the affected joint. Compression, torsion, or traction is then applied to \"activate\" the area. Soft tissue relaxation may be felt at this point. The patient will remain in a position of ease for about 5 seconds while the activating force is maintained on the dysfunctional segment. Dr. Schiowitz frequently\u00a0ended\u00a0the treatment by\u00a0setting the segment against a barrier. However, it is not a required step. [29] [30]", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Mechanism. The clinician first places the patient in a neutral position to\u00a0unload any pressure on the affected joint. Compression, torsion, or traction is then applied to \"activate\" the area. Soft tissue relaxation may be felt at this point. The patient will remain in a position of ease for about 5 seconds while the activating force is maintained on the dysfunctional segment. Dr. Schiowitz frequently\u00a0ended\u00a0the treatment by\u00a0setting the segment against a barrier. However, it is not a required step. [29] [30]"}
+{"id": "article-102987_21", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Related Testing", "content": "Since Dr. Jones' time, up to 200 tenderpoints have been identified. There is no definitive imaging technique for tenderpoints. However, these areas can be appreciated by ultrasonography and sonomyoelastography,\u00a0unlike fibromyalgia. [31]", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Related Testing. Since Dr. Jones' time, up to 200 tenderpoints have been identified. There is no definitive imaging technique for tenderpoints. However, these areas can be appreciated by ultrasonography and sonomyoelastography,\u00a0unlike fibromyalgia. [31]"}
+{"id": "article-102987_22", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Related Testing", "content": "The tender areas in fibromyalgia are usually found in tendinous junctions where muscles attach to bones.\u00a0Patients with fibromyalgia have a lower pain threshold, such that even the tension between muscle and bone is enough to elicit pain. [32]", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Related Testing. The tender areas in fibromyalgia are usually found in tendinous junctions where muscles attach to bones.\u00a0Patients with fibromyalgia have a lower pain threshold, such that even the tension between muscle and bone is enough to elicit pain. [32]"}
+{"id": "article-102987_23", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Related Testing", "content": "SCS tenderpoints also differ from Travell's triggerpoints despite the overlap\u00a0in the segments\u00a0involved. Triggerpoints typically radiate pain\u00a0to other body areas, while tenderpoints do not. Triggerpoints also respond to injections,\u00a0soft tissue manipulation, and the spray-and-stretch technique.", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Related Testing. SCS tenderpoints also differ from Travell's triggerpoints despite the overlap\u00a0in the segments\u00a0involved. Triggerpoints typically radiate pain\u00a0to other body areas, while tenderpoints do not. Triggerpoints also respond to injections,\u00a0soft tissue manipulation, and the spray-and-stretch technique."}
+{"id": "article-102987_24", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Pathophysiology", "content": "The formation of tenderpoints and their responsiveness to SCS may be explained by 3 theories, namely, the\u00a0proprioceptive theory, local inflammatory circulatory effects, and the ligamento-muscular reflex. These concepts are explained below.", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Pathophysiology. The formation of tenderpoints and their responsiveness to SCS may be explained by 3 theories, namely, the\u00a0proprioceptive theory, local inflammatory circulatory effects, and the ligamento-muscular reflex. These concepts are explained below."}
+{"id": "article-102987_25", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Pathophysiology -- Proprioceptive Theory", "content": "The proprioceptive theory is the most widely used\u00a0explanation for SCS effectiveness.\u00a0The theory argues that the antagonist muscle spindles activate a counter-contraction response to the stretch reflex. This response creates a persisting muscle spasm, resulting in neuromuscular imbalance, hypertonicity, and referred pain,\u00a0all of which characterize the tenderpoint. The resulting neuromuscular imbalance is likely responsible for some tenderpoints' ropelike quality. Tenderpoints are considered active injuries and can last as long as the strained muscle continues to shorten.", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Pathophysiology -- Proprioceptive Theory. The proprioceptive theory is the most widely used\u00a0explanation for SCS effectiveness.\u00a0The theory argues that the antagonist muscle spindles activate a counter-contraction response to the stretch reflex. This response creates a persisting muscle spasm, resulting in neuromuscular imbalance, hypertonicity, and referred pain,\u00a0all of which characterize the tenderpoint. The resulting neuromuscular imbalance is likely responsible for some tenderpoints' ropelike quality. Tenderpoints are considered active injuries and can last as long as the strained muscle continues to shorten."}
+{"id": "article-102987_26", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Pathophysiology -- Proprioceptive Theory", "content": "Muscle shortening can limit joint mobility.\u00a0SCS\u00a0resets the \u03b3-motor neuron output and decreases the intrafusal and extrafusal fiber disparity. This effect\u00a0inhibits the muscle's contraction reflex and\u00a0returns it to resting length. Studies have shown that symptomatic individuals with tenderpoints experience the following before and after SCS: Tenderness at lower electrical thresholds Reduced stretch reflex amplitudes when treated with SCS Reduced pain and improved range of motion after SCS However, studies that tried to test the proprioceptive theory directly have produced conflicting results. [33] [34]", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Pathophysiology -- Proprioceptive Theory. Muscle shortening can limit joint mobility.\u00a0SCS\u00a0resets the \u03b3-motor neuron output and decreases the intrafusal and extrafusal fiber disparity. This effect\u00a0inhibits the muscle's contraction reflex and\u00a0returns it to resting length. Studies have shown that symptomatic individuals with tenderpoints experience the following before and after SCS: Tenderness at lower electrical thresholds Reduced stretch reflex amplitudes when treated with SCS Reduced pain and improved range of motion after SCS However, studies that tried to test the proprioceptive theory directly have produced conflicting results. [33] [34]"}
+{"id": "article-102987_27", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Pathophysiology -- Local Inflammatory Circulatory Effects", "content": "Local inflammatory and circulatory effects may also explain\u00a0the effectiveness of SCS and FPR. Repositioning an individual can increase circulation in the tenderpoint. Improving blood circulation helps enhance nutrient delivery, remove waste,\u00a0reduce swelling, and ameliorate ischemic pain. A study measuring cytokines released by fibroblasts during the treatment found that 1 minute of SCS reduced IL-6 production in the tenderpoint, suggesting local circulatory effects. [35]", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Pathophysiology -- Local Inflammatory Circulatory Effects. Local inflammatory and circulatory effects may also explain\u00a0the effectiveness of SCS and FPR. Repositioning an individual can increase circulation in the tenderpoint. Improving blood circulation helps enhance nutrient delivery, remove waste,\u00a0reduce swelling, and ameliorate ischemic pain. A study measuring cytokines released by fibroblasts during the treatment found that 1 minute of SCS reduced IL-6 production in the tenderpoint, suggesting local circulatory effects. [35]"}
+{"id": "article-102987_28", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Pathophysiology -- Ligamento-Muscular Reflex", "content": "The ligamento-muscular reflex protects ligaments from damage by contracting some muscles and relaxing others, thus reducing ligament mobility when\u00a0injured. [36] SCS and FPR can relax the affected muscle by\u00a0using the inhibitory responses generated from the\u00a0ligamento-muscular and GTO reflexes. This theory is not as widely used as the other two.", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Pathophysiology -- Ligamento-Muscular Reflex. The ligamento-muscular reflex protects ligaments from damage by contracting some muscles and relaxing others, thus reducing ligament mobility when\u00a0injured. [36] SCS and FPR can relax the affected muscle by\u00a0using the inhibitory responses generated from the\u00a0ligamento-muscular and GTO reflexes. This theory is not as widely used as the other two."}
+{"id": "article-102987_29", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Pathophysiology -- Ligamento-Muscular Reflex", "content": "In SCS, the tenderpoint arises from the body's attempts to contract\u00a0and protect an\u00a0injured muscle,\u00a0causing the antagonist muscle to stretch reflexively. Palpable hypertonic myofascial tissue subsequently forms in the antagonistic muscle. SCS shortens the antagonist muscle to dampen the persistently faulty proprioceptive signals and relieve muscle strain.", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Pathophysiology -- Ligamento-Muscular Reflex. In SCS, the tenderpoint arises from the body's attempts to contract\u00a0and protect an\u00a0injured muscle,\u00a0causing the antagonist muscle to stretch reflexively. Palpable hypertonic myofascial tissue subsequently forms in the antagonistic muscle. SCS shortens the antagonist muscle to dampen the persistently faulty proprioceptive signals and relieve muscle strain."}
+{"id": "article-102987_30", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Pathophysiology -- Ligamento-Muscular Reflex", "content": "In FPR, the muscle spindle becomes more sensitive to stretch when stimulated by \u03b3-motor neurons. In this way, the\u00a0stretch fibers of the affected muscle can still send signals to the spinal cord even at rest, keeping the\u00a0\u03b1-motor neurons constantly stimulated. The muscle remains hypertonic even in a neutral position. Easing\u00a0the muscle with an activating force allows it to \"reset\"\u00a0its \u03b3-motor neurons and stop contraction signals.", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Pathophysiology -- Ligamento-Muscular Reflex. In FPR, the muscle spindle becomes more sensitive to stretch when stimulated by \u03b3-motor neurons. In this way, the\u00a0stretch fibers of the affected muscle can still send signals to the spinal cord even at rest, keeping the\u00a0\u03b1-motor neurons constantly stimulated. The muscle remains hypertonic even in a neutral position. Easing\u00a0the muscle with an activating force allows it to \"reset\"\u00a0its \u03b3-motor neurons and stop contraction signals."}
+{"id": "article-102987_31", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Clinical Significance", "content": "SCS and FPR\u00a0are especially useful\u00a0in treating individuals with chronic pain who prefer gentle osteopathic techniques or do not respond to other treatments. [37] These techniques' contraindications are few, and they\u00a0include fractures and significant ligamentous tears in the affected area or when the patient cannot relax.\u00a0Evidence shows that SCS is indicated in the treatment of the following areas: [38] [39] [40] [41] Hip tender points Trapezius pain Mechanical neck pain Chronic ankle instability and sprains Plantar fasciitis pain Shoulder pain Sacral torsion Lower back pain Cervical hysteresis Iliotibial band friction syndrome Headache Tendonitis Epicondylalgia Knee pain Rotator cuff syndrome Fibromyalgia Osteoarthritis", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Clinical Significance. SCS and FPR\u00a0are especially useful\u00a0in treating individuals with chronic pain who prefer gentle osteopathic techniques or do not respond to other treatments. [37] These techniques' contraindications are few, and they\u00a0include fractures and significant ligamentous tears in the affected area or when the patient cannot relax.\u00a0Evidence shows that SCS is indicated in the treatment of the following areas: [38] [39] [40] [41] Hip tender points Trapezius pain Mechanical neck pain Chronic ankle instability and sprains Plantar fasciitis pain Shoulder pain Sacral torsion Lower back pain Cervical hysteresis Iliotibial band friction syndrome Headache Tendonitis Epicondylalgia Knee pain Rotator cuff syndrome Fibromyalgia Osteoarthritis"}
+{"id": "article-102987_32", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Clinical Significance", "content": "If a tenderpoint can be identified, it can be treated with SCS. Osteopathic medical students have a saying, \"fold and hold,\" to describe SCS techniques, which means\u00a0folding the segment to shorten the muscles and then holding the position for at least 90 seconds. FPR's effectiveness in treating pain and somatic dysfunctions is not widely supported by clinical research. However, this technique's similarity to SCS makes it useful for similar indications.", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Clinical Significance. If a tenderpoint can be identified, it can be treated with SCS. Osteopathic medical students have a saying, \"fold and hold,\" to describe SCS techniques, which means\u00a0folding the segment to shorten the muscles and then holding the position for at least 90 seconds. FPR's effectiveness in treating pain and somatic dysfunctions is not widely supported by clinical research. However, this technique's similarity to SCS makes it useful for similar indications."}
+{"id": "article-102987_33", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Clinical Significance", "content": "The use of\u00a0SCS and FPR\u00a0in treating piriformis syndrome, iliacus, and psoas dysfunction has not been fully established. However, treating these conditions with the 2 indirect manipulations is part of the\u00a0osteopathic physicians' curriculum and practice. Students must keep in mind that these modalities are contraindicated in the following settings: Tenderpoint is in a site of active inflammation Pain may be\u00a0due to another cause, such as an infection Patient cannot communicate tenderness feedback Patient cannot tolerate manual therapy", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Clinical Significance. The use of\u00a0SCS and FPR\u00a0in treating piriformis syndrome, iliacus, and psoas dysfunction has not been fully established. However, treating these conditions with the 2 indirect manipulations is part of the\u00a0osteopathic physicians' curriculum and practice. Students must keep in mind that these modalities are contraindicated in the following settings: Tenderpoint is in a site of active inflammation Pain may be\u00a0due to another cause, such as an infection Patient cannot communicate tenderness feedback Patient cannot tolerate manual therapy"}
+{"id": "article-102987_34", "title": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Physiology, Counterstrain and Facilitated Positional Release (FPR) -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

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+{"id": "article-102988_0", "title": "Physiology, Viscerosomatic Reflexes -- Introduction", "content": "In 1907, an osteopathic researcher named Louisa Burns observed that \"a very important, if not the only, pathway of viscerosensory impulses enters the spinal cord through its posterior roots.\" [1] She went on to explain that \"somato-visceral reflexes are less circumscribed and less direct than are viscerosomatic reflexes\" and clarified that \"normal visceral activity depends in part upon the stimulation derived from the somatosensory nerves\u2026the possibility of recognition of abnormal viscerosomatic reflexes as an aid in diagnosis is inferred\". [1] She had been studying the mechanisms of reflex arcs in animal models to understand better the complex interactions between the viscera, spinal cord, and soft tissues. These landmark statements paved the way for extensive osteopathic study from the likes of future leaders in osteopathic education such as Wilbur Cole, DO, H. V. Halladay, DO, John Martin Littlejohn, MD, DO, William Smith, MD, DO, Irvin Korr, Ph.D., John Stedman Denslow, Ph.D., and William Johnston, DO, FAAO.", "contents": "Physiology, Viscerosomatic Reflexes -- Introduction. In 1907, an osteopathic researcher named Louisa Burns observed that \"a very important, if not the only, pathway of viscerosensory impulses enters the spinal cord through its posterior roots.\" [1] She went on to explain that \"somato-visceral reflexes are less circumscribed and less direct than are viscerosomatic reflexes\" and clarified that \"normal visceral activity depends in part upon the stimulation derived from the somatosensory nerves\u2026the possibility of recognition of abnormal viscerosomatic reflexes as an aid in diagnosis is inferred\". [1] She had been studying the mechanisms of reflex arcs in animal models to understand better the complex interactions between the viscera, spinal cord, and soft tissues. These landmark statements paved the way for extensive osteopathic study from the likes of future leaders in osteopathic education such as Wilbur Cole, DO, H. V. Halladay, DO, John Martin Littlejohn, MD, DO, William Smith, MD, DO, Irvin Korr, Ph.D., John Stedman Denslow, Ph.D., and William Johnston, DO, FAAO."}
+{"id": "article-102988_1", "title": "Physiology, Viscerosomatic Reflexes -- Introduction", "content": "The result was an explanation of the phenomenon that would later be known as somatic dysfunction. Somatic dysfunction is defined as \"impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial, and myofascial structures, and related vascular, lymphatic, and neural elements.\" [2] the acronym T-A-R-T may help clinicians remember the criteria for the diagnosis of somatic dysfunction: T issue texture changes; A symmetry; R estriction of motion; T enderness (primarily used for specific osteopathic manipulative techniques, namely counterstrain). These criteria are commonly referred to as \"TART changes\".", "contents": "Physiology, Viscerosomatic Reflexes -- Introduction. The result was an explanation of the phenomenon that would later be known as somatic dysfunction. Somatic dysfunction is defined as \"impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial, and myofascial structures, and related vascular, lymphatic, and neural elements.\" [2] the acronym T-A-R-T may help clinicians remember the criteria for the diagnosis of somatic dysfunction: T issue texture changes; A symmetry; R estriction of motion; T enderness (primarily used for specific osteopathic manipulative techniques, namely counterstrain). These criteria are commonly referred to as \"TART changes\"."}
+{"id": "article-102988_2", "title": "Physiology, Viscerosomatic Reflexes -- Introduction", "content": "One or more of the criteria are required to diagnose somatic dysfunction. [3] It is important to note that tenderness is subjective and considered a controversial criterion. Similarly, the examining physician should consider a finding of focal tenderness concerning the entire clinical picture, developed by way of a thorough history and physical, before establishing a definitive diagnosis of somatic dysfunction. There are many causes of the aforementioned criteria, and thus, there are many causes of somatic dysfunction. Dr. Burns' research explained viscerosomatic reflexes as a contributing etiology. This article portends to explain the anatomical basis for viscerosomatic reflexes, detail their mechanism of development, outline their pathophysiology, and delineate their clinical significance.", "contents": "Physiology, Viscerosomatic Reflexes -- Introduction. One or more of the criteria are required to diagnose somatic dysfunction. [3] It is important to note that tenderness is subjective and considered a controversial criterion. Similarly, the examining physician should consider a finding of focal tenderness concerning the entire clinical picture, developed by way of a thorough history and physical, before establishing a definitive diagnosis of somatic dysfunction. There are many causes of the aforementioned criteria, and thus, there are many causes of somatic dysfunction. Dr. Burns' research explained viscerosomatic reflexes as a contributing etiology. This article portends to explain the anatomical basis for viscerosomatic reflexes, detail their mechanism of development, outline their pathophysiology, and delineate their clinical significance."}
+{"id": "article-102988_3", "title": "Physiology, Viscerosomatic Reflexes -- Issues of Concern", "content": "The therapeutic value of diagnosing viscerosomatic reflexes is a distinctive component of the field of medicine known as osteopathic manipulative medicine (OMM). Correspondingly, the use of manual therapies to correct somatic dysfunction is one of its mainstays. An osteopathic structural exam is essential in the evaluation and treatment of any patient and includes an observation of the skin, layer-by-layer palpation, regional range of motion testing of the vertebral column, and segmental regional range of motion testing (i.e., of the extremities).", "contents": "Physiology, Viscerosomatic Reflexes -- Issues of Concern. The therapeutic value of diagnosing viscerosomatic reflexes is a distinctive component of the field of medicine known as osteopathic manipulative medicine (OMM). Correspondingly, the use of manual therapies to correct somatic dysfunction is one of its mainstays. An osteopathic structural exam is essential in the evaluation and treatment of any patient and includes an observation of the skin, layer-by-layer palpation, regional range of motion testing of the vertebral column, and segmental regional range of motion testing (i.e., of the extremities)."}
+{"id": "article-102988_4", "title": "Physiology, Viscerosomatic Reflexes -- Issues of Concern", "content": "Diagnosis of somatic dysfunction follows a deliberate survey of the paravertebral musculature and soft tissues to identify TART changes that reflect underlying visceral (\u201cviscerosomatic\u201d) or somatic (\u201csomato-somatic\u201d) irritation.\u00a0TART changes are thus direct sequelae of segmental facilitation, as will be explained in-depth in later sections. Osteopathic manipulative techniques (OMT) are then used to treat somatic dysfunction. Given their implication in the pathogenesis of somatic dysfunction, it is crucial to understand the physiology, and inherent pathophysiology, of viscerosomatic reflexes. [4]", "contents": "Physiology, Viscerosomatic Reflexes -- Issues of Concern. Diagnosis of somatic dysfunction follows a deliberate survey of the paravertebral musculature and soft tissues to identify TART changes that reflect underlying visceral (\u201cviscerosomatic\u201d) or somatic (\u201csomato-somatic\u201d) irritation.\u00a0TART changes are thus direct sequelae of segmental facilitation, as will be explained in-depth in later sections. Osteopathic manipulative techniques (OMT) are then used to treat somatic dysfunction. Given their implication in the pathogenesis of somatic dysfunction, it is crucial to understand the physiology, and inherent pathophysiology, of viscerosomatic reflexes. [4]"}
+{"id": "article-102988_5", "title": "Physiology, Viscerosomatic Reflexes -- Development", "content": "During fetal development, a mesodermal structure called the notochord - the future nucleus pulposus of the vertebral disc - induces the overlying ectoderm (known as neuroectoderm) to thicken and form the neural plate. The primitive neuroectodermal tissue ultimately\u00a0matures into various components of the nervous system while the surrounding neural plate lengthens and broadens. In the middle of the neural plate, a neural groove forms and is flanked by bands of nervous tissue known as neural folds. By the end of the third week of gestation, these neural folds fuse to form the neural tube, which will further develop into the central nervous system (CNS). Lateral to the neural tube lie regions of the neural crest that produce neural crest cells that migrate to produce the afferent nerves of the peripheral nervous system, including somatic afferents, autonomic ganglia, and postganglionic nerves. As the cells migrate, they pass through the dorsal root ganglia (DRG) on the way to the dorsal portion of the primordial spinal cord known as the alar plate. The cell bodies of the afferent nerves remain in the DRG while their axons continue to travel until they ultimately terminate within the dorsal horn. The ventrally-situated basal plate of the neural tube differentiates into efferent nerves, including the somatic, preganglionic, and autonomic nerves. This migration and differentiation of nervous system primordia provide an opportunity for the crossing of visceral and somatic signaling pathways. [5] [6] [7]", "contents": "Physiology, Viscerosomatic Reflexes -- Development. During fetal development, a mesodermal structure called the notochord - the future nucleus pulposus of the vertebral disc - induces the overlying ectoderm (known as neuroectoderm) to thicken and form the neural plate. The primitive neuroectodermal tissue ultimately\u00a0matures into various components of the nervous system while the surrounding neural plate lengthens and broadens. In the middle of the neural plate, a neural groove forms and is flanked by bands of nervous tissue known as neural folds. By the end of the third week of gestation, these neural folds fuse to form the neural tube, which will further develop into the central nervous system (CNS). Lateral to the neural tube lie regions of the neural crest that produce neural crest cells that migrate to produce the afferent nerves of the peripheral nervous system, including somatic afferents, autonomic ganglia, and postganglionic nerves. As the cells migrate, they pass through the dorsal root ganglia (DRG) on the way to the dorsal portion of the primordial spinal cord known as the alar plate. The cell bodies of the afferent nerves remain in the DRG while their axons continue to travel until they ultimately terminate within the dorsal horn. The ventrally-situated basal plate of the neural tube differentiates into efferent nerves, including the somatic, preganglionic, and autonomic nerves. This migration and differentiation of nervous system primordia provide an opportunity for the crossing of visceral and somatic signaling pathways. [5] [6] [7]"}
+{"id": "article-102988_6", "title": "Physiology, Viscerosomatic Reflexes -- Development", "content": "Autonomic motor efferents arise within the ventral ventricular zone, an anteriorly situated region near the central canal of the developing spinal cord. These neurons migrate toward the ventral horn, where they coalesce with somatic motor efferents to form a single primordial motor column. Eventually, autonomic efferents separate from somatic efferents and migrate dorsally into the intermediate spinal cord, the portion of the gray matter that lies between the dorsal and ventral horns. Once in the intermediate spinal cord, the autonomic efferents increase their polarity and change their orientation, establishing their permanent placement within one of the three columns of grey matter in the spinal cord known as the interomediolateral columns (IML). [8] This temporary consolidation of autonomics and somatics within the primordial motor column offers another opportunity for the crossing of visceral and somatic signaling.", "contents": "Physiology, Viscerosomatic Reflexes -- Development. Autonomic motor efferents arise within the ventral ventricular zone, an anteriorly situated region near the central canal of the developing spinal cord. These neurons migrate toward the ventral horn, where they coalesce with somatic motor efferents to form a single primordial motor column. Eventually, autonomic efferents separate from somatic efferents and migrate dorsally into the intermediate spinal cord, the portion of the gray matter that lies between the dorsal and ventral horns. Once in the intermediate spinal cord, the autonomic efferents increase their polarity and change their orientation, establishing their permanent placement within one of the three columns of grey matter in the spinal cord known as the interomediolateral columns (IML). [8] This temporary consolidation of autonomics and somatics within the primordial motor column offers another opportunity for the crossing of visceral and somatic signaling."}
+{"id": "article-102988_7", "title": "Physiology, Viscerosomatic Reflexes -- Development", "content": "The IML is found within the gray matter of the spinal cord between vertebral levels T1 to L2 and has projections to the CNS. Collectively, it houses the cell bodies of preganglionic sympathetic general visceral efferents and is responsible for sympathetic output to visceral structures. It is an important autonomic nervous system structure that maintains resting sympathetic tone. The clinical utility of viscerosomatic reflexes as a diagnostic aid has its basis in the relatively unique innervation of visceral structures. [9]", "contents": "Physiology, Viscerosomatic Reflexes -- Development. The IML is found within the gray matter of the spinal cord between vertebral levels T1 to L2 and has projections to the CNS. Collectively, it houses the cell bodies of preganglionic sympathetic general visceral efferents and is responsible for sympathetic output to visceral structures. It is an important autonomic nervous system structure that maintains resting sympathetic tone. The clinical utility of viscerosomatic reflexes as a diagnostic aid has its basis in the relatively unique innervation of visceral structures. [9]"}
+{"id": "article-102988_8", "title": "Physiology, Viscerosomatic Reflexes -- Organ Systems Involved", "content": "Each viscus relays information to the central nervous system through a homogenous segment of the spinal cord. Therefore, somatic findings in related dermatomal areas are often related to simultaneous dysfunction originating from a specific visceral source. [9] A full table of the spinal levels of sympathetic innervation leaving the IML appears below. Levels commonly observed in clinical practice include the heart (T1-T5, to the left of the midline), lungs (T1-T6), foregut (T5-T9), midgut (T10-T11), and hindgut (T12-L2). The specific levels sometimes vary for segmental innervation in either the cephalad or caudad direction, but typically only deviate by a single spinal level.", "contents": "Physiology, Viscerosomatic Reflexes -- Organ Systems Involved. Each viscus relays information to the central nervous system through a homogenous segment of the spinal cord. Therefore, somatic findings in related dermatomal areas are often related to simultaneous dysfunction originating from a specific visceral source. [9] A full table of the spinal levels of sympathetic innervation leaving the IML appears below. Levels commonly observed in clinical practice include the heart (T1-T5, to the left of the midline), lungs (T1-T6), foregut (T5-T9), midgut (T10-T11), and hindgut (T12-L2). The specific levels sometimes vary for segmental innervation in either the cephalad or caudad direction, but typically only deviate by a single spinal level."}
+{"id": "article-102988_9", "title": "Physiology, Viscerosomatic Reflexes -- Function", "content": "Reflexes in the human body are inherently protective. Without primitive reflexes, babies would be unable to interact meaningfully with their environment (e.g., to breastfeed using the suckle or latch reflexes, to hold objects using the grasp reflex, etc.). Brainstem reflexes are useful in diagnosing disorders of consciousness and evaluate for brain death. [10] [11] In upper motor neuron injuries, a maladaptive stretch reflex results from an imbalance in signaling to and from the muscle and is responsible for the clinical manifestations of muscle hypertonicity and spasticity. [12] [13] An awareness of the key structures of a reflex arc and how they can reinforce improper muscle biomechanics illuminates how viscerosomatic reflexes become established.", "contents": "Physiology, Viscerosomatic Reflexes -- Function. Reflexes in the human body are inherently protective. Without primitive reflexes, babies would be unable to interact meaningfully with their environment (e.g., to breastfeed using the suckle or latch reflexes, to hold objects using the grasp reflex, etc.). Brainstem reflexes are useful in diagnosing disorders of consciousness and evaluate for brain death. [10] [11] In upper motor neuron injuries, a maladaptive stretch reflex results from an imbalance in signaling to and from the muscle and is responsible for the clinical manifestations of muscle hypertonicity and spasticity. [12] [13] An awareness of the key structures of a reflex arc and how they can reinforce improper muscle biomechanics illuminates how viscerosomatic reflexes become established."}
+{"id": "article-102988_10", "title": "Physiology, Viscerosomatic Reflexes -- Function", "content": "The two key physiological structures that comprise the muscle stretch reflex include the muscle spindle apparatus and the Golgi tendon organ. The muscle spindle apparatus is both a sensory organ and a motor organ. Its function is to allow balanced tension between agonist and antagonist muscles. [14] [15] This function is particularly important in large muscle groups that surround a joint as muscle imbalance in these structures causes impaired functional mobility, gait dysfunction, and discomfort. It affects distal regions of the body by way of an altered kinetic chain and decompensated arrangement of the contiguous myofascial elements. The muscle spindle apparatus is composed of two distinctive muscle fiber types: intra- and extrafusal fibers. Intrafusal fibers primarily contribute to the resting (tonic) tone of muscle, and extrafusal fibers contribute to the dynamic (phasic) function of the muscle. The intrafusal fibers contain alpha Ia (described as \u201cannulospiral\u201d fibers) and alpha 2a (known as \u201cflower spray\u201d fibers due to their specific arrangement around the intrafusal fibers) afferent fibers that sense changes in muscle length. Their receptors are located in the central portion of the fiber. These fibers are non-contractile and are part of the body\u2019s proprioceptive system. They illustrate the muscle\u2019s position in space to the CNS. By contrast, there are contractile fibers located in the periphery of the intrafusal fiber. They are innervated by gamma 1 (i.e., dynamic) and gamma 2 (i.e., static) efferent fibers that are sensitive to the rate of change of muscle length and degree of muscle stretch, respectively. These fibers contract in response to feedback from the alpha afferent fibers to protect the muscle from too much stretch. The extrafusal fibers of a muscle contain gamma efferent fibers and are responsible for gross muscle contraction.", "contents": "Physiology, Viscerosomatic Reflexes -- Function. The two key physiological structures that comprise the muscle stretch reflex include the muscle spindle apparatus and the Golgi tendon organ. The muscle spindle apparatus is both a sensory organ and a motor organ. Its function is to allow balanced tension between agonist and antagonist muscles. [14] [15] This function is particularly important in large muscle groups that surround a joint as muscle imbalance in these structures causes impaired functional mobility, gait dysfunction, and discomfort. It affects distal regions of the body by way of an altered kinetic chain and decompensated arrangement of the contiguous myofascial elements. The muscle spindle apparatus is composed of two distinctive muscle fiber types: intra- and extrafusal fibers. Intrafusal fibers primarily contribute to the resting (tonic) tone of muscle, and extrafusal fibers contribute to the dynamic (phasic) function of the muscle. The intrafusal fibers contain alpha Ia (described as \u201cannulospiral\u201d fibers) and alpha 2a (known as \u201cflower spray\u201d fibers due to their specific arrangement around the intrafusal fibers) afferent fibers that sense changes in muscle length. Their receptors are located in the central portion of the fiber. These fibers are non-contractile and are part of the body\u2019s proprioceptive system. They illustrate the muscle\u2019s position in space to the CNS. By contrast, there are contractile fibers located in the periphery of the intrafusal fiber. They are innervated by gamma 1 (i.e., dynamic) and gamma 2 (i.e., static) efferent fibers that are sensitive to the rate of change of muscle length and degree of muscle stretch, respectively. These fibers contract in response to feedback from the alpha afferent fibers to protect the muscle from too much stretch. The extrafusal fibers of a muscle contain gamma efferent fibers and are responsible for gross muscle contraction."}
+{"id": "article-102988_11", "title": "Physiology, Viscerosomatic Reflexes -- Function", "content": "The Golgi tendon organs are similarly designed to protect muscles from\u00a0overwhelming elongation or force. They are located in the collagenous tissue fibers of tendon bodies and transmit information about tendon tension and rate of change of tension. When the Golgi tendon organs sense excessive tension at the musculotendinous junction, they send a signal to gamma efferent extrafusal fibers located in surrounding muscle tissue to inhibit agonist muscle firing and increase antagonist muscle activity. These actions function to decrease the amount of tension placed on the tendon. In the absence of this response, muscles are avulsed from their distal attachments in the setting of surfeit and prolonged muscle loading. The spinal cord receives the somatic afferents sent from both the muscle spindle apparatus and Golgi tendon organs at individual segmental levels. They comprise but one collection of a variety of signals that the spinal cord must receive, modulate via inhibitory Renshaw cells in the grey matter, and either send to the CNS for higher-order processing or relay back to the periphery for an efferent response. [16] [17] [18] [19] [20]", "contents": "Physiology, Viscerosomatic Reflexes -- Function. The Golgi tendon organs are similarly designed to protect muscles from\u00a0overwhelming elongation or force. They are located in the collagenous tissue fibers of tendon bodies and transmit information about tendon tension and rate of change of tension. When the Golgi tendon organs sense excessive tension at the musculotendinous junction, they send a signal to gamma efferent extrafusal fibers located in surrounding muscle tissue to inhibit agonist muscle firing and increase antagonist muscle activity. These actions function to decrease the amount of tension placed on the tendon. In the absence of this response, muscles are avulsed from their distal attachments in the setting of surfeit and prolonged muscle loading. The spinal cord receives the somatic afferents sent from both the muscle spindle apparatus and Golgi tendon organs at individual segmental levels. They comprise but one collection of a variety of signals that the spinal cord must receive, modulate via inhibitory Renshaw cells in the grey matter, and either send to the CNS for higher-order processing or relay back to the periphery for an efferent response. [16] [17] [18] [19] [20]"}
+{"id": "article-102988_12", "title": "Physiology, Viscerosomatic Reflexes -- Mechanism", "content": "Under normal circumstances, muscle stretch reflexes are mediated by the muscle spindle apparatus and Golgi tendon organs to protect the muscle from excessive stretch and effort injury. The spinal cord simultaneously manages somatic efferent and afferent stimulation, as well as visceral afferent input at the same segmental level via the autonomic nervous system. There is a high degree of subsequent somatic and visceral convergence within lamina I of its grey matter. Somatic and visceral C fibers both synapse on lamina I interneurons. Excitation of these interneurons initiates sympathetic output back to the dysfunctional viscus/viscera in addition to alpha and gamma motor neurons that project to segmentally-related skeletal muscles. This interaction is the origin of the somatic component of a muscle stretch reflex and, therefore, a viscerosomatic reflex.", "contents": "Physiology, Viscerosomatic Reflexes -- Mechanism. Under normal circumstances, muscle stretch reflexes are mediated by the muscle spindle apparatus and Golgi tendon organs to protect the muscle from excessive stretch and effort injury. The spinal cord simultaneously manages somatic efferent and afferent stimulation, as well as visceral afferent input at the same segmental level via the autonomic nervous system. There is a high degree of subsequent somatic and visceral convergence within lamina I of its grey matter. Somatic and visceral C fibers both synapse on lamina I interneurons. Excitation of these interneurons initiates sympathetic output back to the dysfunctional viscus/viscera in addition to alpha and gamma motor neurons that project to segmentally-related skeletal muscles. This interaction is the origin of the somatic component of a muscle stretch reflex and, therefore, a viscerosomatic reflex."}
+{"id": "article-102988_13", "title": "Physiology, Viscerosomatic Reflexes -- Mechanism", "content": "Additionally,\u00a0the current belief is that visceral and somatic pain are both carried to the thalamus for processing in the brain via the anterolateral system, meaning that both types of pain arrive in the cerebral cortex via the same route. When the CNS cannot delineate these signals, a maladaptive reflex materializes. In the presence of visceral dysfunction, the CNS confuses afferent input arising from viscera as originating from somatic structures. If the CNS is unable to distinguish between the sensory signals, it misconstrues the information as originating from both structures simultaneously. This misapprehended activity creates a feed-forward loop of muscle spasm and sustained hypertonicity that relays somatic afferent signals along the same CNS pathway as the dysfunctional viscera, known as segmental facilitation. [21] [22] Inappropriate nervous system activity at these spinal levels forms a maladaptive reflex arc that further contributes to visceral dysfunction and may impede the body\u2019s attempts to restore physiological autonomic tone to the viscera. It is this reflex activity that causes somatic dysfunction and leads patients to seek treatment. [23] [24] [25]", "contents": "Physiology, Viscerosomatic Reflexes -- Mechanism. Additionally,\u00a0the current belief is that visceral and somatic pain are both carried to the thalamus for processing in the brain via the anterolateral system, meaning that both types of pain arrive in the cerebral cortex via the same route. When the CNS cannot delineate these signals, a maladaptive reflex materializes. In the presence of visceral dysfunction, the CNS confuses afferent input arising from viscera as originating from somatic structures. If the CNS is unable to distinguish between the sensory signals, it misconstrues the information as originating from both structures simultaneously. This misapprehended activity creates a feed-forward loop of muscle spasm and sustained hypertonicity that relays somatic afferent signals along the same CNS pathway as the dysfunctional viscera, known as segmental facilitation. [21] [22] Inappropriate nervous system activity at these spinal levels forms a maladaptive reflex arc that further contributes to visceral dysfunction and may impede the body\u2019s attempts to restore physiological autonomic tone to the viscera. It is this reflex activity that causes somatic dysfunction and leads patients to seek treatment. [23] [24] [25]"}
+{"id": "article-102988_14", "title": "Physiology, Viscerosomatic Reflexes -- Mechanism", "content": "Viscerosomatic reflexes may be better understood by way of example. A familiar presentation of a viscerosomatic reflex is myocardial infarction that presents with pain radiating to the upper arm, shoulder, or jaw. The viscerosomatic reflex arc initiates following visceral dysfunction (i.e., ischemia of the myocardium), which increases the propagation of action potentials along visceral afferent fibers that terminate within the dorsal gray matter of the spinal cord. Within the dorsal horn, segmental facilitation lowers the threshold of inhibitory interneuron signaling, known as central sensitization. Consequently, nervous system activity in the setting of facilitation results in an exaggerated efferent response within segmentally-related somatic structures (i.e., pain in the shoulder or upper extremity in the setting of an MI) via increased somatic, sympathetic, and motor efferent firing. The clinical response to these efferent signals is a constellation of tissue texture changes, asymmetry, restriction within the tissues, and/or tenderness on palpation. [26]", "contents": "Physiology, Viscerosomatic Reflexes -- Mechanism. Viscerosomatic reflexes may be better understood by way of example. A familiar presentation of a viscerosomatic reflex is myocardial infarction that presents with pain radiating to the upper arm, shoulder, or jaw. The viscerosomatic reflex arc initiates following visceral dysfunction (i.e., ischemia of the myocardium), which increases the propagation of action potentials along visceral afferent fibers that terminate within the dorsal gray matter of the spinal cord. Within the dorsal horn, segmental facilitation lowers the threshold of inhibitory interneuron signaling, known as central sensitization. Consequently, nervous system activity in the setting of facilitation results in an exaggerated efferent response within segmentally-related somatic structures (i.e., pain in the shoulder or upper extremity in the setting of an MI) via increased somatic, sympathetic, and motor efferent firing. The clinical response to these efferent signals is a constellation of tissue texture changes, asymmetry, restriction within the tissues, and/or tenderness on palpation. [26]"}
+{"id": "article-102988_15", "title": "Physiology, Viscerosomatic Reflexes -- Mechanism", "content": "Another common example of an easily recognizable and clinically relevant viscerosomatic reflex is the sensation of upper shoulder pain in the setting of hepatobiliary disease. Most often a complication of biliary obstruction (e.g., cholelithiases), gallbladder inflammation (e.g., cholecystitis), infection (e.g., ascending cholangitis), or neoplasm (e.g., cholangiocarcinoma), irritation of the gallbladder epithelium activates visceral afferent receptors, increasing the transmission of abnormal sensory input into the dorsal horn of the spinal cord. This input from the gallbladder facilitates regional interneurons from spinal levels T5 to T9. Normal input to the interneurons at these segmental levels then becomes amplified, causing excessive motor, sensory, and autonomic efferent responses. Therefore, a patient with gallbladder dysfunction may present with contracture of the paraspinal musculature surrounding T5 to T9 (via motor efferents), pain and/or tenderness in the right upper quadrant (via somatic efferents), and/or warmth and erythema of the skin (due to local ischemia and autonomic efferent signaling) in the same region.", "contents": "Physiology, Viscerosomatic Reflexes -- Mechanism. Another common example of an easily recognizable and clinically relevant viscerosomatic reflex is the sensation of upper shoulder pain in the setting of hepatobiliary disease. Most often a complication of biliary obstruction (e.g., cholelithiases), gallbladder inflammation (e.g., cholecystitis), infection (e.g., ascending cholangitis), or neoplasm (e.g., cholangiocarcinoma), irritation of the gallbladder epithelium activates visceral afferent receptors, increasing the transmission of abnormal sensory input into the dorsal horn of the spinal cord. This input from the gallbladder facilitates regional interneurons from spinal levels T5 to T9. Normal input to the interneurons at these segmental levels then becomes amplified, causing excessive motor, sensory, and autonomic efferent responses. Therefore, a patient with gallbladder dysfunction may present with contracture of the paraspinal musculature surrounding T5 to T9 (via motor efferents), pain and/or tenderness in the right upper quadrant (via somatic efferents), and/or warmth and erythema of the skin (due to local ischemia and autonomic efferent signaling) in the same region."}
+{"id": "article-102988_16", "title": "Physiology, Viscerosomatic Reflexes -- Related Testing", "content": "A complete osteopathic structural exam can reveal tissue texture changes in body areas related to specific visceral structures. Identification of the regions of greatest restriction during a structural exam, along with recognition of relevant TART findings, suggest somatic dysfunction and warrant further evaluation. [27] TART changes direct the physician toward the somatic dysfunction and may provide clues as to their chronicity. However, the presentation of somatic dysfunction is highly variable from patient to patient. While some patients can localize their complaints, others use vague descriptors such as \u201ctight,\u201d \u201cachy,\u201d or \u201cnagging.\u201d Acute tissue texture changes are generally edematous, moist, and erythematous with hypertonic (viz. \u201ctight\u201d) underlying musculature. In contradistinction, chronic tissue texture changes are typically flaccid, fibrotic, cool, or \u201cropy.\u201d [28]", "contents": "Physiology, Viscerosomatic Reflexes -- Related Testing. A complete osteopathic structural exam can reveal tissue texture changes in body areas related to specific visceral structures. Identification of the regions of greatest restriction during a structural exam, along with recognition of relevant TART findings, suggest somatic dysfunction and warrant further evaluation. [27] TART changes direct the physician toward the somatic dysfunction and may provide clues as to their chronicity. However, the presentation of somatic dysfunction is highly variable from patient to patient. While some patients can localize their complaints, others use vague descriptors such as \u201ctight,\u201d \u201cachy,\u201d or \u201cnagging.\u201d Acute tissue texture changes are generally edematous, moist, and erythematous with hypertonic (viz. \u201ctight\u201d) underlying musculature. In contradistinction, chronic tissue texture changes are typically flaccid, fibrotic, cool, or \u201cropy.\u201d [28]"}
+{"id": "article-102988_17", "title": "Physiology, Viscerosomatic Reflexes -- Related Testing", "content": "An important diagnostic aid related to viscerosomatic reflexes and specific to osteopathic medicine is the identification of Chapman\u2019s points. Chapman\u2019s points are small, tender, palpable fascial congestions deep to the subcutaneous tissue. While their exact mechanism is not completely understood, they appear to represent the somatic manifestation of a visceral dysfunction. [29] [30] Chapman\u2019s points are often described as a grain of rice or tapioca pearl found within the deep fascia and are tender upon palpation. [30] They do not refer pain when palpated. In this way, they may be differentiated from myofascial trigger points, which are similarly tender to palpation but do refer pain. [31] [32] Myofascial trigger points also appear in taut bands of muscle tissue, not the deep fascia.", "contents": "Physiology, Viscerosomatic Reflexes -- Related Testing. An important diagnostic aid related to viscerosomatic reflexes and specific to osteopathic medicine is the identification of Chapman\u2019s points. Chapman\u2019s points are small, tender, palpable fascial congestions deep to the subcutaneous tissue. While their exact mechanism is not completely understood, they appear to represent the somatic manifestation of a visceral dysfunction. [29] [30] Chapman\u2019s points are often described as a grain of rice or tapioca pearl found within the deep fascia and are tender upon palpation. [30] They do not refer pain when palpated. In this way, they may be differentiated from myofascial trigger points, which are similarly tender to palpation but do refer pain. [31] [32] Myofascial trigger points also appear in taut bands of muscle tissue, not the deep fascia."}
+{"id": "article-102988_18", "title": "Physiology, Viscerosomatic Reflexes -- Clinical Significance", "content": "Viscerosomatic reflexes produce somatic findings (such as referred pain or segmentally-related tissue texture changes) that can help direct a physician to a specific focus of visceral dysfunction. They may also assist the examining physician in narrowing the differential diagnosis when the clinical picture is unclear. When coupled with a thorough history and physical, medication reconciliation, and consideration of environmental factors (viz. common masqueraders such as tight clothing or a sunburn), somatic dysfunction can expose occult visceral dysfunction. For example, a middle-aged male with a history of primary hyperparathyroidism may present with hypertonicity in the paraspinal musculature from T10 to T11, a tender Chapman\u2019s point one inch superiorly and one inch to the left of the umbilicus, and a complaint of waxing and waning lower back pain that radiates into his groin. The chief complaint alone is suggestive of nephrolithiasis; the presence of segmentally-related tissue texture changes, and a Chapman\u2019s point further supports an illness script that illustrates renal pathology.", "contents": "Physiology, Viscerosomatic Reflexes -- Clinical Significance. Viscerosomatic reflexes produce somatic findings (such as referred pain or segmentally-related tissue texture changes) that can help direct a physician to a specific focus of visceral dysfunction. They may also assist the examining physician in narrowing the differential diagnosis when the clinical picture is unclear. When coupled with a thorough history and physical, medication reconciliation, and consideration of environmental factors (viz. common masqueraders such as tight clothing or a sunburn), somatic dysfunction can expose occult visceral dysfunction. For example, a middle-aged male with a history of primary hyperparathyroidism may present with hypertonicity in the paraspinal musculature from T10 to T11, a tender Chapman\u2019s point one inch superiorly and one inch to the left of the umbilicus, and a complaint of waxing and waning lower back pain that radiates into his groin. The chief complaint alone is suggestive of nephrolithiasis; the presence of segmentally-related tissue texture changes, and a Chapman\u2019s point further supports an illness script that illustrates renal pathology."}
+{"id": "article-102988_19", "title": "Physiology, Viscerosomatic Reflexes -- Clinical Significance", "content": "An important clinical consequence of central sensitization is hyperalgesia. Abnormal and/or steady visceral and somatic sensory input sensitize the interneurons of the dorsal horn and lower their excitation threshold as they contemporaneously lower the threshold of the receptive fields of related somatic structures. Due to the hyperexcitability of the convergent nerves within the spinal cord and the local sensory receptors, less irritation to the somatic structure is required to potentiate an action potential through the sensory pathways, ultimately resulting in increased sensitivity to pain. Another postulate is that the increased contraction of the segmentally-related musculature due to exaggerated motor output results in some peripheral sensitization at the nociceptors within the muscles themselves. [33] [34] Given these cellular mechanisms, it is not uncommon for patients with visceral dysfunction to present with hyperalgesia of segmentally-related somatic structures.", "contents": "Physiology, Viscerosomatic Reflexes -- Clinical Significance. An important clinical consequence of central sensitization is hyperalgesia. Abnormal and/or steady visceral and somatic sensory input sensitize the interneurons of the dorsal horn and lower their excitation threshold as they contemporaneously lower the threshold of the receptive fields of related somatic structures. Due to the hyperexcitability of the convergent nerves within the spinal cord and the local sensory receptors, less irritation to the somatic structure is required to potentiate an action potential through the sensory pathways, ultimately resulting in increased sensitivity to pain. Another postulate is that the increased contraction of the segmentally-related musculature due to exaggerated motor output results in some peripheral sensitization at the nociceptors within the muscles themselves. [33] [34] Given these cellular mechanisms, it is not uncommon for patients with visceral dysfunction to present with hyperalgesia of segmentally-related somatic structures."}
+{"id": "article-102988_20", "title": "Physiology, Viscerosomatic Reflexes -- Clinical Significance", "content": "Osteopathic physicians employ manipulative therapy to attenuate sympathetic nervous system activity - and therefore visceral dysfunction - via networks of somatovisceral reflexes. Paraspinal inhibition, rib raising, and soft tissue manipulation to areas of hypertonicity can directly influence the underlying sympathetic nerves and associated visceral structures. [35] [36] Rotary manipulation of Chapman\u2019s points appears to possibly rebalance the viscerosomatic reflex arc and normalize autonomic tone. [37] Regardless of the technique used, the goal of osteopathic manipulative treatment is to eliminate, or at least reduce, somatic dysfunction to decrease the somatic component of segmental facilitation within the spinal cord and improve global nervous system function. Optimization of nervous system function and minimization of somatic dysfunction helps establish an internal environment that is conducive to the resolution of visceral dysfunction.", "contents": "Physiology, Viscerosomatic Reflexes -- Clinical Significance. Osteopathic physicians employ manipulative therapy to attenuate sympathetic nervous system activity - and therefore visceral dysfunction - via networks of somatovisceral reflexes. Paraspinal inhibition, rib raising, and soft tissue manipulation to areas of hypertonicity can directly influence the underlying sympathetic nerves and associated visceral structures. [35] [36] Rotary manipulation of Chapman\u2019s points appears to possibly rebalance the viscerosomatic reflex arc and normalize autonomic tone. [37] Regardless of the technique used, the goal of osteopathic manipulative treatment is to eliminate, or at least reduce, somatic dysfunction to decrease the somatic component of segmental facilitation within the spinal cord and improve global nervous system function. Optimization of nervous system function and minimization of somatic dysfunction helps establish an internal environment that is conducive to the resolution of visceral dysfunction."}
+{"id": "article-102988_21", "title": "Physiology, Viscerosomatic Reflexes -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Physiology, Viscerosomatic Reflexes -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

statpearls/chunk/article-102993.jsonl

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+{"id": "article-102993_0", "title": "Physiology, Chapman\u2019s Points -- Introduction", "content": "The intimate connection between the nervous system and the lymphatic system in both health and disease has long been acknowledged in osteopathic medicine. In fact, treatments such as rib raising and occipital inhibition have as their foundation this very principle. [1] Though first described as neuro-lymphatic points by Frank Chapman, DO in the early 1900s, Chapman's points are now defined as organ-specific gangliform contractions associated with underlying visceral dysfunction. [2] [3] More specifically, Chapman's points present as smooth and discreetly palpable nodules located\u00a0deep within the fascia\u00a0in regions related\u00a0by dermatome to the dysfunctional viscera. These points are sharp, pinpoint, non-radiating, and anatomically consistent between individuals. [4] [5] [3]", "contents": "Physiology, Chapman\u2019s Points -- Introduction. The intimate connection between the nervous system and the lymphatic system in both health and disease has long been acknowledged in osteopathic medicine. In fact, treatments such as rib raising and occipital inhibition have as their foundation this very principle. [1] Though first described as neuro-lymphatic points by Frank Chapman, DO in the early 1900s, Chapman's points are now defined as organ-specific gangliform contractions associated with underlying visceral dysfunction. [2] [3] More specifically, Chapman's points present as smooth and discreetly palpable nodules located\u00a0deep within the fascia\u00a0in regions related\u00a0by dermatome to the dysfunctional viscera. These points are sharp, pinpoint, non-radiating, and anatomically consistent between individuals. [4] [5] [3]"}
+{"id": "article-102993_1", "title": "Physiology, Chapman\u2019s Points -- Introduction", "content": "Though initially considered somatic representations of neuro-lymphatic reflexes, the contributions of osteopathic physicians such as Charles Owens, DO, H.L. Samblanet, DO, and Paul Kimberly, DO, expanded the consideration of these nodules to be somatic manifestations of general visceral dysfunction, including of the lymphatics and endocrine glands. [6] Eventually, these nodules were\u00a0coined Chapman's points or Chapman's reflexes. This article intends to expand on issues of concern regarding Chapman's points, their embryologic basis, mechanism of development, and\u00a0function in clinical practice.", "contents": "Physiology, Chapman\u2019s Points -- Introduction. Though initially considered somatic representations of neuro-lymphatic reflexes, the contributions of osteopathic physicians such as Charles Owens, DO, H.L. Samblanet, DO, and Paul Kimberly, DO, expanded the consideration of these nodules to be somatic manifestations of general visceral dysfunction, including of the lymphatics and endocrine glands. [6] Eventually, these nodules were\u00a0coined Chapman's points or Chapman's reflexes. This article intends to expand on issues of concern regarding Chapman's points, their embryologic basis, mechanism of development, and\u00a0function in clinical practice."}
+{"id": "article-102993_2", "title": "Physiology, Chapman\u2019s Points -- Issues of Concern", "content": "An issue of great concern to the osteopathic community is the minimal collection of peer-reviewed clinical research regarding the physiology and presence of Chapman's points. Currently, much of the information about Chapman's points are anecdotal and based heavily on the clinical observations of a limited number of physicians. As of yet, there is no evidence confirming the presence of Chapman's points in tissue biopsies, but there exists a few studies demonstrating that sympathetic and endocrine alterations occur after\u00a0rotatory manipulation of Chapman's points.\u00a0The findings of these studies\u00a0support the hypothesized physiology and presence of Chapman's points, as will be explained further in successive sections. [7] [4]", "contents": "Physiology, Chapman\u2019s Points -- Issues of Concern. An issue of great concern to the osteopathic community is the minimal collection of peer-reviewed clinical research regarding the physiology and presence of Chapman's points. Currently, much of the information about Chapman's points are anecdotal and based heavily on the clinical observations of a limited number of physicians. As of yet, there is no evidence confirming the presence of Chapman's points in tissue biopsies, but there exists a few studies demonstrating that sympathetic and endocrine alterations occur after\u00a0rotatory manipulation of Chapman's points.\u00a0The findings of these studies\u00a0support the hypothesized physiology and presence of Chapman's points, as will be explained further in successive sections. [7] [4]"}
+{"id": "article-102993_3", "title": "Physiology, Chapman\u2019s Points -- Issues of Concern", "content": "Despite the minimal research into their physiology, Chapman's points are included in the curricula of osteopathic medical schools. Education of future osteopathic physicians of Chapman's points fosters the opportunity for future research that may ameliorate some of the allusiveness of these nodules.", "contents": "Physiology, Chapman\u2019s Points -- Issues of Concern. Despite the minimal research into their physiology, Chapman's points are included in the curricula of osteopathic medical schools. Education of future osteopathic physicians of Chapman's points fosters the opportunity for future research that may ameliorate some of the allusiveness of these nodules."}
+{"id": "article-102993_4", "title": "Physiology, Chapman\u2019s Points -- Issues of Concern", "content": "Dr. Chapman left no written legacy regarding the reflex point interpretation system, but his brother-in-law, Charles Owens, D.O., and his wife, Ada Hinchley Chapman D.O., published the only existing text on this topic.", "contents": "Physiology, Chapman\u2019s Points -- Issues of Concern. Dr. Chapman left no written legacy regarding the reflex point interpretation system, but his brother-in-law, Charles Owens, D.O., and his wife, Ada Hinchley Chapman D.O., published the only existing text on this topic."}
+{"id": "article-102993_5", "title": "Physiology, Chapman\u2019s Points -- Development", "content": "During fetal development, autonomic efferents arise within the ventral ventricular zone, an anterior region of the primordial spinal cord. The primordial cells migrate toward the ventral horn and temporarily coalesce with somatic efferents, forming a singular primordial motor column. Eventually, the autonomic efferents will separate from the somatic efferents and migrate dorsally. Once in the intermediate spinal cord, the cell bodies of the autonomic efferents increase their polarity and\u00a0fix their orientation within the gray matter, thus establishing their permanent placement within the intermediolateral columns (IML). [8] This temporary primordial motor column provides an opportunity for the\u00a0intersection of visceral and somatic signaling, thereby\u00a0laying the foundation for\u00a0an embryologic basis of future reflex arcs connecting visceral and somatic systems.", "contents": "Physiology, Chapman\u2019s Points -- Development. During fetal development, autonomic efferents arise within the ventral ventricular zone, an anterior region of the primordial spinal cord. The primordial cells migrate toward the ventral horn and temporarily coalesce with somatic efferents, forming a singular primordial motor column. Eventually, the autonomic efferents will separate from the somatic efferents and migrate dorsally. Once in the intermediate spinal cord, the cell bodies of the autonomic efferents increase their polarity and\u00a0fix their orientation within the gray matter, thus establishing their permanent placement within the intermediolateral columns (IML). [8] This temporary primordial motor column provides an opportunity for the\u00a0intersection of visceral and somatic signaling, thereby\u00a0laying the foundation for\u00a0an embryologic basis of future reflex arcs connecting visceral and somatic systems."}
+{"id": "article-102993_6", "title": "Physiology, Chapman\u2019s Points -- Development", "content": "The IML is located within the spinal cord gray matter from T1 to L2 with projections peripherally via sympathetic nerves, and the central nervous system. Collectively, the IML houses cell bodies of the preganglionic sympathetic efferents and is therefore responsible for sympathetic output to the viscera, including the lymphatics. The diagnostic utility of Chapman's points lies in the relatively\u00a0distinct innervation of each viscus. Each structure\u00a0transmits information to and from the central nervous system via a relatively homogenous segment of the spinal cord, resulting in somatic findings, such as the nodules of Chapman's points, within related dermatomal regions specific to the underlying dysfunctional viscus. [9]", "contents": "Physiology, Chapman\u2019s Points -- Development. The IML is located within the spinal cord gray matter from T1 to L2 with projections peripherally via sympathetic nerves, and the central nervous system. Collectively, the IML houses cell bodies of the preganglionic sympathetic efferents and is therefore responsible for sympathetic output to the viscera, including the lymphatics. The diagnostic utility of Chapman's points lies in the relatively\u00a0distinct innervation of each viscus. Each structure\u00a0transmits information to and from the central nervous system via a relatively homogenous segment of the spinal cord, resulting in somatic findings, such as the nodules of Chapman's points, within related dermatomal regions specific to the underlying dysfunctional viscus. [9]"}
+{"id": "article-102993_7", "title": "Physiology, Chapman\u2019s Points -- Development", "content": "After exiting the IML, preganglionic\u00a0sympathetic efferents enter the sympathetic chain ganglia that lie alongside the vertebral column and synapse. From here, postganglionic\u00a0sympathetic efferents branch and run alongside the ribs with the intercostal neurovascular bundle. These sympathetic branches are responsible for the sympathetic innervation of the arteries, veins, and lymphatic tissue contained within the bundle, which lies between the anterior and posterior layers of the intercostal fascia. [10]", "contents": "Physiology, Chapman\u2019s Points -- Development. After exiting the IML, preganglionic\u00a0sympathetic efferents enter the sympathetic chain ganglia that lie alongside the vertebral column and synapse. From here, postganglionic\u00a0sympathetic efferents branch and run alongside the ribs with the intercostal neurovascular bundle. These sympathetic branches are responsible for the sympathetic innervation of the arteries, veins, and lymphatic tissue contained within the bundle, which lies between the anterior and posterior layers of the intercostal fascia. [10]"}
+{"id": "article-102993_8", "title": "Physiology, Chapman\u2019s Points -- Organ Systems Involved", "content": "A conceptualized diagram of the locations of commonly encountered anterior Chapman\u2019s points appears below. Additionally, this review includes a table of selected Chapman\u2019s points.\u00a0While unnecessary to memorize, familiarity with the location of these major anterior Chapman\u2019s points can be of diagnostic utility to osteopathic physicians.", "contents": "Physiology, Chapman\u2019s Points -- Organ Systems Involved. A conceptualized diagram of the locations of commonly encountered anterior Chapman\u2019s points appears below. Additionally, this review includes a table of selected Chapman\u2019s points.\u00a0While unnecessary to memorize, familiarity with the location of these major anterior Chapman\u2019s points can be of diagnostic utility to osteopathic physicians."}
+{"id": "article-102993_9", "title": "Physiology, Chapman\u2019s Points -- Function", "content": "Presently, there is no definitive consensus or guidelines regarding the function and value of Chapman's points. If utilized, most osteopathic physicians consider the finding of a Chapman's point a diagnostic tool.\u00a0When considered concurrently with information gathered via a thorough history and physical, the presence of Chapman's points increases the clinical suspicion for underlying visceral disease. [7] While this diagnostic utility is agreed upon by many osteopathic physicians, the presence of a Chapman's point alone is never considered sufficient for diagnosis. A much smaller subset of osteopathic physicians uses rotary manipulation to treat Chapman's points as the hypothesis is to balance autonomic tone to related lymphatics and viscera, which may encourage lymphatic drainage and minimization of visceral dysfunction. [3] [5]", "contents": "Physiology, Chapman\u2019s Points -- Function. Presently, there is no definitive consensus or guidelines regarding the function and value of Chapman's points. If utilized, most osteopathic physicians consider the finding of a Chapman's point a diagnostic tool.\u00a0When considered concurrently with information gathered via a thorough history and physical, the presence of Chapman's points increases the clinical suspicion for underlying visceral disease. [7] While this diagnostic utility is agreed upon by many osteopathic physicians, the presence of a Chapman's point alone is never considered sufficient for diagnosis. A much smaller subset of osteopathic physicians uses rotary manipulation to treat Chapman's points as the hypothesis is to balance autonomic tone to related lymphatics and viscera, which may encourage lymphatic drainage and minimization of visceral dysfunction. [3] [5]"}
+{"id": "article-102993_10", "title": "Physiology, Chapman\u2019s Points -- Function", "content": "Another hypothesis to consider for the identity of these ganglionic formations may be due to the presence of vessels of the system known as the \"primo vascular system\" (PVS). PVS have vessels and nodes from the surface to the periphery, connected to all the viscera and ubiquitously present in the human body. The liquid that these vessels carry is rich in protein, hormones, and more. The movement is influenced by the structures adjacent to the PVS, by the heartbeat and by the breath; moreover, the same vessels can contract, having their own electrical activity, through endothelial cells similar to the actin of smooth muscle. The liquid transport speed can be slower than the lymphatic transport speed or faster; this will depend on the location where PVS is present.", "contents": "Physiology, Chapman\u2019s Points -- Function. Another hypothesis to consider for the identity of these ganglionic formations may be due to the presence of vessels of the system known as the \"primo vascular system\" (PVS). PVS have vessels and nodes from the surface to the periphery, connected to all the viscera and ubiquitously present in the human body. The liquid that these vessels carry is rich in protein, hormones, and more. The movement is influenced by the structures adjacent to the PVS, by the heartbeat and by the breath; moreover, the same vessels can contract, having their own electrical activity, through endothelial cells similar to the actin of smooth muscle. The liquid transport speed can be slower than the lymphatic transport speed or faster; this will depend on the location where PVS is present."}
+{"id": "article-102993_11", "title": "Physiology, Chapman\u2019s Points -- Mechanism", "content": "Chapman\u2019s points are easily defined clinically, but physiologically they are much more complex. Visceral inflammation, spasm, and distention are all postulates as causes of positive Chapman\u2019s points. The leading theory is that Chapman\u2019s points develop from lymphatic dysfunction, secondary to underlying visceral dysfunction. Accordingly, Chapman\u2019s points are broadly referred to as examples of viscero-somatic reflexes. [11] [6]", "contents": "Physiology, Chapman\u2019s Points -- Mechanism. Chapman\u2019s points are easily defined clinically, but physiologically they are much more complex. Visceral inflammation, spasm, and distention are all postulates as causes of positive Chapman\u2019s points. The leading theory is that Chapman\u2019s points develop from lymphatic dysfunction, secondary to underlying visceral dysfunction. Accordingly, Chapman\u2019s points are broadly referred to as examples of viscero-somatic reflexes. [11] [6]"}
+{"id": "article-102993_12", "title": "Physiology, Chapman\u2019s Points -- Mechanism", "content": "Currently, the best hypothesis for the development of Chapman\u2019s points lies in central sensitization and the facilitation of interneurons within the spinal cord gray matter. Visceral dysfunction, in the form of infection, inflammation, ischemia, etc. activate visceral afferent receptors, resulting in the transmission of abnormal or excessive input into the dorsal horn of the spinal cord. This abnormal input sensitizes the interneurons to subsequent stimuli.\u00a0This facilitation maintains the interneurons at sub-threshold excitation, meaning that\u00a0normal input to these interneurons\u00a0is now amplified and results in excessive efferent responses. [2] [12] [13] In the case of Chapman\u2019s points, the most important of these efferent responses is via the sympathetic signal back\u00a0to the dysfunctional organ and surrounding lymphatic tissue. [14] It is suspected that this altered sympathetic tone results in dysfunction of the lymphatic tissues and creates gangliform contractions that impede lymphatic flow, which may exacerbate the preexisting visceral dysfunction and create inflammation distal to the contraction. [7]", "contents": "Physiology, Chapman\u2019s Points -- Mechanism. Currently, the best hypothesis for the development of Chapman\u2019s points lies in central sensitization and the facilitation of interneurons within the spinal cord gray matter. Visceral dysfunction, in the form of infection, inflammation, ischemia, etc. activate visceral afferent receptors, resulting in the transmission of abnormal or excessive input into the dorsal horn of the spinal cord. This abnormal input sensitizes the interneurons to subsequent stimuli.\u00a0This facilitation maintains the interneurons at sub-threshold excitation, meaning that\u00a0normal input to these interneurons\u00a0is now amplified and results in excessive efferent responses. [2] [12] [13] In the case of Chapman\u2019s points, the most important of these efferent responses is via the sympathetic signal back\u00a0to the dysfunctional organ and surrounding lymphatic tissue. [14] It is suspected that this altered sympathetic tone results in dysfunction of the lymphatic tissues and creates gangliform contractions that impede lymphatic flow, which may exacerbate the preexisting visceral dysfunction and create inflammation distal to the contraction. [7]"}
+{"id": "article-102993_13", "title": "Physiology, Chapman\u2019s Points -- Mechanism", "content": "While a variety of underlying visceral dysfunctions appear to cause Chapman\u2019s points, they are most specifically representations of neuro-lymphatic reflexes. [7] Lymphatic capillaries receive input from the sympathetic nervous system. Activation of alpha-adrenergic receptors by epinephrine initially induces constriction and peristalsis of lymphatic channels. With sustained hyper-sympathetic stimulation, as occurs with visceral dysfunction, peristalsis decreases and results in stasis of lymph. This stasis exacerbates the underlying visceral dysfunction and induces positive feedback on the viscero-somatic reflex arc. [15] [16] [17] Further evidence of this neuro-lymphatic etiology lies in that Chapman\u2019s points commonly present at the cutaneous vascular-lymphatic and cutaneous nerve interface. [18]", "contents": "Physiology, Chapman\u2019s Points -- Mechanism. While a variety of underlying visceral dysfunctions appear to cause Chapman\u2019s points, they are most specifically representations of neuro-lymphatic reflexes. [7] Lymphatic capillaries receive input from the sympathetic nervous system. Activation of alpha-adrenergic receptors by epinephrine initially induces constriction and peristalsis of lymphatic channels. With sustained hyper-sympathetic stimulation, as occurs with visceral dysfunction, peristalsis decreases and results in stasis of lymph. This stasis exacerbates the underlying visceral dysfunction and induces positive feedback on the viscero-somatic reflex arc. [15] [16] [17] Further evidence of this neuro-lymphatic etiology lies in that Chapman\u2019s points commonly present at the cutaneous vascular-lymphatic and cutaneous nerve interface. [18]"}
+{"id": "article-102993_14", "title": "Physiology, Chapman\u2019s Points -- Mechanism", "content": "Another possible physiologic mechanism of Chapman\u2019s points lies in the axon reflex. Sustained visceral dysfunction repeatedly depolarizes the\u00a0visceral afferent receptors, triggering the release of neuropeptides. These neuropeptides stimulate C-fibers, resulting in depolarization and an action potential along sympathetic afferents. This sensory input into the CNS can establish\u00a0central sensitization and/or maintain facilitation resulting from mechanisms discussed above. Additionally, the neuropeptides stimulate antidromic activity within nerve branches in sites unrelated to the underlying visceral dysfunction. This mechanism may explain Chapman\u2019s points in seemingly unrelated areas. [19]", "contents": "Physiology, Chapman\u2019s Points -- Mechanism. Another possible physiologic mechanism of Chapman\u2019s points lies in the axon reflex. Sustained visceral dysfunction repeatedly depolarizes the\u00a0visceral afferent receptors, triggering the release of neuropeptides. These neuropeptides stimulate C-fibers, resulting in depolarization and an action potential along sympathetic afferents. This sensory input into the CNS can establish\u00a0central sensitization and/or maintain facilitation resulting from mechanisms discussed above. Additionally, the neuropeptides stimulate antidromic activity within nerve branches in sites unrelated to the underlying visceral dysfunction. This mechanism may explain Chapman\u2019s points in seemingly unrelated areas. [19]"}
+{"id": "article-102993_15", "title": "Physiology, Chapman\u2019s Points -- Related Testing", "content": "When screening for Chapman's points, it is important to note that there are both anterior and posterior points. In general, anterior Chapman's points are found in the intercostal space between segmentally related ribs, near the sternocostal or costochondral junctions. Posterior points typically appear between the spinous and transverse processes of vertebrae of the same numbered ribs as the anterior points. For example, innervation to and from the heart is routed via the gray matter of spinal cord levels T1-T5. The anterior point is found in the intercostal space between ribs 2 and 3 at the sternocostal junction, and the posterior point is present midway between the transverse and spinous processes of T2 and T3. [4]", "contents": "Physiology, Chapman\u2019s Points -- Related Testing. When screening for Chapman's points, it is important to note that there are both anterior and posterior points. In general, anterior Chapman's points are found in the intercostal space between segmentally related ribs, near the sternocostal or costochondral junctions. Posterior points typically appear between the spinous and transverse processes of vertebrae of the same numbered ribs as the anterior points. For example, innervation to and from the heart is routed via the gray matter of spinal cord levels T1-T5. The anterior point is found in the intercostal space between ribs 2 and 3 at the sternocostal junction, and the posterior point is present midway between the transverse and spinous processes of T2 and T3. [4]"}
+{"id": "article-102993_16", "title": "Physiology, Chapman\u2019s Points -- Related Testing", "content": "Osteopathic physicians that\u00a0include Chapman's points in their\u00a0development of differential diagnoses often use a 30- or 45-second screen, in which they systematically screen for positive Chapman's points related to common pathologies. Studies have shown that including a Chapman's screen increases the credibility of a diagnosis. [7]", "contents": "Physiology, Chapman\u2019s Points -- Related Testing. Osteopathic physicians that\u00a0include Chapman's points in their\u00a0development of differential diagnoses often use a 30- or 45-second screen, in which they systematically screen for positive Chapman's points related to common pathologies. Studies have shown that including a Chapman's screen increases the credibility of a diagnosis. [7]"}
+{"id": "article-102993_17", "title": "Physiology, Chapman\u2019s Points -- Related Testing", "content": "It is necessary clinically to differentiate\u00a0Chapman's points from myofascial trigger points, Jones' strain-counterstrain tender points, and fibromyalgia points, which can all present similarly. Myofascial trigger points are present within taut bands of skeletal muscle or the muscle fascia. Trigger points elicit pain that radiates in specific, reproducible patterns when compressed. [20] [21] [22] Jones' strain-counterstrain tender points are simply points of tenderness, without other somatic findings like the nodularity of Chapman's points. Named by Lawrence Jones, DO, counter strain tender points occur in muscles that aberrantly signal strain to the central nervous system in the absence of physical strain. These points are used entirely for the treatment of somatic dysfunction using counterstrain (also referred to as strain-counterstrain). [23] [24] Fibromyalgia points are also points of tenderness that are used for the diagnosis of fibromyalgia. One of the diagnostic sets of criteria for fibromyalgia requires the presence of widespread chronic pain and the presence of 11 of 18 of these tender points. [25]", "contents": "Physiology, Chapman\u2019s Points -- Related Testing. It is necessary clinically to differentiate\u00a0Chapman's points from myofascial trigger points, Jones' strain-counterstrain tender points, and fibromyalgia points, which can all present similarly. Myofascial trigger points are present within taut bands of skeletal muscle or the muscle fascia. Trigger points elicit pain that radiates in specific, reproducible patterns when compressed. [20] [21] [22] Jones' strain-counterstrain tender points are simply points of tenderness, without other somatic findings like the nodularity of Chapman's points. Named by Lawrence Jones, DO, counter strain tender points occur in muscles that aberrantly signal strain to the central nervous system in the absence of physical strain. These points are used entirely for the treatment of somatic dysfunction using counterstrain (also referred to as strain-counterstrain). [23] [24] Fibromyalgia points are also points of tenderness that are used for the diagnosis of fibromyalgia. One of the diagnostic sets of criteria for fibromyalgia requires the presence of widespread chronic pain and the presence of 11 of 18 of these tender points. [25]"}
+{"id": "article-102993_18", "title": "Physiology, Chapman\u2019s Points -- Related Testing", "content": "To diagnose a positive Chapman's point, the anterior and corresponding posterior point both need to be present, despite the general use of posterior points for treatment. Furthermore, a reference chart, similar to those included at the conclusion of this article, should be used when screening. [4]", "contents": "Physiology, Chapman\u2019s Points -- Related Testing. To diagnose a positive Chapman's point, the anterior and corresponding posterior point both need to be present, despite the general use of posterior points for treatment. Furthermore, a reference chart, similar to those included at the conclusion of this article, should be used when screening. [4]"}
+{"id": "article-102993_19", "title": "Physiology, Chapman\u2019s Points -- Related Testing", "content": "While diagnostically valuable, the presence of Chapman's points should be considered in light of all information gleaned from a full structural exam, history, and physical. [7] For example, a physician should also screen for other viscero-somatic reflex findings in related tissues. For instance, if a patient presents with colicky right upper quadrant pain that is exacerbated by fatty meals, it is likely\u00a0a physician will find a gallbladder Chapman's point in the intercostal space between ribs 5 and 6 on the right along with hypertonicity of the paraspinal musculature from T5 to T9 on the right. The presence of a gallbladder Chapman's points and viscero-somatic reflex tissue texture changes in tissues segmentally related to the gallbladder lead the physician to assume\u00a0biliary pathology. When considered in conjunction with the patient's history, there is high clinical suspicion of cholelithiasis.", "contents": "Physiology, Chapman\u2019s Points -- Related Testing. While diagnostically valuable, the presence of Chapman's points should be considered in light of all information gleaned from a full structural exam, history, and physical. [7] For example, a physician should also screen for other viscero-somatic reflex findings in related tissues. For instance, if a patient presents with colicky right upper quadrant pain that is exacerbated by fatty meals, it is likely\u00a0a physician will find a gallbladder Chapman's point in the intercostal space between ribs 5 and 6 on the right along with hypertonicity of the paraspinal musculature from T5 to T9 on the right. The presence of a gallbladder Chapman's points and viscero-somatic reflex tissue texture changes in tissues segmentally related to the gallbladder lead the physician to assume\u00a0biliary pathology. When considered in conjunction with the patient's history, there is high clinical suspicion of cholelithiasis."}
+{"id": "article-102993_20", "title": "Physiology, Chapman\u2019s Points -- Clinical Significance", "content": "Because Chapman's points are somatic representations of viscero-somatic reflexes, they are typically used diagnostically, rather than therapeutically, and provide further clinical evidence of the presence or absence of visceral disease. [6] [7] When taken in context with other findings elucidated during a patient visit, Chapman's points can contribute to a physician's differential diagnosis. Many osteopathic leaders indicate that a non-tender Chapman's point alone is indicative of nothing and that a diagnosis can never be made based solely on the presence of a non-tender Chapman's point. Despite this, they also encourage physicians never to ignore or trivialize the presence of a tender Chapman's point, unless the physician can provide a sound explanation for the finding, especially when the point is persistently tender. [6]", "contents": "Physiology, Chapman\u2019s Points -- Clinical Significance. Because Chapman's points are somatic representations of viscero-somatic reflexes, they are typically used diagnostically, rather than therapeutically, and provide further clinical evidence of the presence or absence of visceral disease. [6] [7] When taken in context with other findings elucidated during a patient visit, Chapman's points can contribute to a physician's differential diagnosis. Many osteopathic leaders indicate that a non-tender Chapman's point alone is indicative of nothing and that a diagnosis can never be made based solely on the presence of a non-tender Chapman's point. Despite this, they also encourage physicians never to ignore or trivialize the presence of a tender Chapman's point, unless the physician can provide a sound explanation for the finding, especially when the point is persistently tender. [6]"}
+{"id": "article-102993_21", "title": "Physiology, Chapman\u2019s Points -- Clinical Significance", "content": "If a physician does decide to use a Chapman's point for treatment, rotatory movement over the point is believed to normalize the autonomic tone of the associated dysfunctional viscera by decreasing sympathetic input to the visceral structure. [3] [6] While there is currently no research supporting this mechanism exactly, studies have shown that rotary manipulation of the suboccipital region dampens sympathetic outflow, indicated by a lowered heart rate in test subjects. [26]", "contents": "Physiology, Chapman\u2019s Points -- Clinical Significance. If a physician does decide to use a Chapman's point for treatment, rotatory movement over the point is believed to normalize the autonomic tone of the associated dysfunctional viscera by decreasing sympathetic input to the visceral structure. [3] [6] While there is currently no research supporting this mechanism exactly, studies have shown that rotary manipulation of the suboccipital region dampens sympathetic outflow, indicated by a lowered heart rate in test subjects. [26]"}
+{"id": "article-102993_22", "title": "Physiology, Chapman\u2019s Points -- Clinical Significance", "content": "These findings support the potential for the treatment of Chapman's points to alter the sympathetic tone to associated structures. There is also a belief that the treatment of Chapman's points improves lymphatic return and\u00a0maximizes myofascial motion surrounding the dysfunctional viscera. Again, there is currently no evidence directly supporting this theory, but studies have found that manipulation of lymphatic channels via rhythmic compression of the abdomen or thorax has increased flow through the thoracic duct and increased the leukocyte count of the lymphatic fluids, even at distant sites.", "contents": "Physiology, Chapman\u2019s Points -- Clinical Significance. These findings support the potential for the treatment of Chapman's points to alter the sympathetic tone to associated structures. There is also a belief that the treatment of Chapman's points improves lymphatic return and\u00a0maximizes myofascial motion surrounding the dysfunctional viscera. Again, there is currently no evidence directly supporting this theory, but studies have found that manipulation of lymphatic channels via rhythmic compression of the abdomen or thorax has increased flow through the thoracic duct and increased the leukocyte count of the lymphatic fluids, even at distant sites."}
+{"id": "article-102993_23", "title": "Physiology, Chapman\u2019s Points -- Clinical Significance", "content": "Assuming that Chapman's points are, in fact, due to gangliform contractions within lymphatic tissues, these findings support that manipulation of lymphatic tissues, by rotary manipulation of Chapman's points in this case, mobilizes immune cells and may aid in disease recovery. [27] [28] [5] To sufficiently treat a Chapman's point, especially a posterior point located within paraspinal musculature or a\u00a0particularly painful point, treatment of the overlying tissues to reduce tissue texture changes may be necessary before treating the actual point. [29]", "contents": "Physiology, Chapman\u2019s Points -- Clinical Significance. Assuming that Chapman's points are, in fact, due to gangliform contractions within lymphatic tissues, these findings support that manipulation of lymphatic tissues, by rotary manipulation of Chapman's points in this case, mobilizes immune cells and may aid in disease recovery. [27] [28] [5] To sufficiently treat a Chapman's point, especially a posterior point located within paraspinal musculature or a\u00a0particularly painful point, treatment of the overlying tissues to reduce tissue texture changes may be necessary before treating the actual point. [29]"}
+{"id": "article-102993_24", "title": "Physiology, Chapman\u2019s Points -- Clinical Significance", "content": "Taking up the theory of developing PVS, other authors relate Chapman's points to this system. [30] [31] The PVS would be related to the meridians, and, as a hypothesis, the Chapman points could be the same points where Chinese medicine identifies the areas of insertion of the needles. [30]", "contents": "Physiology, Chapman\u2019s Points -- Clinical Significance. Taking up the theory of developing PVS, other authors relate Chapman's points to this system. [30] [31] The PVS would be related to the meridians, and, as a hypothesis, the Chapman points could be the same points where Chinese medicine identifies the areas of insertion of the needles. [30]"}
+{"id": "article-102993_25", "title": "Physiology, Chapman\u2019s Points -- Clinical Significance", "content": "To conclude, one must remember that the lack of strong evidence does not mean that the phenomenon does not exist. EBM is a tripod in perfect balance: clinical experience, patient response to treatment, research. These three branches have equal value. [32]", "contents": "Physiology, Chapman\u2019s Points -- Clinical Significance. To conclude, one must remember that the lack of strong evidence does not mean that the phenomenon does not exist. EBM is a tripod in perfect balance: clinical experience, patient response to treatment, research. These three branches have equal value. [32]"}
+{"id": "article-102993_26", "title": "Physiology, Chapman\u2019s Points -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Physiology, Chapman\u2019s Points -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

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+{"id": "article-102994_0", "title": "Physiology, Fascia -- Introduction", "content": "Several interpretations of the term \"fascia\" exist within the research community, with no\u00a0singular\u00a0agreed-upon\u00a0definition. [1] However, in simplest terms, fascia can be described as a thin layer of connective tissue that separates muscles and organs from other\u00a0structures within the body.\u00a0It supports and protects muscles and internal organs and reduces friction between muscles. Fascia also\u00a0forms distinct muscular compartments, provides attachments, and improves circulation. [2]", "contents": "Physiology, Fascia -- Introduction. Several interpretations of the term \"fascia\" exist within the research community, with no\u00a0singular\u00a0agreed-upon\u00a0definition. [1] However, in simplest terms, fascia can be described as a thin layer of connective tissue that separates muscles and organs from other\u00a0structures within the body.\u00a0It supports and protects muscles and internal organs and reduces friction between muscles. Fascia also\u00a0forms distinct muscular compartments, provides attachments, and improves circulation. [2]"}
+{"id": "article-102994_1", "title": "Physiology, Fascia -- Issues of Concern", "content": "Many factors can compromise fascial integrity, including aging, genetics, and surgery. Dysfunctions in fascia may result in clinical conditions due to altered structure and functional properties. There exist two main categories of fascial dysfunction; lack of fascial stiffness and an increase in fascial stiffness.", "contents": "Physiology, Fascia -- Issues of Concern. Many factors can compromise fascial integrity, including aging, genetics, and surgery. Dysfunctions in fascia may result in clinical conditions due to altered structure and functional properties. There exist two main categories of fascial dysfunction; lack of fascial stiffness and an increase in fascial stiffness."}
+{"id": "article-102994_2", "title": "Physiology, Fascia -- Issues of Concern", "content": "Lack of fascial stiffness can be seen in inguinal, abdominal, femoral, and incisional hernias. Increased fascial stiffness can be seen in Dupuytren contracture, adhesive capsulitis, and Peyronie disease. Genetic conditions\u00a0leading to widespread fascia laxity include Ehlers-Danlos syndrome and Marfan syndrome. [3]", "contents": "Physiology, Fascia -- Issues of Concern. Lack of fascial stiffness can be seen in inguinal, abdominal, femoral, and incisional hernias. Increased fascial stiffness can be seen in Dupuytren contracture, adhesive capsulitis, and Peyronie disease. Genetic conditions\u00a0leading to widespread fascia laxity include Ehlers-Danlos syndrome and Marfan syndrome. [3]"}
+{"id": "article-102994_3", "title": "Physiology, Fascia -- Cellular Level", "content": "The\u00a0histologic composition of fascia differs based on\u00a0its location within the body. The superficial fascia\u00a0consists primarily of collagen, elastin fibers, and adipose tissue. Superficial fascia requires the ability to resist tensile forces while also allowing elasticity. Hence, the superficial fascia is composed of many elastic fibers. [4]", "contents": "Physiology, Fascia -- Cellular Level. The\u00a0histologic composition of fascia differs based on\u00a0its location within the body. The superficial fascia\u00a0consists primarily of collagen, elastin fibers, and adipose tissue. Superficial fascia requires the ability to resist tensile forces while also allowing elasticity. Hence, the superficial fascia is composed of many elastic fibers. [4]"}
+{"id": "article-102994_4", "title": "Physiology, Fascia -- Cellular Level", "content": "The deep fascia similarly consists of collagen and elastin,\u00a0but the composition varies. The deep fascia has fewer elastin fibers, and the collagen fibers are aligned in parallel. This composition gives fascia remarkable tensile strength and the ability to\u00a0stretch and contract with the musculoskeletal system. Other cell types are also\u00a0present within the deep fascia, including myofibroblasts, fibroblasts, and endothelial cells. [5] Additionally, hyaluronic acid is produced and concentrated within the deep fascia and underlying muscles. [6]", "contents": "Physiology, Fascia -- Cellular Level. The deep fascia similarly consists of collagen and elastin,\u00a0but the composition varies. The deep fascia has fewer elastin fibers, and the collagen fibers are aligned in parallel. This composition gives fascia remarkable tensile strength and the ability to\u00a0stretch and contract with the musculoskeletal system. Other cell types are also\u00a0present within the deep fascia, including myofibroblasts, fibroblasts, and endothelial cells. [5] Additionally, hyaluronic acid is produced and concentrated within the deep fascia and underlying muscles. [6]"}
+{"id": "article-102994_5", "title": "Physiology, Fascia -- Development", "content": "The majority of the fascial system is derived from the mesoderm, except\u00a0for the fascia of the face and anterior region of the neck, which originates from the\u00a0ectodermal cranial neural crest. [7]", "contents": "Physiology, Fascia -- Development. The majority of the fascial system is derived from the mesoderm, except\u00a0for the fascia of the face and anterior region of the neck, which originates from the\u00a0ectodermal cranial neural crest. [7]"}
+{"id": "article-102994_6", "title": "Physiology, Fascia -- Organ Systems Involved", "content": "There are four fundamental categories of fascia:", "contents": "Physiology, Fascia -- Organ Systems Involved. There are four fundamental categories of fascia:"}
+{"id": "article-102994_7", "title": "Physiology, Fascia -- Organ Systems Involved -- Superficial Fascia", "content": "A thin layer of loose connective tissue directly beneath the skin", "contents": "Physiology, Fascia -- Organ Systems Involved -- Superficial Fascia. A thin layer of loose connective tissue directly beneath the skin"}
+{"id": "article-102994_8", "title": "Physiology, Fascia -- Organ Systems Involved -- Deep Fascia", "content": "Surrounds individual muscles and forms fascial compartments Is categorized as axial or appendicular fascia based on location within the\u00a0body", "contents": "Physiology, Fascia -- Organ Systems Involved -- Deep Fascia. Surrounds individual muscles and forms fascial compartments Is categorized as axial or appendicular fascia based on location within the\u00a0body"}
+{"id": "article-102994_9", "title": "Physiology, Fascia -- Organ Systems Involved -- Parietal\u00a0Fascia", "content": "Layers of connective tissue\u00a0lining the walls of body cavities which lie outside the parietal layer of the serosa", "contents": "Physiology, Fascia -- Organ Systems Involved -- Parietal\u00a0Fascia. Layers of connective tissue\u00a0lining the walls of body cavities which lie outside the parietal layer of the serosa"}
+{"id": "article-102994_10", "title": "Physiology, Fascia -- Organ Systems Involved -- Visceral Fascia", "content": "Supports organs in their cavities and encloses them in layers of connective tissue", "contents": "Physiology, Fascia -- Organ Systems Involved -- Visceral Fascia. Supports organs in their cavities and encloses them in layers of connective tissue"}
+{"id": "article-102994_11", "title": "Physiology, Fascia -- Function", "content": "Among the many functions of fascia considered in detail are its ectoskeletal role (acting as a soft tissue skeleton for muscle attachments), its importance for creating osteofascial muscle compartments,\u00a0assisting venous return in the lower limb,\u00a0decreasing stress concentration at entheses, and acting as a protective sheet for underlying structures.\u00a0It is essential to recognize\u00a0the continuity of fascia between regions and\u00a0appreciate its\u00a0vital role in coordinating muscular activity and acting as a body-wide proprioceptive organ. [2]", "contents": "Physiology, Fascia -- Function. Among the many functions of fascia considered in detail are its ectoskeletal role (acting as a soft tissue skeleton for muscle attachments), its importance for creating osteofascial muscle compartments,\u00a0assisting venous return in the lower limb,\u00a0decreasing stress concentration at entheses, and acting as a protective sheet for underlying structures.\u00a0It is essential to recognize\u00a0the continuity of fascia between regions and\u00a0appreciate its\u00a0vital role in coordinating muscular activity and acting as a body-wide proprioceptive organ. [2]"}
+{"id": "article-102994_12", "title": "Physiology, Fascia -- Function -- Protective Function", "content": "In multiple areas of the body, the fascia provides support for the underlying nerves, vessels, and lymphatics. An anatomic relationship that illustrates this principle is seen within the carpal tunnel, as the flexor retinaculum overlies the carpal tunnel\u00a0protecting the median nerve.", "contents": "Physiology, Fascia -- Function -- Protective Function. In multiple areas of the body, the fascia provides support for the underlying nerves, vessels, and lymphatics. An anatomic relationship that illustrates this principle is seen within the carpal tunnel, as the flexor retinaculum overlies the carpal tunnel\u00a0protecting the median nerve."}
+{"id": "article-102994_13", "title": "Physiology, Fascia -- Function -- Myofascial Force Transmission", "content": "Myofascial force transmission occurs when a muscle produces force toward a tendon and joint and transmits that force to the connective tissue within and around the muscle.\u00a0Due to the intimate relationship between muscle and fascia, the fascia plays a role in force transmission. When a muscle produces force,\u00a0the force is transmitted toward the joint's direction and towards the muscle's surface. The connective tissue overlying the surface of the muscle is involved in transmitting this force. The\u00a0myofascial connections can play a role in up to 30% of force transmission.  At the macroscopic level, force is transmitted from the muscle to the surrounding connective tissue. At the microscopic level, cellular changes occur\u00a0involving the various cells making up the fascia. Fibroblasts, one of the principal cells within the fascia, respond to the increased force by increasing cellular signaling and gene expression. These changes lead to increase cell proliferation and connective tissue remodeling. [8]", "contents": "Physiology, Fascia -- Function -- Myofascial Force Transmission. Myofascial force transmission occurs when a muscle produces force toward a tendon and joint and transmits that force to the connective tissue within and around the muscle.\u00a0Due to the intimate relationship between muscle and fascia, the fascia plays a role in force transmission. When a muscle produces force,\u00a0the force is transmitted toward the joint's direction and towards the muscle's surface. The connective tissue overlying the surface of the muscle is involved in transmitting this force. The\u00a0myofascial connections can play a role in up to 30% of force transmission.  At the macroscopic level, force is transmitted from the muscle to the surrounding connective tissue. At the microscopic level, cellular changes occur\u00a0involving the various cells making up the fascia. Fibroblasts, one of the principal cells within the fascia, respond to the increased force by increasing cellular signaling and gene expression. These changes lead to increase cell proliferation and connective tissue remodeling. [8]"}
+{"id": "article-102994_14", "title": "Physiology, Fascia -- Function -- Vascular Support Function", "content": "Interestingly, the deep fascia is more abundant within the lower limbs than the upper limbs. It is hypothesized that this abundance of fascia in the lower limbs serves as a \"compression device\" to increase the venous return from the lower limbs to the heart. This\u00a0distinct role is seen in specific pathologies such as deep vein thrombosis that can form after long periods of inactivity. Without adequate muscle contraction, the blood becomes stagnant, fulfilling one factor of the Virchow triad, leading to thrombus formation.", "contents": "Physiology, Fascia -- Function -- Vascular Support Function. Interestingly, the deep fascia is more abundant within the lower limbs than the upper limbs. It is hypothesized that this abundance of fascia in the lower limbs serves as a \"compression device\" to increase the venous return from the lower limbs to the heart. This\u00a0distinct role is seen in specific pathologies such as deep vein thrombosis that can form after long periods of inactivity. Without adequate muscle contraction, the blood becomes stagnant, fulfilling one factor of the Virchow triad, leading to thrombus formation."}
+{"id": "article-102994_15", "title": "Physiology, Fascia -- Function -- Vascular Support Function", "content": "Compartment syndrome describes a pathology where fascia restricts blood flow to the muscle leading to ischemia. In cases where a fasciotomy is required, the decreased fascial tension due to surgically incised tissue may lead to chronic venous insufficiency. These pathologies illustrate how fascia contributes to vascular support, specifically in the lower limbs. [9]", "contents": "Physiology, Fascia -- Function -- Vascular Support Function. Compartment syndrome describes a pathology where fascia restricts blood flow to the muscle leading to ischemia. In cases where a fasciotomy is required, the decreased fascial tension due to surgically incised tissue may lead to chronic venous insufficiency. These pathologies illustrate how fascia contributes to vascular support, specifically in the lower limbs. [9]"}
+{"id": "article-102994_16", "title": "Physiology, Fascia -- Pathophysiology", "content": "The list of fascia and musculoskeletal systems diseases is extensive (i.e., frozen shoulder, Dupuytren contracture, hernias, compartment syndrome). These pathologies are due to several etiologies: increased fascia stiffness caused by increased inflammation from overuse or trauma systemic disease genetic disorders a fascial defect or disruption in the fascia the tension produced within a body compartment", "contents": "Physiology, Fascia -- Pathophysiology. The list of fascia and musculoskeletal systems diseases is extensive (i.e., frozen shoulder, Dupuytren contracture, hernias, compartment syndrome). These pathologies are due to several etiologies: increased fascia stiffness caused by increased inflammation from overuse or trauma systemic disease genetic disorders a fascial defect or disruption in the fascia the tension produced within a body compartment"}
+{"id": "article-102994_17", "title": "Physiology, Fascia -- Pathophysiology -- Adhesive Capsulitis", "content": "Patients with adhesive capsulitis (frozen shoulder) have\u00a0restricted and painful movements at the shoulder joint. The pain is described as constant and severe, leading to decreased passive and active range of motion. Many etiologies have been described, including rotator cuff tears, biceps tendinopathy, and shoulder trauma. [10] Biopsies have revealed an increased density of fibroblasts and myofibroblasts within the shoulder capsule. These cells are responsible for producing type III collagen, which is present in various inflammatory conditions. The initial inflammation produces pain, and the subsequent fibrosis leads to decreased range of motion. [3]", "contents": "Physiology, Fascia -- Pathophysiology -- Adhesive Capsulitis. Patients with adhesive capsulitis (frozen shoulder) have\u00a0restricted and painful movements at the shoulder joint. The pain is described as constant and severe, leading to decreased passive and active range of motion. Many etiologies have been described, including rotator cuff tears, biceps tendinopathy, and shoulder trauma. [10] Biopsies have revealed an increased density of fibroblasts and myofibroblasts within the shoulder capsule. These cells are responsible for producing type III collagen, which is present in various inflammatory conditions. The initial inflammation produces pain, and the subsequent fibrosis leads to decreased range of motion. [3]"}
+{"id": "article-102994_18", "title": "Physiology, Fascia -- Pathophysiology -- Dupuytren Contracture", "content": "Dupuytren contracture is a progressive condition caused by the shortening and thickening of the fibrous tissue of the palmar fascia. This disease\u00a0tends to affect men older than 40 years,\u00a0those of Northern European descent, and individuals who smoke, drink alcohol, or have diabetes. Patients typically present with a small, pitted nodule (or multiple nodules) on the palm, which slowly progresses to finger contracture. The disease is caused by increased production of type III collagen by fibroblasts and myofibroblasts within the fascia. Patients typically have difficulty with daily tasks such as hair combing, face washing, and putting their hands in their pockets.", "contents": "Physiology, Fascia -- Pathophysiology -- Dupuytren Contracture. Dupuytren contracture is a progressive condition caused by the shortening and thickening of the fibrous tissue of the palmar fascia. This disease\u00a0tends to affect men older than 40 years,\u00a0those of Northern European descent, and individuals who smoke, drink alcohol, or have diabetes. Patients typically present with a small, pitted nodule (or multiple nodules) on the palm, which slowly progresses to finger contracture. The disease is caused by increased production of type III collagen by fibroblasts and myofibroblasts within the fascia. Patients typically have difficulty with daily tasks such as hair combing, face washing, and putting their hands in their pockets."}
+{"id": "article-102994_19", "title": "Physiology, Fascia -- Pathophysiology -- Dupuytren Contracture", "content": "The disease regresses approximately 10 percent of patients without treatment or surgical intervention. Steroid injections into the nodule(s) have been shown to reduce the need for surgery. Surgical intervention should occur when the metacarpophalangeal (MCP) joint contractures\u00a0exceed 40 degrees or when proximal interphalangeal (PIP) joint contracture\u00a0exceeds 20 degrees. Percutaneous needle aponeurotomy performed in-office may be an effective alternative to surgery in some cases. [11]", "contents": "Physiology, Fascia -- Pathophysiology -- Dupuytren Contracture. The disease regresses approximately 10 percent of patients without treatment or surgical intervention. Steroid injections into the nodule(s) have been shown to reduce the need for surgery. Surgical intervention should occur when the metacarpophalangeal (MCP) joint contractures\u00a0exceed 40 degrees or when proximal interphalangeal (PIP) joint contracture\u00a0exceeds 20 degrees. Percutaneous needle aponeurotomy performed in-office may be an effective alternative to surgery in some cases. [11]"}
+{"id": "article-102994_20", "title": "Physiology, Fascia -- Pathophysiology -- Hernias", "content": "Hernias are a common condition caused by a defect or disruption in the fascia. This increased laxity\u00a0within the fascial compartment leads to herniation of contents through the fascia. Hernias are classified based on where they occur throughout the body.", "contents": "Physiology, Fascia -- Pathophysiology -- Hernias. Hernias are a common condition caused by a defect or disruption in the fascia. This increased laxity\u00a0within the fascial compartment leads to herniation of contents through the fascia. Hernias are classified based on where they occur throughout the body."}
+{"id": "article-102994_21", "title": "Physiology, Fascia -- Pathophysiology -- Hernias", "content": "Inguinal hernias Indirect Most common Passes through the inguinal canal Incomplete obliteration of the processus vaginalis during fetal development Lateral to the inferior epigastric vessels Direct An acquired condition caused by the weakening of the transversalis fascia Medial to the inferior epigastric vessels Passes through Hesselbach triangle Lateral to rectus abdominis muscle Femoral More common in\u00a0females Intraabdominal contents\u00a0herniate through the femoral ring into the femoral canal Inferior to the inguinal ligament, medial to the femoral vein, and lateral to the pubic tubercle Umbilical hernias Congenital umbilical hernia Failed spontaneous closure of the umbilical ring Protrusion through the umbilical orifice Acquired umbilical hernia Caused by persistently elevated intra-abdominal pressure Located adjacent to the umbilical orifice Incisional hernias Herniation of intraabdominal contents through weakened fascia caused by a previous surgery", "contents": "Physiology, Fascia -- Pathophysiology -- Hernias. Inguinal hernias Indirect Most common Passes through the inguinal canal Incomplete obliteration of the processus vaginalis during fetal development Lateral to the inferior epigastric vessels Direct An acquired condition caused by the weakening of the transversalis fascia Medial to the inferior epigastric vessels Passes through Hesselbach triangle Lateral to rectus abdominis muscle Femoral More common in\u00a0females Intraabdominal contents\u00a0herniate through the femoral ring into the femoral canal Inferior to the inguinal ligament, medial to the femoral vein, and lateral to the pubic tubercle Umbilical hernias Congenital umbilical hernia Failed spontaneous closure of the umbilical ring Protrusion through the umbilical orifice Acquired umbilical hernia Caused by persistently elevated intra-abdominal pressure Located adjacent to the umbilical orifice Incisional hernias Herniation of intraabdominal contents through weakened fascia caused by a previous surgery"}
+{"id": "article-102994_22", "title": "Physiology, Fascia -- Pathophysiology -- Compartment Syndrome", "content": "Compartment syndrome is a common orthopedic and surgical emergency that involves increasing pressures within a compartment leading to\u00a0local ischemia. The fascia surrounding a compartment provides tension that compresses the nearby structures. In trauma or other clinical scenarios, swelling within a compartment can occur, leading to increased intraluminal pressures. These pressures grow steadily and eventually\u00a0become higher than the surrounding vasculature, reducing\u00a0perfusion. The reduced perfusion leads to surrounding hypoxia, ultimately leading to the death of the muscles and nerves. An emergent fasciotomy is\u00a0necessary to correct compartment syndrome to release the\u00a0built-up pressure. [12]", "contents": "Physiology, Fascia -- Pathophysiology -- Compartment Syndrome. Compartment syndrome is a common orthopedic and surgical emergency that involves increasing pressures within a compartment leading to\u00a0local ischemia. The fascia surrounding a compartment provides tension that compresses the nearby structures. In trauma or other clinical scenarios, swelling within a compartment can occur, leading to increased intraluminal pressures. These pressures grow steadily and eventually\u00a0become higher than the surrounding vasculature, reducing\u00a0perfusion. The reduced perfusion leads to surrounding hypoxia, ultimately leading to the death of the muscles and nerves. An emergent fasciotomy is\u00a0necessary to correct compartment syndrome to release the\u00a0built-up pressure. [12]"}
+{"id": "article-102994_23", "title": "Physiology, Fascia -- Pathophysiology -- Plantar Fasciopathy", "content": "The origin of the plantar fascia occurs at the posteromedial calcaneal tuberosity, with its insertion occurring at each metatarsal head to form the longitudinal arch of the foot. Plantar fasciopathy is an overuse disorder resulting in degenerative changes at the calcaneal attachment. Histologic inspection of samples taken from patients undergoing plantar fascia release surgery shows myxoid degeneration with fragmentation and degeneration of the plantar fascia. Collectively, these findings support the premise that this condition is a degenerative fasciosis without inflammation, not fasciitis. Therefore, plantar fasciopathy is\u00a0a more accurate descriptor of the condition. Risk factors for developing plantar fasciopathy include excessive running, obesity, and occupations associated with long periods of standing. [13]", "contents": "Physiology, Fascia -- Pathophysiology -- Plantar Fasciopathy. The origin of the plantar fascia occurs at the posteromedial calcaneal tuberosity, with its insertion occurring at each metatarsal head to form the longitudinal arch of the foot. Plantar fasciopathy is an overuse disorder resulting in degenerative changes at the calcaneal attachment. Histologic inspection of samples taken from patients undergoing plantar fascia release surgery shows myxoid degeneration with fragmentation and degeneration of the plantar fascia. Collectively, these findings support the premise that this condition is a degenerative fasciosis without inflammation, not fasciitis. Therefore, plantar fasciopathy is\u00a0a more accurate descriptor of the condition. Risk factors for developing plantar fasciopathy include excessive running, obesity, and occupations associated with long periods of standing. [13]"}
+{"id": "article-102994_24", "title": "Physiology, Fascia -- Pathophysiology -- Genetic Disorders", "content": "Two specific genetic disorders associated with increased laxity of fascia include Ehlers-Danlos syndrome and Marfan syndrome. Ehlers-Danlos is a group of connective tissue disorders characterized by defective collagen synthesis with symptoms including hyperextensible skin, tissue fragility, and joint hypermobility. Marfan syndrome is a connective tissue disorder of autosomal dominant inheritance that affects elastin and microfibrils in connective tissue throughout the body. These patients typically have tall stature with long extremities, joint hypermobility, subluxation of the\u00a0eye lens, and are prone to cardiovascular disorders such as mitral valve prolapse, aortic aneurysm, and dissection. [14]", "contents": "Physiology, Fascia -- Pathophysiology -- Genetic Disorders. Two specific genetic disorders associated with increased laxity of fascia include Ehlers-Danlos syndrome and Marfan syndrome. Ehlers-Danlos is a group of connective tissue disorders characterized by defective collagen synthesis with symptoms including hyperextensible skin, tissue fragility, and joint hypermobility. Marfan syndrome is a connective tissue disorder of autosomal dominant inheritance that affects elastin and microfibrils in connective tissue throughout the body. These patients typically have tall stature with long extremities, joint hypermobility, subluxation of the\u00a0eye lens, and are prone to cardiovascular disorders such as mitral valve prolapse, aortic aneurysm, and dissection. [14]"}
+{"id": "article-102994_25", "title": "Physiology, Fascia -- Pathophysiology -- Genetic Disorders", "content": "Scleroderma (systemic sclerosis) is a well-known genetic disorder associated with increased\u00a0rigidity of fascia. Systemic sclerosis is a disease of abnormal connective tissue growth, which leads to diffuse thickening and hardening of the skin and inner organs. Limited systemic sclerosis is associated with symptoms of CREST syndrome, including calcinosis cutis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia. [15]", "contents": "Physiology, Fascia -- Pathophysiology -- Genetic Disorders. Scleroderma (systemic sclerosis) is a well-known genetic disorder associated with increased\u00a0rigidity of fascia. Systemic sclerosis is a disease of abnormal connective tissue growth, which leads to diffuse thickening and hardening of the skin and inner organs. Limited systemic sclerosis is associated with symptoms of CREST syndrome, including calcinosis cutis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia. [15]"}
+{"id": "article-102994_26", "title": "Physiology, Fascia -- Clinical Significance", "content": "As noted above, many clinical manifestations of pain syndromes are associated with fascial tissue.\u00a0Fascia surrounds and\u00a0penetrates skeletal muscle, organs, joints, nerves, and vascular beds. Therefore, fascial tissue forms a whole-body structural support system and is of great clinical significance. [3]", "contents": "Physiology, Fascia -- Clinical Significance. As noted above, many clinical manifestations of pain syndromes are associated with fascial tissue.\u00a0Fascia surrounds and\u00a0penetrates skeletal muscle, organs, joints, nerves, and vascular beds. Therefore, fascial tissue forms a whole-body structural support system and is of great clinical significance. [3]"}
+{"id": "article-102994_27", "title": "Physiology, Fascia -- Clinical Significance", "content": "Stiffening of connective tissue can be seen in the clinical setting as runner's knee, tennis elbow, golfer's elbow, adhesive capsulitis, and plantar fasciopathy. Recent data suggests fascia as a central participant in the pathogenesis of sport-induced delayed onset muscle soreness and injuries. Unspecific back pain, especially the thoracolumbar fascia, is suggested to be mediated in part by fascial structures. As fascia is rich in nociceptive nerve endings, any stretch, tear, or laxity in the fascial system may be accompanied by irritation and pain.", "contents": "Physiology, Fascia -- Clinical Significance. Stiffening of connective tissue can be seen in the clinical setting as runner's knee, tennis elbow, golfer's elbow, adhesive capsulitis, and plantar fasciopathy. Recent data suggests fascia as a central participant in the pathogenesis of sport-induced delayed onset muscle soreness and injuries. Unspecific back pain, especially the thoracolumbar fascia, is suggested to be mediated in part by fascial structures. As fascia is rich in nociceptive nerve endings, any stretch, tear, or laxity in the fascial system may be accompanied by irritation and pain."}
+{"id": "article-102994_28", "title": "Physiology, Fascia -- Clinical Significance", "content": "Of specific clinical\u00a0interest is the role of fascia in chronic neck pain. An ultrasound examination of patients with chronic neck pain revealed a greater fascial thickness at the sternal end of the sternocleidomastoid and the lower and upper side of the medial scalene muscle. This thickening of fascia was associated with a reduction in active\u00a0and passive cervical range of motion. [3]", "contents": "Physiology, Fascia -- Clinical Significance. Of specific clinical\u00a0interest is the role of fascia in chronic neck pain. An ultrasound examination of patients with chronic neck pain revealed a greater fascial thickness at the sternal end of the sternocleidomastoid and the lower and upper side of the medial scalene muscle. This thickening of fascia was associated with a reduction in active\u00a0and passive cervical range of motion. [3]"}
+{"id": "article-102994_29", "title": "Physiology, Fascia -- Clinical Significance", "content": "Out of\u00a0the vast\u00a0array of symptoms patients report, pain is the most common and most debilitating. To treat a patient's pain, the etiology must be known and researched. In many different studies, fascia has been elicited as a potential cause of pain and, therefore, is of great clinical importance.", "contents": "Physiology, Fascia -- Clinical Significance. Out of\u00a0the vast\u00a0array of symptoms patients report, pain is the most common and most debilitating. To treat a patient's pain, the etiology must be known and researched. In many different studies, fascia has been elicited as a potential cause of pain and, therefore, is of great clinical importance."}
+{"id": "article-102994_30", "title": "Physiology, Fascia -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Physiology, Fascia -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}

statpearls/chunk/article-103.jsonl

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+{"id": "article-103_0", "title": "Nebivolol -- Continuing Education Activity", "content": "This\u00a0activity focuses on\u00a0nebivolol, a potent medication used to treat\u00a0hypertension.\u00a0A thorough discussion of\u00a0nebivolol\u2019s dual role as a vasodilator and cardioselective \u03b2-blocker underscores its versatility\u00a0when managing cardiovascular conditions. As a selective \u03b2-blocker targeting \u03b2-1 adrenergic receptors, nebivolol\u2019s mechanism of action\u00a0allows\u00a0modulation of cardiac function while sparing \u03b2-2 receptors in the lungs and smooth muscles. This cardioselective profile\u00a0makes nebivolol crucial\u00a0for managing hypertension and vascular disease. By\u00a0understanding\u00a0its pharmacological actions, indications, contraindications,\u00a0pharmacokinetics, and adverse event profiles, healthcare professionals gain the necessary knowledge to administer this medication effectively.", "contents": "Nebivolol -- Continuing Education Activity. This\u00a0activity focuses on\u00a0nebivolol, a potent medication used to treat\u00a0hypertension.\u00a0A thorough discussion of\u00a0nebivolol\u2019s dual role as a vasodilator and cardioselective \u03b2-blocker underscores its versatility\u00a0when managing cardiovascular conditions. As a selective \u03b2-blocker targeting \u03b2-1 adrenergic receptors, nebivolol\u2019s mechanism of action\u00a0allows\u00a0modulation of cardiac function while sparing \u03b2-2 receptors in the lungs and smooth muscles. This cardioselective profile\u00a0makes nebivolol crucial\u00a0for managing hypertension and vascular disease. By\u00a0understanding\u00a0its pharmacological actions, indications, contraindications,\u00a0pharmacokinetics, and adverse event profiles, healthcare professionals gain the necessary knowledge to administer this medication effectively."}
+{"id": "article-103_1", "title": "Nebivolol -- Continuing Education Activity", "content": "Objectives: Identify\u00a0the mechanism of action of nebivolol. Assess\u00a0the adverse\u00a0drug reactions of nebivolol. Determine\u00a0the appropriate clinical monitoring\u00a0of\u00a0patients receiving nebivolol. Implement effective collaboration and communication among interprofessional team members to improve outcomes and treatment efficacy for patients who might benefit from\u00a0nebivolol pharmacotherapy. Access free multiple choice questions on this topic.", "contents": "Nebivolol -- Continuing Education Activity. Objectives: Identify\u00a0the mechanism of action of nebivolol. Assess\u00a0the adverse\u00a0drug reactions of nebivolol. Determine\u00a0the appropriate clinical monitoring\u00a0of\u00a0patients receiving nebivolol. Implement effective collaboration and communication among interprofessional team members to improve outcomes and treatment efficacy for patients who might benefit from\u00a0nebivolol pharmacotherapy. Access free multiple choice questions on this topic."}
+{"id": "article-103_2", "title": "Nebivolol -- Indications", "content": "Nebivolol is an FDA-approved medication used to treat hypertension. [1] Beta-blockers are a class of agents used to treat multiple conditions, including\u00a0hypertension, angina, arrhythmias, anxiety, hyperthyroidism, migraine prevention, and prevention of essential tremors. [2] [3] The American College of Cardiology (ACC)/American Heart Association (AHA) guidelines advise against using \u03b2-blockers as the first-line treatment for hypertension and to reserve them for patients\u00a0with comorbidities such as ischemic heart disease. [4]", "contents": "Nebivolol -- Indications. Nebivolol is an FDA-approved medication used to treat hypertension. [1] Beta-blockers are a class of agents used to treat multiple conditions, including\u00a0hypertension, angina, arrhythmias, anxiety, hyperthyroidism, migraine prevention, and prevention of essential tremors. [2] [3] The American College of Cardiology (ACC)/American Heart Association (AHA) guidelines advise against using \u03b2-blockers as the first-line treatment for hypertension and to reserve them for patients\u00a0with comorbidities such as ischemic heart disease. [4]"}
+{"id": "article-103_3", "title": "Nebivolol -- Indications", "content": "Beta-blockers fall into\u00a02 categories based on whether they block \u03b2-1 receptors in cardiac muscles, \u03b2-2 receptors in the lungs and smooth muscles, or both. Beta-blockers are also classified as vasodilators\u00a0or non-vasodilators based on their vasodilatory capabilities. The FDA has also approved a fixed-dose combination of nebivolol and valsartan\u00a0for hypertension management. [5]", "contents": "Nebivolol -- Indications. Beta-blockers fall into\u00a02 categories based on whether they block \u03b2-1 receptors in cardiac muscles, \u03b2-2 receptors in the lungs and smooth muscles, or both. Beta-blockers are also classified as vasodilators\u00a0or non-vasodilators based on their vasodilatory capabilities. The FDA has also approved a fixed-dose combination of nebivolol and valsartan\u00a0for hypertension management. [5]"}
+{"id": "article-103_4", "title": "Nebivolol -- Indications -- FDA-Approved Indications", "content": "Nebivolol is approved by the U.S. Food and Drug Administration (FDA) for the treatment of hypertension. Clinicians should prioritize the use of medications such as \u03b2-blockers, ACE inhibitors, or ARBs for adults with a diagnosis of stable ischemic heart disease (SIHD)\u00a0or hypertension and a history of myocardial infarction or stable angina. Additionally, individuals who have experienced a myocardial infarction or acute coronary syndrome are advised to continue guideline-directed medical therapy (including \u03b2-blockers) for at least 3 years as part of their long-term hypertension management. [4]", "contents": "Nebivolol -- Indications -- FDA-Approved Indications. Nebivolol is approved by the U.S. Food and Drug Administration (FDA) for the treatment of hypertension. Clinicians should prioritize the use of medications such as \u03b2-blockers, ACE inhibitors, or ARBs for adults with a diagnosis of stable ischemic heart disease (SIHD)\u00a0or hypertension and a history of myocardial infarction or stable angina. Additionally, individuals who have experienced a myocardial infarction or acute coronary syndrome are advised to continue guideline-directed medical therapy (including \u03b2-blockers) for at least 3 years as part of their long-term hypertension management. [4]"}
+{"id": "article-103_5", "title": "Nebivolol -- Indications -- Off-Label Uses", "content": "The 2021 European Society of Cardiology (ESC) Guidelines for Heart Failure suggest nebivolol as a treatment option in combination with first-line therapies. [6] Nebivolol can also\u00a0help manage\u00a0microvascular angina. [7] There is potential for nebivolol\u00a0in\u00a0managing\u00a0cancer therapy-related cardiac dysfunction (CTRCD), but further research is required. [8] [9] [10]", "contents": "Nebivolol -- Indications -- Off-Label Uses. The 2021 European Society of Cardiology (ESC) Guidelines for Heart Failure suggest nebivolol as a treatment option in combination with first-line therapies. [6] Nebivolol can also\u00a0help manage\u00a0microvascular angina. [7] There is potential for nebivolol\u00a0in\u00a0managing\u00a0cancer therapy-related cardiac dysfunction (CTRCD), but further research is required. [8] [9] [10]"}
+{"id": "article-103_6", "title": "Nebivolol -- Mechanism of Action", "content": "Nebivolol is a \u03b2-1 adrenergic receptor antagonist that works\u00a0by blocking beta-1 receptors, making it\u00a0a cardioselective \u03b2-blocker. This drug also acts on the vascular endothelium by stimulating nitric oxide (NO) synthase, which induces NO-mediated vasodilation. Nebivolol stimulates NO synthase production from the endothelium via \u03b2-3 agonism, reducing systemic vascular resistance. Beta-blockers such as labetalol and carvedilol also have vasodilatory effects; however, their mechanism is via the blockade of \u03b1-adrenergic receptors. Patients with diabetes mellitus, erectile dysfunction, and vascular disease may have abnormal endothelial function, and nebivolol is more effective in these populations due to its NO-induced vasodilatory effect. [11] [12] [13]", "contents": "Nebivolol -- Mechanism of Action. Nebivolol is a \u03b2-1 adrenergic receptor antagonist that works\u00a0by blocking beta-1 receptors, making it\u00a0a cardioselective \u03b2-blocker. This drug also acts on the vascular endothelium by stimulating nitric oxide (NO) synthase, which induces NO-mediated vasodilation. Nebivolol stimulates NO synthase production from the endothelium via \u03b2-3 agonism, reducing systemic vascular resistance. Beta-blockers such as labetalol and carvedilol also have vasodilatory effects; however, their mechanism is via the blockade of \u03b1-adrenergic receptors. Patients with diabetes mellitus, erectile dysfunction, and vascular disease may have abnormal endothelial function, and nebivolol is more effective in these populations due to its NO-induced vasodilatory effect. [11] [12] [13]"}
+{"id": "article-103_7", "title": "Nebivolol -- Mechanism of Action", "content": "Nebivolol is chemically composed of a racemic mixture of L-nebivolol and D-nebivolol. This medication is classified as\u00a0a third-generation \u03b2-1 adrenergic receptor antagonist and has the\u00a0strongest \u03b2-receptor affinity\u00a0of all \u03b2-blockers. This affinity explains its\u00a0excellent tolerability in patients with lung disease. Nebivolol is also unique\u00a0because of its \u03b2-1 vs. \u03b2-1 and \u03b2-2 selectivity. At low doses (\u226410 mg) and in patients who are fast metabolizers, nebivolol is \u03b2-1 selective. However, nebivolol loses its selectivity and blocks \u03b2-1 and \u03b2-2 receptors at higher doses and in patients\u00a0who are\u00a0slower\u00a0metabolizers. [14]", "contents": "Nebivolol -- Mechanism of Action. Nebivolol is chemically composed of a racemic mixture of L-nebivolol and D-nebivolol. This medication is classified as\u00a0a third-generation \u03b2-1 adrenergic receptor antagonist and has the\u00a0strongest \u03b2-receptor affinity\u00a0of all \u03b2-blockers. This affinity explains its\u00a0excellent tolerability in patients with lung disease. Nebivolol is also unique\u00a0because of its \u03b2-1 vs. \u03b2-1 and \u03b2-2 selectivity. At low doses (\u226410 mg) and in patients who are fast metabolizers, nebivolol is \u03b2-1 selective. However, nebivolol loses its selectivity and blocks \u03b2-1 and \u03b2-2 receptors at higher doses and in patients\u00a0who are\u00a0slower\u00a0metabolizers. [14]"}
+{"id": "article-103_8", "title": "Nebivolol -- Mechanism of Action -- Pharmacokinetics", "content": "Absorption: Nebivolol reaches peak plasma concentration after 1.5\u00a0to 4 hours. Since food does not modify its pharmacokinetics, nebivolol tablets may be administered without regard to meals. Distribution: Nebivolol is 98 % protein-bound and binds primarily to albumin.", "contents": "Nebivolol -- Mechanism of Action -- Pharmacokinetics. Absorption: Nebivolol reaches peak plasma concentration after 1.5\u00a0to 4 hours. Since food does not modify its pharmacokinetics, nebivolol tablets may be administered without regard to meals. Distribution: Nebivolol is 98 % protein-bound and binds primarily to albumin."}
+{"id": "article-103_9", "title": "Nebivolol -- Mechanism of Action -- Pharmacokinetics", "content": "Metabolism: Nebivolol is primarily metabolized in the liver via direct glucuronidation and secondarily through CYP2D6. The hydroxyl and glucuronide metabolites\u00a0are pharmacologically active. Nebivolol is metabolized by CYP2D6. Pharmacogenetic variations of this enzyme can affect various pharmacokinetics parameters; the active isomer (D-nebivolol) has a half-life of about 12 hours in\u00a0fast metabolizers of CYP2D6 and 19 hours in\u00a0slow metabolizers of CYP2D6. However,\u00a0these variations\u00a0are only mildly\u00a0relevant as the circulating hydroxyl and glucuronide metabolites also contribute to the \u03b2-blocking activity. The clinical efficacy and safety profiles of nebivolol are similar regardless of\u00a0slow or\u00a0fast metabolism status; no dose adjustment is necessary.", "contents": "Nebivolol -- Mechanism of Action -- Pharmacokinetics. Metabolism: Nebivolol is primarily metabolized in the liver via direct glucuronidation and secondarily through CYP2D6. The hydroxyl and glucuronide metabolites\u00a0are pharmacologically active. Nebivolol is metabolized by CYP2D6. Pharmacogenetic variations of this enzyme can affect various pharmacokinetics parameters; the active isomer (D-nebivolol) has a half-life of about 12 hours in\u00a0fast metabolizers of CYP2D6 and 19 hours in\u00a0slow metabolizers of CYP2D6. However,\u00a0these variations\u00a0are only mildly\u00a0relevant as the circulating hydroxyl and glucuronide metabolites also contribute to the \u03b2-blocking activity. The clinical efficacy and safety profiles of nebivolol are similar regardless of\u00a0slow or\u00a0fast metabolism status; no dose adjustment is necessary."}
+{"id": "article-103_10", "title": "Nebivolol -- Mechanism of Action -- Pharmacokinetics", "content": "Elimination: Nebivolol is excreted via\u00a0urine (35%) and\u00a0feces (44%); patients who are\u00a0slow metabolizers excrete 67% in urine and 13% in feces. Nebivolol\u00a0is excreted as oxidative metabolites or glucuronide conjugates. [15]", "contents": "Nebivolol -- Mechanism of Action -- Pharmacokinetics. Elimination: Nebivolol is excreted via\u00a0urine (35%) and\u00a0feces (44%); patients who are\u00a0slow metabolizers excrete 67% in urine and 13% in feces. Nebivolol\u00a0is excreted as oxidative metabolites or glucuronide conjugates. [15]"}
+{"id": "article-103_11", "title": "Nebivolol -- Administration -- Available Dosage Forms and Strengths", "content": "Nebivolol is administered orally and\u00a0is not\u00a0available in intravenous form. Oral tablets are available as\u00a0nebivolol hydrochloride salt equivalent to 2.5, 5, 10, and 20 mg of nebivolol.", "contents": "Nebivolol -- Administration -- Available Dosage Forms and Strengths. Nebivolol is administered orally and\u00a0is not\u00a0available in intravenous form. Oral tablets are available as\u00a0nebivolol hydrochloride salt equivalent to 2.5, 5, 10, and 20 mg of nebivolol."}
+{"id": "article-103_12", "title": "Nebivolol -- Administration -- Adult Dosage", "content": "Hypertension: In a patient with hypertension, nebivolol dosing should be based on the patient's individual needs. The recommended starting dose for most patients is 5 mg once daily, which\u00a0can\u00a0be taken independently of meals. If further\u00a0blood pressure reduction is necessary, the dose can be titrated up at 2 to 4-week intervals based on the clinical response. The maximum dose is 40 mg once daily. Nebivolol is a CYP2D6 substrate; drug-drug interactions should be considered before prescribing nebivolol.\u00a0A recent review suggests that nebivolol\u00a0is also effective in African-American patients with hypertension, who demonstrate\u00a0decreased\u00a0responsiveness to \u03b2-blockers\u00a0compared to other ethnicities. [16]", "contents": "Nebivolol -- Administration -- Adult Dosage. Hypertension: In a patient with hypertension, nebivolol dosing should be based on the patient's individual needs. The recommended starting dose for most patients is 5 mg once daily, which\u00a0can\u00a0be taken independently of meals. If further\u00a0blood pressure reduction is necessary, the dose can be titrated up at 2 to 4-week intervals based on the clinical response. The maximum dose is 40 mg once daily. Nebivolol is a CYP2D6 substrate; drug-drug interactions should be considered before prescribing nebivolol.\u00a0A recent review suggests that nebivolol\u00a0is also effective in African-American patients with hypertension, who demonstrate\u00a0decreased\u00a0responsiveness to \u03b2-blockers\u00a0compared to other ethnicities. [16]"}
+{"id": "article-103_13", "title": "Nebivolol -- Administration -- Adult Dosage", "content": "Nebivolol\u00a0should never be\u00a0discontinued abruptly, and taper-off dosing\u00a0is recommended if the patient needs to stop using nebivolol. Rebound hypertension, tachycardia, exacerbation of cardiac arrhythmia, and hospitalization are reported when \u03b2-blockers are stopped abruptly. [17]", "contents": "Nebivolol -- Administration -- Adult Dosage. Nebivolol\u00a0should never be\u00a0discontinued abruptly, and taper-off dosing\u00a0is recommended if the patient needs to stop using nebivolol. Rebound hypertension, tachycardia, exacerbation of cardiac arrhythmia, and hospitalization are reported when \u03b2-blockers are stopped abruptly. [17]"}
+{"id": "article-103_14", "title": "Nebivolol -- Administration -- Specific Patient Population", "content": "Hepatic impairment: Per product labeling, the initial recommended dose is 2.5 mg orally once daily, which is titrated slowly (if needed) for patients with moderate hepatic impairment. No data is available on nebivolol use\u00a0for patients with severe hepatic impairment.", "contents": "Nebivolol -- Administration -- Specific Patient Population. Hepatic impairment: Per product labeling, the initial recommended dose is 2.5 mg orally once daily, which is titrated slowly (if needed) for patients with moderate hepatic impairment. No data is available on nebivolol use\u00a0for patients with severe hepatic impairment."}
+{"id": "article-103_15", "title": "Nebivolol -- Administration -- Specific Patient Population", "content": "Renal impairment: Per product labeling, the initial recommended dose for patients with severe renal impairment (CrCl <30 mL/min) is 2.5 mg orally once daily, titrated slowly if needed. There is no data available on nebivolol use\u00a0for patients on dialysis.", "contents": "Nebivolol -- Administration -- Specific Patient Population. Renal impairment: Per product labeling, the initial recommended dose for patients with severe renal impairment (CrCl <30 mL/min) is 2.5 mg orally once daily, titrated slowly if needed. There is no data available on nebivolol use\u00a0for patients on dialysis."}
+{"id": "article-103_16", "title": "Nebivolol -- Administration -- Specific Patient Population", "content": "Pregnancy considerations: Nebivolol\u00a0is a former\u00a0FDA pregnancy Category C\u00a0medicine.\u00a0If nebivolol is required\u00a0for a pregnant woman with a history of hypertension, then fetal monitoring is indicated.\u00a0The baby should be monitored for the first 48 hours post-delivery for possible\u00a0hypoglycemia, bradycardia, and respiratory depression. [18] [19] The American College of Gynecology & Obstetrics (ACOG) recommends treatment with labetalol for hypertensive disorders of pregnancy. [20]", "contents": "Nebivolol -- Administration -- Specific Patient Population. Pregnancy considerations: Nebivolol\u00a0is a former\u00a0FDA pregnancy Category C\u00a0medicine.\u00a0If nebivolol is required\u00a0for a pregnant woman with a history of hypertension, then fetal monitoring is indicated.\u00a0The baby should be monitored for the first 48 hours post-delivery for possible\u00a0hypoglycemia, bradycardia, and respiratory depression. [18] [19] The American College of Gynecology & Obstetrics (ACOG) recommends treatment with labetalol for hypertensive disorders of pregnancy. [20]"}
+{"id": "article-103_17", "title": "Nebivolol -- Administration -- Specific Patient Population", "content": "Breastfeeding considerations: There is no information on using nebivolol\u00a0for\u00a0women who are breastfeeding. The risk of \u03b2-blockers causing bradycardia in breastfed infants should be considered, and an alternate drug with safer profiles should be administered. [19] Pediatric patients: The safety and efficacy of nebivolol\u00a0for pediatric patients have not been verified.", "contents": "Nebivolol -- Administration -- Specific Patient Population. Breastfeeding considerations: There is no information on using nebivolol\u00a0for\u00a0women who are breastfeeding. The risk of \u03b2-blockers causing bradycardia in breastfed infants should be considered, and an alternate drug with safer profiles should be administered. [19] Pediatric patients: The safety and efficacy of nebivolol\u00a0for pediatric patients have not been verified."}
+{"id": "article-103_18", "title": "Nebivolol -- Administration -- Specific Patient Population", "content": "Older patients: The SENIORS study assessed nebivolol's effects in heart failure patients aged 70 or older, regardless of ejection fraction. Nebivolol reduced combined mortality and cardiovascular admissions compared to placebo, independent of age, gender, or ejection fraction. In conclusion, nebivolol was effective and well-tolerated in older\u00a0patients with heart failure. [21]", "contents": "Nebivolol -- Administration -- Specific Patient Population. Older patients: The SENIORS study assessed nebivolol's effects in heart failure patients aged 70 or older, regardless of ejection fraction. Nebivolol reduced combined mortality and cardiovascular admissions compared to placebo, independent of age, gender, or ejection fraction. In conclusion, nebivolol was effective and well-tolerated in older\u00a0patients with heart failure. [21]"}
+{"id": "article-103_19", "title": "Nebivolol -- Adverse Effects", "content": "Nebivolol's reported adverse effects typically involve the central nervous system (CNS). Headache is the most commonly reported\u00a0adverse\u00a0effect (6% to 9%). [22] [23] Other common\u00a0adverse effects include: [24] Fatigue (Dose-dependent) Dizziness Rhinitis Insomnia Asthenia Hyperuricemia Paresthesias Weakness Some less observed adverse\u00a0drug reactions are skin rash\u00a0and\u00a0gastrointestinal\u00a0adverse effects such as diarrhea, nausea, and abdominal pain. Less common\u00a0adverse effects\u00a0documented in case reports and post-marketing reports include: Acute pulmonary edema Acute kidney injury Second and third-degree atrioventricular (AV) block Bronchospasm Angioedema Hypersensitivity reaction Claudication Drug-induced liver injury:\u00a0elevated serum ALT, AST, and serum bilirubin Thrombocytopenia Raynaud phenomenon Somnolence Syncope Erectile dysfunction (less common than for conventional \u03b2-blockers) [16] [25] Psoriasis [26]", "contents": "Nebivolol -- Adverse Effects. Nebivolol's reported adverse effects typically involve the central nervous system (CNS). Headache is the most commonly reported\u00a0adverse\u00a0effect (6% to 9%). [22] [23] Other common\u00a0adverse effects include: [24] Fatigue (Dose-dependent) Dizziness Rhinitis Insomnia Asthenia Hyperuricemia Paresthesias Weakness Some less observed adverse\u00a0drug reactions are skin rash\u00a0and\u00a0gastrointestinal\u00a0adverse effects such as diarrhea, nausea, and abdominal pain. Less common\u00a0adverse effects\u00a0documented in case reports and post-marketing reports include: Acute pulmonary edema Acute kidney injury Second and third-degree atrioventricular (AV) block Bronchospasm Angioedema Hypersensitivity reaction Claudication Drug-induced liver injury:\u00a0elevated serum ALT, AST, and serum bilirubin Thrombocytopenia Raynaud phenomenon Somnolence Syncope Erectile dysfunction (less common than for conventional \u03b2-blockers) [16] [25] Psoriasis [26]"}
+{"id": "article-103_20", "title": "Nebivolol -- Adverse Effects -- Drug-Drug Interactions", "content": "The CYP2D6 system metabolizes nebivolol. The dose may need to be reduced when giving nebivolol and CYP2D6 inhibitors. Nebivolol's potential drug-drug interactions include medication classes that are either substrate or inhibitors/inducers of CYP2D6. [16]", "contents": "Nebivolol -- Adverse Effects -- Drug-Drug Interactions. The CYP2D6 system metabolizes nebivolol. The dose may need to be reduced when giving nebivolol and CYP2D6 inhibitors. Nebivolol's potential drug-drug interactions include medication classes that are either substrate or inhibitors/inducers of CYP2D6. [16]"}
+{"id": "article-103_21", "title": "Nebivolol -- Adverse Effects -- Drug-Drug Interactions", "content": "CYP2D6 substrates: antiarrhythmics (class 1), 5-HT3 receptor antagonists, antidepressants, analgesics (opioids), protease inhibitors (ritonavir),\u00a0antipsychotics, cholinesterase inhibitors CYP2D6 inhibitors: antiarrhythmics (class 3), antihistamines, antipsychotics, protease inhibitors (eg, ritonavir, tipranavir), antimalarials, H2 receptor antagonists CYP2D6 inducers: antiseizure medications When \u03b2-blockers are administered with non-dihydropyridine calcium channel blockers (eg, verapamil, diltiazem), they may cause significant negative inotropic and chronotropic effects. EKG and blood pressure monitoring are recommended when\u00a0these agents are administered together. [27] Rivastigmine administered with \u03b2-blockers can\u00a0cause bradycardia and possible syncope. [3]", "contents": "Nebivolol -- Adverse Effects -- Drug-Drug Interactions. CYP2D6 substrates: antiarrhythmics (class 1), 5-HT3 receptor antagonists, antidepressants, analgesics (opioids), protease inhibitors (ritonavir),\u00a0antipsychotics, cholinesterase inhibitors CYP2D6 inhibitors: antiarrhythmics (class 3), antihistamines, antipsychotics, protease inhibitors (eg, ritonavir, tipranavir), antimalarials, H2 receptor antagonists CYP2D6 inducers: antiseizure medications When \u03b2-blockers are administered with non-dihydropyridine calcium channel blockers (eg, verapamil, diltiazem), they may cause significant negative inotropic and chronotropic effects. EKG and blood pressure monitoring are recommended when\u00a0these agents are administered together. [27] Rivastigmine administered with \u03b2-blockers can\u00a0cause bradycardia and possible syncope. [3]"}
+{"id": "article-103_22", "title": "Nebivolol -- Contraindications", "content": "Nebivolol should be used cautiously with a history of severe anaphylaxis to various allergens. Repeat challenges among patients taking \u03b2-blockers may cause increased sensitivity to severe anaphylaxis. Treating anaphylaxis in patients\u00a0using \u03b2-blockers may not be effective and promote undesirable effects. [28] [29] [30]", "contents": "Nebivolol -- Contraindications. Nebivolol should be used cautiously with a history of severe anaphylaxis to various allergens. Repeat challenges among patients taking \u03b2-blockers may cause increased sensitivity to severe anaphylaxis. Treating anaphylaxis in patients\u00a0using \u03b2-blockers may not be effective and promote undesirable effects. [28] [29] [30]"}
+{"id": "article-103_23", "title": "Nebivolol -- Contraindications", "content": "Nebivolol is contraindicated in severe bradycardia, cardiogenic shock, decompensated heart failure, second or\u00a0third-degree heart block,\u00a0severe hepatic impairment, and sick sinus syndrome. However, it is still useful if a functioning pacemaker is present. [31]", "contents": "Nebivolol -- Contraindications. Nebivolol is contraindicated in severe bradycardia, cardiogenic shock, decompensated heart failure, second or\u00a0third-degree heart block,\u00a0severe hepatic impairment, and sick sinus syndrome. However, it is still useful if a functioning pacemaker is present. [31]"}
+{"id": "article-103_24", "title": "Nebivolol -- Contraindications -- Warning and Precautions", "content": "Other disease-related/age group-related relative contraindications include:", "contents": "Nebivolol -- Contraindications -- Warning and Precautions. Other disease-related/age group-related relative contraindications include:"}
+{"id": "article-103_25", "title": "Nebivolol -- Contraindications -- Warning and Precautions", "content": "Bronchospastic disease: \u03b2-blockers are not recommended in patients with bronchospastic disease.", "contents": "Nebivolol -- Contraindications -- Warning and Precautions. Bronchospastic disease: \u03b2-blockers are not recommended in patients with bronchospastic disease."}
+{"id": "article-103_26", "title": "Nebivolol -- Contraindications -- Warning and Precautions", "content": "Diabetes: Nebivolol may enhance hypoglycemia and mask signs and symptoms (eg, tachycardia) of hypoglycemia.", "contents": "Nebivolol -- Contraindications -- Warning and Precautions. Diabetes: Nebivolol may enhance hypoglycemia and mask signs and symptoms (eg, tachycardia) of hypoglycemia."}
+{"id": "article-103_27", "title": "Nebivolol -- Contraindications -- Warning and Precautions", "content": "Hepatic impairment:\u00a0Nebivolol\u00a0is contraindicated in patients with Child-Pugh Class C hepatic impairment.", "contents": "Nebivolol -- Contraindications -- Warning and Precautions. Hepatic impairment:\u00a0Nebivolol\u00a0is contraindicated in patients with Child-Pugh Class C hepatic impairment."}
+{"id": "article-103_28", "title": "Nebivolol -- Contraindications -- Warning and Precautions", "content": "Myasthenia gravis: Nebivolol should be used cautiously in patients with myasthenia gravis.", "contents": "Nebivolol -- Contraindications -- Warning and Precautions. Myasthenia gravis: Nebivolol should be used cautiously in patients with myasthenia gravis."}
+{"id": "article-103_29", "title": "Nebivolol -- Contraindications -- Warning and Precautions", "content": "Peripheral vascular disease (PVD) and Raynaud disease: Nebivolol can precipitate the symptoms of arterial insufficiency.", "contents": "Nebivolol -- Contraindications -- Warning and Precautions. Peripheral vascular disease (PVD) and Raynaud disease: Nebivolol can precipitate the symptoms of arterial insufficiency."}
+{"id": "article-103_30", "title": "Nebivolol -- Contraindications -- Warning and Precautions", "content": "Pheochromocytoma (not on treatment): The patient should be\u00a0administered \u03b1-blockers before any \u03b2-blockers.", "contents": "Nebivolol -- Contraindications -- Warning and Precautions. Pheochromocytoma (not on treatment): The patient should be\u00a0administered \u03b1-blockers before any \u03b2-blockers."}
+{"id": "article-103_31", "title": "Nebivolol -- Contraindications -- Warning and Precautions", "content": "Psoriasis: \u03b2-blockers can induce or exacerbate psoriasis, but the cause and effect remain unestablished. The proposed mechanism indicates that \u03b2-blockers cause intracellular changes in calcium,\u00a0affecting\u00a0keratinocyte and granulocyte function\u00a0by reducing cyclic adenosine monophosphate (cAMP) levels. [26]", "contents": "Nebivolol -- Contraindications -- Warning and Precautions. Psoriasis: \u03b2-blockers can induce or exacerbate psoriasis, but the cause and effect remain unestablished. The proposed mechanism indicates that \u03b2-blockers cause intracellular changes in calcium,\u00a0affecting\u00a0keratinocyte and granulocyte function\u00a0by reducing cyclic adenosine monophosphate (cAMP) levels. [26]"}
+{"id": "article-103_32", "title": "Nebivolol -- Contraindications -- Warning and Precautions", "content": "Renal impairment: Dose adjustment is necessary with severe renal impairment (CrCl <30 mL/min).", "contents": "Nebivolol -- Contraindications -- Warning and Precautions. Renal impairment: Dose adjustment is necessary with severe renal impairment (CrCl <30 mL/min)."}
+{"id": "article-103_33", "title": "Nebivolol -- Contraindications -- Warning and Precautions", "content": "Thyroid disease: Nebivolol may mask signs and symptoms of hyperthyroidism (eg, tachycardia). If thyrotoxicosis is suspected, careful management and monitoring are required. Abrupt withdrawal may worsen symptoms of hyperthyroidism or precipitate thyroid storm.", "contents": "Nebivolol -- Contraindications -- Warning and Precautions. Thyroid disease: Nebivolol may mask signs and symptoms of hyperthyroidism (eg, tachycardia). If thyrotoxicosis is suspected, careful management and monitoring are required. Abrupt withdrawal may worsen symptoms of hyperthyroidism or precipitate thyroid storm."}
+{"id": "article-103_34", "title": "Nebivolol -- Contraindications -- Warning and Precautions", "content": "Pregnancy: Category C medication; it is unclear if nebivolol gets excreted in breast milk; \u03b2-blockers can cause serious adverse\u00a0effects in nursing infants (eg, bradycardia).", "contents": "Nebivolol -- Contraindications -- Warning and Precautions. Pregnancy: Category C medication; it is unclear if nebivolol gets excreted in breast milk; \u03b2-blockers can cause serious adverse\u00a0effects in nursing infants (eg, bradycardia)."}
+{"id": "article-103_35", "title": "Nebivolol -- Contraindications -- Warning and Precautions", "content": "Older\u00a0population: Increased frequency of bradycardia in patients aged 65 or older; dose reduction should be considered.", "contents": "Nebivolol -- Contraindications -- Warning and Precautions. Older\u00a0population: Increased frequency of bradycardia in patients aged 65 or older; dose reduction should be considered."}
+{"id": "article-103_36", "title": "Nebivolol -- Contraindications -- Warning and Precautions", "content": "Surgery: Per ACC/AHA guidelines, patients with hypertension and a history of chronic\u00a0\u03b2-blocker use who are preparing for major surgery should continue their \u03b2-blocker regimen. However, initiating \u03b2-blockers the day of surgery is not recommended for patients who have not previously used them. [4]", "contents": "Nebivolol -- Contraindications -- Warning and Precautions. Surgery: Per ACC/AHA guidelines, patients with hypertension and a history of chronic\u00a0\u03b2-blocker use who are preparing for major surgery should continue their \u03b2-blocker regimen. However, initiating \u03b2-blockers the day of surgery is not recommended for patients who have not previously used them. [4]"}
+{"id": "article-103_37", "title": "Nebivolol -- Monitoring", "content": "Parameters that should be monitored include: Blood pressure EKG for possible bradycardia Serum glucose in patients with diabetes mellitus [31]", "contents": "Nebivolol -- Monitoring. Parameters that should be monitored include: Blood pressure EKG for possible bradycardia Serum glucose in patients with diabetes mellitus [31]"}
+{"id": "article-103_38", "title": "Nebivolol -- Toxicity -- Signs and Symptoms of Overdose", "content": "Clinical presentations of nebivolol overdose usually include bradycardia\u00a0and hypotension. Further adverse effects linked to excessive nebivolol intake can cause\u00a0vomiting,\u00a0heart failure, bronchospasm, and\u00a0AV\u00a0block.", "contents": "Nebivolol -- Toxicity -- Signs and Symptoms of Overdose. Clinical presentations of nebivolol overdose usually include bradycardia\u00a0and hypotension. Further adverse effects linked to excessive nebivolol intake can cause\u00a0vomiting,\u00a0heart failure, bronchospasm, and\u00a0AV\u00a0block."}
+{"id": "article-103_39", "title": "Nebivolol -- Toxicity -- Management of Overdose", "content": "Glucagon is the first-line treatment for \u03b2-blocker overdose. Glucagon is only effective for a short time, and prolonged use can cause tachyphylaxis,\u00a0rendering\u00a0therapy ineffective. Glucagon is administered intravenously (IV) as a slow bolus followed by a continuous infusion. The initial bolus dose is typically 5 mg administered over\u00a01 minute. Constant\u00a0heart rate and blood pressure monitoring are required. If\u00a0these measures do not increase after 15 minutes, administer another bolus. Glucagon starts working within 3 minutes, with a peak response at 5\u00a0to 7 minutes. If there is no notable effect within 10 minutes\u00a0of the\u00a0second bolus, then it is doubtful that an infusion would benefit the patient. If there is an increase in heart rate and blood pressure, an infusion will be beneficial. The infusion rate should be\u00a0between 2 to 5 mg/h. The goal is a mean arterial pressure (MAP) of 60 mm Hg. If a MAP of 60 mm Hg cannot be achieved, the patient\u00a0may require additional therapies. [32] [33]", "contents": "Nebivolol -- Toxicity -- Management of Overdose. Glucagon is the first-line treatment for \u03b2-blocker overdose. Glucagon is only effective for a short time, and prolonged use can cause tachyphylaxis,\u00a0rendering\u00a0therapy ineffective. Glucagon is administered intravenously (IV) as a slow bolus followed by a continuous infusion. The initial bolus dose is typically 5 mg administered over\u00a01 minute. Constant\u00a0heart rate and blood pressure monitoring are required. If\u00a0these measures do not increase after 15 minutes, administer another bolus. Glucagon starts working within 3 minutes, with a peak response at 5\u00a0to 7 minutes. If there is no notable effect within 10 minutes\u00a0of the\u00a0second bolus, then it is doubtful that an infusion would benefit the patient. If there is an increase in heart rate and blood pressure, an infusion will be beneficial. The infusion rate should be\u00a0between 2 to 5 mg/h. The goal is a mean arterial pressure (MAP) of 60 mm Hg. If a MAP of 60 mm Hg cannot be achieved, the patient\u00a0may require additional therapies. [32] [33]"}
+{"id": "article-103_40", "title": "Nebivolol -- Toxicity -- Management of Overdose", "content": "Supportive care is required in overdose. Intravenous atropine administration\u00a0may be\u00a0required to manage bradycardia. Transthoracic or transvenous pacemaker placement may be necessary for heart block (second or third-degree). Intravenous fluids should be administered for hypotension, while inhaled \u03b2-2 agonists are indicated for bronchospasm. Intravenous glucose is advised for managing hypoglycemia.", "contents": "Nebivolol -- Toxicity -- Management of Overdose. Supportive care is required in overdose. Intravenous atropine administration\u00a0may be\u00a0required to manage bradycardia. Transthoracic or transvenous pacemaker placement may be necessary for heart block (second or third-degree). Intravenous fluids should be administered for hypotension, while inhaled \u03b2-2 agonists are indicated for bronchospasm. Intravenous glucose is advised for managing hypoglycemia."}
+{"id": "article-103_41", "title": "Nebivolol -- Toxicity -- Management of Overdose", "content": "Treating anaphylaxis in the setting of \u03b2-blocker administration\u00a0can be challenging. If epinephrine is ineffective, then glucagon\u00a0should be administered as\u00a0it can reverse refractory hypotension and bronchospasm during anaphylaxis in patients on \u03b2-blockers. Glucagon works by activating adenyl cyclase directly. [34]", "contents": "Nebivolol -- Toxicity -- Management of Overdose. Treating anaphylaxis in the setting of \u03b2-blocker administration\u00a0can be challenging. If epinephrine is ineffective, then glucagon\u00a0should be administered as\u00a0it can reverse refractory hypotension and bronchospasm during anaphylaxis in patients on \u03b2-blockers. Glucagon works by activating adenyl cyclase directly. [34]"}
+{"id": "article-103_42", "title": "Nebivolol -- Enhancing Healthcare Team Outcomes", "content": "Nebivolol is a\u00a0medication that is FDA-approved to treat hypertension. All interprofessional healthcare team members must be aware of the\u00a0current indications, interactions, adverse effects, and other pharmacodynamics and pharmacokinetic factors that can affect successful therapy implementation and improve patient outcomes. [12] [35] Cardiologists treat refractory hypertension and complications associated with therapy. Pharmacists review the appropriateness of the selected drug and the dose, look for interactions or other contraindications, and consult the prescriber as necessary. They also counsel patients and their families about appropriate use and\u00a0adverse effects. Nurses monitor vital signs, counsel the patient on dosing and administration, monitor for potential adverse effects, and report issues to the team for therapy adjustment. In an overdose of nebivolol, critical care\u00a0input is crucial. A medical toxicologist should be consulted as the direct care provided by these specialists has been shown to reduce the length of stay and decrease healthcare utilization. [36]", "contents": "Nebivolol -- Enhancing Healthcare Team Outcomes. Nebivolol is a\u00a0medication that is FDA-approved to treat hypertension. All interprofessional healthcare team members must be aware of the\u00a0current indications, interactions, adverse effects, and other pharmacodynamics and pharmacokinetic factors that can affect successful therapy implementation and improve patient outcomes. [12] [35] Cardiologists treat refractory hypertension and complications associated with therapy. Pharmacists review the appropriateness of the selected drug and the dose, look for interactions or other contraindications, and consult the prescriber as necessary. They also counsel patients and their families about appropriate use and\u00a0adverse effects. Nurses monitor vital signs, counsel the patient on dosing and administration, monitor for potential adverse effects, and report issues to the team for therapy adjustment. In an overdose of nebivolol, critical care\u00a0input is crucial. A medical toxicologist should be consulted as the direct care provided by these specialists has been shown to reduce the length of stay and decrease healthcare utilization. [36]"}
+{"id": "article-103_43", "title": "Nebivolol -- Enhancing Healthcare Team Outcomes", "content": "If an overdose is intentional, a psychiatric consultation should be obtained. Nebivolol therapy has its best chance for therapeutic success with minimal adverse events if the interprofessional teamwork\u00a0between MDs, DOs, PAs, NPs, and pharmacists is in place.\u00a0The 2017 ACC/AHA guidelines for hypertension recommend interprofessional team-based care,\u00a0which involves\u00a0primary care providers, patients, cardiologists,\u00a0physician assistants, nurses, pharmacists, dietitians, community health workers, and social workers.\u00a0Randomized controlled trials\u00a0and meta-analyses of interprofessional team-based hypertension care involving nurse or pharmacist-led lead intervention have demonstrated optimal blood pressure control compared\u00a0to routine care. [37] [38] [39]", "contents": "Nebivolol -- Enhancing Healthcare Team Outcomes. If an overdose is intentional, a psychiatric consultation should be obtained. Nebivolol therapy has its best chance for therapeutic success with minimal adverse events if the interprofessional teamwork\u00a0between MDs, DOs, PAs, NPs, and pharmacists is in place.\u00a0The 2017 ACC/AHA guidelines for hypertension recommend interprofessional team-based care,\u00a0which involves\u00a0primary care providers, patients, cardiologists,\u00a0physician assistants, nurses, pharmacists, dietitians, community health workers, and social workers.\u00a0Randomized controlled trials\u00a0and meta-analyses of interprofessional team-based hypertension care involving nurse or pharmacist-led lead intervention have demonstrated optimal blood pressure control compared\u00a0to routine care. [37] [38] [39]"}
+{"id": "article-103_44", "title": "Nebivolol -- Review Questions", "content": "Access free multiple choice questions on this topic. Comment on this article.", "contents": "Nebivolol -- Review Questions. Access free multiple choice questions on this topic. Comment on this article."}