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Comparison of localized proton NMR signals of skeletal muscle and fat tissue in vivo: two lipid compartments in muscle tissue discount 2 mg requip fast delivery. Therefore discount 0.5mg requip amex, an adequate clinical classification is essential before starting physical therapy or medical purchase requip 2 mg amex, surgical, or cosmetic treatments. The attempt to classify cel- lulite is as old as the history of the first description of cellulite but, because it is difficult to define and register the pathophysiologic evolution of cellulite, it is difficult to define a true classification. In the recent past, there have been various attempts at classification that fol- lowed the evolutionary and physiopathological theories. Today, it is agreed that cellulite can be described as a predominantly interstitial endocrine–metabolic pathology (1–7). Binazzi, the famous vascular medicine physician from Bologna University, in 1978. He divided the cellulite into three clinical classes (Fig. Mixed cellulitis Figure 1 First clinical classification of cellulite by Prof. Binazzi classified cellulite as ‘‘soft,’’ which is characterized not by adherent tissue to the deep planes; ‘‘hard,’’ which represents the adiposeous cellulite with tonic tis- sues adherent to the deep plans, and ‘‘mixed,’’ an intermediate between the two. Today Binazzi’s is the clinical classification that is most often used in practice; it is easy but does not have the ability to analyze the pathophysiology because it is merely descriptive (8). Curri, chair of molecular biology in the University of Milan. It is the first true classification that is founded on scientific data. It constitutes the first attempt at classification to aid in pathophysiologic research. It is based on the characteristics of thermography, offering the possibility of having reproducible pictures that can be randomized and computerized (9–11). Curri described five classes characterized by different types of temperature patterns revealed by plotting the microcir- culation and oxygenation (Fig. This classification can be useful in scientific research and is also easy to perform in clin- ical practice. Note that the test should be performed only after the patient has removed the elastic stockings and has not smoked or taken coffee for at least two hours. Although it does not have scientific value, it is useful in daily evaluation of patients (12,13). It repeats the classification of Binazzi adding a fourth grade class, named as ‘‘false cellulite’’ (Fig. This situation does not require treatment but only electric stimulations or exercise. We believe that this classification is not exact, because the pathological picture is reported as a structural state. This is the Binazzi classification with a new aspect named ‘‘Not true cellulitis. In fact, from the diag- nostic point of view, this form of cellulite is confirmed by an abnormal thermographic test representing microcirculatory alteration, lipodistrophy, and all aspects of the cellulite. Bartoletti to speak about a ‘‘Not true cellulite’’ can be useful to remember that this class of cellulites does not require active treatments, as mesotherapy or carboxytherapy or liposculpture. Used in this cellulite, these treatments can cause more aesthetic pathologies and prolapse of the skin.

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It is frequently the expression of Dercum’s syndrome or of the traditional lipolymphoedema with lipodystrophy requip 2mg low cost. The peau d’orange sign may be detected early purchase requip 2mg mastercard, and a proper diagnosis is needed to discard edema- tous pathologies cheap 1 mg requip. It is a pathology that eventually causes serious arthritic, metabolic, and hormonal sequelae. The aesthetic condition is always affected and most difficult to solve. Mixed Cellulite Normally, the forementioned cellulite pathologies are not found as pure entities but as mixed entities. For example, one may find hard cellulite in the anterior thigh combined with edematous cellulite in the knee and leg. Bitrochanteric lipodystrophy with flaccid cellulite in the internal thigh is characteristic (16,17). Metabolism alteration at the interstitial matrix level. This is frequently accompanied by recurrent lipedema. Diencephalic and endocrine dysfunction with alteration of local peripheral insulin and lipi- dic metabolism. An alteration of hyaluronic acid and mucopolysaccharides is observed with altered ground substance and extracellular fluid. Tissue congestion of the lymphatic type with painful tumefaction, lipolymphoedema, and abdominal strain. Frequently, it is accompanied by the presence of herpes simplex as a result of a reduced immune function due to intestinal flora disorders. There is also a local and systemic neurophysiological disorder due to the alteration of the ionic pump. They hinder veno-lymphatic microcirculation and increase lymph density as well as interstitial ground substance viscosity. Connective tissue fibrosclerotic alterations derived from initial mucoid ‘‘geloide’’ (gel-like) fibroedema and interstitial connective fibrosclerosis may be noticed. Our therapy involves strategic, tactical, methodological, technical, and control measures. For example, a cycle of one session twice a week during the first two months may be devised, followed by a session once a week for the remaining months. Initially, treatment may be associated with carboxytherapy before subdermic therapy techniques are applied prior to local treatments, plus a 15-day cleansing therapy and diet. The cleansing therapy will consist of hydroxycolonother- apy associated with the traditional therapy for intestinal flora recovery. For subdermal 1 therapy, Endermologie should be used in programs for ‘‘edematous cellulitis’’ and ‘‘structural recovery. In the case of carboxytherapy, either the micropercutaneous approach or direct infiltrations may be used. Normally, there is a control visit and a therapist meeting after each six- or eight-session cycle in order to adjust diagnosis and thera- peutic conditions. These meetings and the physiotherapist’s appraisal are of utmost importance, because ultimately the therapist perceives the patient’s sensations and symptomatology as the cellulite therapy progresses. In fact, it is a chronic therapy for a disease that is frequently evolutive and gets worse, due to perpetuation and worsening of intestinal flora alterations and endocrine–metabolic disorders, not to mention today’s lifestyle, usually sedentary and reckless from a nutritional or environ- mental point of view. Medical history should include the patient’s structural diagram, details of the cel- lulite areas, a possible therapeutic strategy, and photographs from different angles taken 96 & LEIBASCHOFF during the first visit, halfway through therapy, and at the end of treatment.

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Gentle stretching exercises ease stiffness and help prevent postural changes purchase requip 0.25mg fast delivery, and muscle-strengthening exercises help in retaining proper posture discount 0.5 mg requip with amex. Passive stretching of the hip joints increases their range of movement and thus improves function and posture buy 0.25 mg requip. Most people with AS feel too stiff to exercise in the morning, although taking a warm bath before exercising tends to ease this discomfort. The use of large Swiss therapeutic exercise balls and group exercise sessions that include hydro- therapy are enjoyable and very helpful. In some European countries, professionally supervised special physiotherapy and hydrotherapy group ses- sions for AS patients have been organized by AS patient organizations. Randomized controlled trials have shown that physiotherapy with disease educa- tion is effective in the treatment of people with AS, and group physical therapy is cost-effective com- pared to individualized therapy. Therapeutic exercises must be tailored to your degree of spinal mobility or involvement, you should do them routinely once or twice daily. Even though you may not be able to do them all daily, you should do at least some of them each day. Most people who comply with a comprehensive manage- ment program that depends upon a lifetime of daily exercises can maintain satisfactory spinal mobility, and can continue to lead full and productive lives. Swimming Swimming is an ideal exercise for those who enjoy it, because it gently uses all the muscles and is very relaxing. It provides aerobic exercise to enhance general fitness and enhance lung capacity. A warm or even hot pool is generally most comfortable. A heated swimming pool or spa helps to decrease pain and stiffness, and therefore allows you to perform exercises when it might otherwise be impossible because of the pain. Low-impact exercises in the water (swimming and water aerobics) and station- ary bicycling can help improve exercise capability, muscle strength, and range of motion. Regular free-style swimming is considered to be one of the best exercises for people with AS, but if your neck is rigid it may be difficult to swim free- style. Using a snorkel may be helpful, provided you swim only under observation and near the edge of a swimming pool if it is deep. This precaution is neces- sary because someone with limited breathing capac- ity may not be able to blow the water out effectively if it inadvertently enters the snorkel tube. You should be very careful not to slip on wet sur- faces in the pool area, and it is also wise to avoid diving. Application of heat A warm shower or application of local heat may promote relaxation and help in passive stretching of thefacts 25 Ankylosing spondylitis: the facts tight muscles. You should not apply local heat to an area for more than 15 minutes at a time. Keep the tempera- ture setting of the heating pad at low or medium level, never on high setting. Do not lie on a heating pad to apply heat to your back, otherwise you will increase the risk of burn due to decreased blood circulation in the area that results from pressure of your body weight. Spinal extension and deep breathing exercises You can perform spinal extension exercises by lying face down on your front and then stretching your arms out at shoulder level and raising your chest, shoulders, arms, and head off the bed as far as possible (Figure 6). Hold your body in that position for about 5 seconds and then relax, and repeat the exercise about 20 times. The chest expansion exercise is performed by lying on your back, clasping your hands behind your Figure 6 26 thefacts Exercise and physical therapy head, and extending your elbows outwards towards the bed while taking a deep breath. Hold the breath for a count of 10 before exhaling and relaxing for about 10 seconds. Give up smoking, in order to prevent its adverse effects on the lungs and heart. You can combine the spinal extension and chest expansion by performing corner push-ups, in which you face a corner and place your hands on the opposing walls at shoulder height. Then bend your elbows to lean forward towards the corner with your head, neck, and spine fully extended, knees fully stretched and heels touching the ground (Figure 7).

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