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The effect of tension of non-uniform distribution of length changes applied to frog muscle fibres buy ivermectin 3mg mastercard. The role of fatigue in susceptibility to acute muscle strain injury buy 3mg ivermectin mastercard. Contraction-induced injury to single fiber segments from fast and slow muscles of rats by single stretches cheap 3mg ivermectin with visa. The positional stability of thick filaments in activated skeletal muscle depends on sarcomere length: evidence for the role of titin filaments. Redistribution of sarcomere length during isometric contraction of frog muscle fibres and its relation to tension creep. Active physical training for long-standing adductor-related groin pain. JOHN M RYAN Introduction The decision of whether or not an individual should play sport when it is known that he or she has only one kidney or he has only one testis is a challenging decision for which there may be no single correct or incorrect answer. The decision must be based on appropriate information and evidence. Furthermore the individual must understand the consequences and demonstrate an understanding of the risks involved. An individual cannot be expected to make a decision without appropriate advice. Physicians involved in a sport need to understand the consequences as well as explain them in a structured manner which the athlete and others understand. This advice must be based on clear evidence from which any risk should be determinable if possible. It is the responsibility of the physician to assist an individual in making a decision but the decision should be a shared one. Some individuals will have to make the decision whether or not to continue with a sport following an injury or loss of an organ or perhaps the discovery of a congenitally absent organ. On these occasions the physician should not neglect the psychological trauma that may be suffered by athletes discontinuing in sport, particularly those who participate at a high level. Physicians should be prepared to offer counselling or direct an athlete for appropriate support. For many, participation in sporting activities with peers is one of the formative events in a child’s development and this fact should not be ignored. Ultimately the individual or his or her parent or guardian will take a risk versus benefit decision which should be based on factual information and evidence. In searching for the evidence one should look for evidence of significant numbers of adverse outcomes to athletes with a single kidney or testicle who participate in sport and who sustain injuries to these organs. Clearly there is a risk for people with solitary organs playing sport. The consequences of the worst case scenario of acute 117 Evidence-based Sports Medicine renal failure, infertility and the ensuing multi-system pathology which can arise following injury are patently obvious. But what is the incidence of such devastating outcomes? Or can we deduce the incidence so we can inform physicians and patients in assisting them to make their decisions? Aims The aim of this paper is to examine the incidence, mechanism and characteristics of renal and testicular trauma in sport with the aim of producing evidence-based advice on whether or not athletes with a single kidney or testicle should be allowed to participate in sport. The paper will also evaluate the potential for injury to individuals with a solitary kidney or testicle participating in sport. Methods The Ovid version of Medline from 1960 to 2001 was searched for papers relating to testicular and renal trauma. Papers were sought using the words renal trauma, kidney trauma, renal injury, kidney injury, testicle trauma, testis trauma, testicle injury, testis injury and solitary organ. These were also linked to the words sport, football and skiing.

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A de- graph was obtained that showed a proximal femoral frac- rotational proximal femoral osteotomy was performed ture (Figure C10 quality ivermectin 3mg. He did well postoperatively 3 mg ivermectin with amex, being mo- radiographs were carefully reviewed and showed an os- bilized to ambulatory weight bearing as tolerated using a teotomy site that was too close to the blade insertion discount ivermectin 3 mg mastercard, walker. Ten days after surgery when he was at home, he therefore making the lateral femoral bone support too narrow. The insertion site should be in the area between the two lateral bends in the plate (Figure C10. The frac- ture may then propagate into the femoral head, with a fragment of the femoral head and neck and trochanter elevating, or only the greater trochanter may fracture free of the plate (Case 10. This fracture can be avoided by never inserting the blade into the apophysis of the greater trochanter and by al- ways staying in or below the subchondral bone of the greater trochanteric apophysis. If the fracture goes into the greater trochanter only, and the greater 10. This created a very demanding three-part oped a left hip dysplasia that slowly progressed and was fracture situation that we resolved with a removal of the believed to merit hip reconstruction. Because of signifi- plate, then fixed the distal two fragments with a small an- cant leg lengthening discrepancy, she also had a femoral terior plate (Figure C10. A new plate was bent to shortening osteotomy on the right side. Although she was the intended degree of varus, approximately 120°, and moderately obese, the operative procedure and postoper- was inserted parallel to the femoral neck until it was just ative course went well until the fifth day postoperatively, short of the epiphysis (Figure C10. This was fol- when the physical therapist reported increased pain with lowed by a cancellous screw inserted above the plate movements of getting her from the bed to chair. A phys- chisel so it got good bone hold right up to the epiphysis ical examination demonstrated increased pain and an (Figure C10. A tension band wire was then inserted external rotation deformity of the femur indicating a through the greater trochanter, pulled down, and twisted probable fracture. The radiograph demonstrated a frac- around the screw, and then brought through a small hole ture proximal to the blade (Figure C10. This left the drilled anterior to posterior in the distal fragment (Figure femur with a free femoral head and trochanter (Figure C10. The tension band wire was tight- #2 and #3) still stabilized with the plate. The cause of this ened so it was lateral to the plate. In this way, it helped fracture was a technical error of placing the blade inser- prevent the plate from backing out (Figure C10. A tion site into the trochanteric apophysis and possibly not single leg spica cast was used to support the construct inserting the plate blade in the same anteroposterior track until there was early callus formation; however, if a Figure C10. This is a rare complication; however, the out- tient developed a wound infection and had the hard- come tends to be good if the deformity is appropriately ware removed after the osteotomy was healed (Figure fixed and healing is obtained. However, if the fracture propagates into the femoral neck and head, such that the proximal fragment includes a component of the femoral neck and head with the greater trochanter, an open reduction with exchange of the plate is required. In this open reduction and plate exchange, screws are placed into the proximal fragment and a new plate is inserted, usually in a much more valgus position, into the femoral head along with lateral cerclage wires. This open reduction is somewhat complicated to perform and it is often helpful to have the middle piece between the proximal fracture and the distal osteotomy fixed to the distal fragment using a small anterior plate. This fracture should be diligently avoided by ensuring that entering too far proximally into the apophysis of the greater trochanter does not occur. Distal End of Plate Fractures Fractures of the distal fixation occur when the screws pull out of the bone.

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Inpatient Hospital Rehabilitation Before 1990 ivermectin 3mg cheap, inpatient rehabilitation programs were commonly used for in- dividuals with CP purchase 3 mg ivermectin free shipping, especially for postoperative rehabilitation discount 3mg ivermectin free shipping. These programs have decreased greatly because of the refusal of insurance companies to pay for the care as there is no good evidence that inpatient therapy is better than outpatient therapy. Today, the role of inpatient rehabilitation therapy is limited to very specific situations where multiple disciplines are needed in a concentrated time period. Such an example might be an individual with good cognitive function who has limited ability to receive therapy during the school year because of academic learning constraints, but would benefit from intensive therapy to assist with independence gaining skills such as self- dressing, self-bathing, improved walking, and wheelchair transfers. For the individual in late childhood or adolescence, an intensive 2- to 4-week in- patient therapy program can provide significant long-term yields. For this to be successful and for insurance companies to pay, a very detailed and specific goal has to be defined before the therapy stay. Both children and 164 Cerebral Palsy Management parents need to have a desire and commitment to make the goals and then to follow through with the goals at home after the therapy admission. School-Based Therapy After age 3 years, many children with CP spend most of time during the day in a school environment and therapy is often provided in school. There has been a tendency to try to segregate educational therapy from medical therapy. Educational therapy is defined as therapy that furthers children’s educational goals, whereas medical therapy is directed at treating medical impairments. For example, a child who needs postoperative rehabilitation therapy clearly falls into the medically required therapy group. On the other hand, the goal of sitting in a desk chair and holding a pencil to write a school lesson is clearly a physi- cal skill that has to be addressed in some way for effective classroom learn- ing to occur. There are, however, many therapies that fall between these two extremes, and it seems the definition is determined most by the availability of a therapist and the attempt of school administrations to provide minimum or maximum services. The extremes range from schools that will provide increased therapy even to help with postoperative rehabilitation, to the other extreme of schools that define any specific therapy recommended from an orthopaedist as medically based therapy. This definition of what is educational therapy rests with the educational system and not the medical system, although developmental pediatricians are seen as experts on special education and can give medical opinions for edu- cation that the school system has to consider. School-based therapy is ideal for children and families because families are not burdened with having to take children to another facility or another appointment. Most educational- based therapy is low intensity and low frequency. The MOVE Program is an ed- a week is the planned therapy intervention. However, educational therapy ucation-based program that depends heavily can be the focus of the educational plans for children with limited cognitive on assistive devices to teach mobility. A new approach called the Mobility Opportunities Via Education devices demonstrate the increasing overlap (MOVE) was developed by Linda Bidade in Bakersfield, CA, as a special ed- of the techniques used by therapists and ucation teaching program, and is being adopted in some schools. These devices include standers, walkers, and var- ious other positioning devices that are used throughout the day, directed at a specific overall motor stimulation program. The real focus of this program is to allow the children to acquire physical skills, such as standing, that will allow them to do weightbearing transfers and to maximize an indivdual’s physical function in the community. This educational therapy approach seems most appropriate for children and adolescents with severe mental re- tardation and limited physical abilities; however, it is very important that the therapy not interfere with cognitive educational classes, especially for indi- viduals with good cognitive function. Special Setting Special environments in which physical therapy also provides a valuable service include seating clinics where physical or occupational therapists serve as primary clinicians in the role of evaluating a child’s specific seating needs. The gait analysis laboratory is another environment in which the therapist usually does most of the direct patient contact testing, such as the examina- tion and placement of markers and EMG electrodes. After the data have been compiled, the therapist is a key member of the data interpretation team. Therapy, Education, and Other Treatment Modalities 165 Occupational Therapy The theories of therapy practice for occupational therapy mirror those of physical therapy.

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According to the basic science of injury buy ivermectin 3mg, there is no reason why elite athletes would be expected to have different results purchase ivermectin 3 mg amex. Does stretching outside 2 RCTs (n = 300–470) purchase ivermectin 3mg free shipping, weaknesses in A1 periods of exercise follow-up and differences in baseline prevent injury? One study suggested a decreased injury rate and the other only decreased severity of injury. Warming-up and stretching for improved physical performance and prevention of sports-related injuries. Biomechanical responses to repeated stretches in human hamstring muscle in vivo. Passive energy absorption by human muscle-tendon unit is unaffected by increase in intramuscular temperature. Optimal duration of static stretching exercises for improvement of coxo-femoral flexibility. Effect of duration of passive stretch on hip abduction range of motion. The effect of heat and stretching on the range of hip motion. Repeated passive stretching: acute effect on the passive muscle moment and extensibility of short hamstrings. Mechanical and physiological responses to stretching with and without preisometric contraction in human skeletal muscle. Sport stretching: effect on passive muscle stiffness of short hamstrings. Comparison of the hold-relax procedure and passive mobilization on increasing muscle length. Electromyographic investigation of muscle stretching techniques. Ipsilateral and contralateral effects of proprioceptive neuromuscular facilitation techniques on hip motion and electromyographic activity. Muscle activation during proprioceptive neuromuscular facilitation (PNF) stretching techniques. Stretching exercises: Effect on passive extensibility and stiffness in short hamstrings of healthy subjects. Myofibrils bear most of the resting tension in frog skeletal muscle. A physiological role for titin and nebulin in skeletal muscle. The short range stiffness of active mammalian muscle and its effect on mechanical properties. Mechanical properties of the cross-bridges of frog striated muscle. The relationship between stiffness of the musculature and static flexibility: an alternative explanation for the occurrence of muscular injury. Muscle stiffness in human ankle dorsiflexors: intrinsic and reflex components. A mechanism for altered flexibility in human skeletal muscle. Force and contractile characteristics after stretch overload in quail anterior latissimus dorsi muscle.

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Secondary adaptation to the internal rotation of the hip includes de- creased knee flexion in weight acceptance in swing phase cheap ivermectin 3mg otc, decreased ankle push-off power burst purchase ivermectin 3 mg visa, and requires the use of more hip power generic ivermectin 3 mg without a prescription. If the inter- nal rotation is unilateral, the pelvis may rotate posteriorly on the side of the internal hip rotation, then the contralateral hip compensates with external rotation. The amount of internal rotation is assessed by physical examination with children prone and the hips extended (Case 7. There are two problems with the kinematic measure of which clinicians must always be aware. First, the measure is very dependent on defining the axis of the knee joint by the person placing the marker. An error of 5° to 10° in defining the knee joint axis is to be expected. The sec- ond major issue is all clinical gait software programs currently use rotation as the last Euler angle to derotate. This means that often the measured de- gree of rotation is less than clinicians perceive, probably because they are mentally derotating the hip first. This is not an error in the kinematics or the clinicians’ assessments but is related only to the method of expressing the po- sition. Clinically, the hip rotation may be more significant than the kinematic measure suggests. The principal cause of the increased internal rotation is increased femoral anteversion. A secondary cause may be a contracture of the inter- nal rotators. A third cause may be motor control problems as mentioned with increased scissoring, which are often seen in marginal ambulators. For children who previously had surgery on the hip and in whom there is a ques- tion as to the specific cause of the internal rotation, measurement of the femoral anteversion with ultrasound or CT scan should be considered. Children in middle childhood or older who are functional ambulators tend to do poorly with internal rotation that is greater than 10° during terminal stance phase. From middle childhood on, there is little apparent sponta- neous correction of the internal rotation. Children who are very functional ambulators and have any internal rotation during stance phase are easily cosmetically observed as having internal rotation. Some children with 0° to 15° of internal rotation of the hip in stance phase seem to have very few measurable mechanical problems; however, parents often notice that they trip more frequently, which may be due to decreased knee flexion to avoid Figure 7. Crossing over of the knees is knees crossing over the midline. These increased problems that require so- often called scissoring gait. However, it is phisticated motor control probably cause children with CP to be more better to use the term scissoring gait only when it is caused by true hip hyperadduction. Also, during running when there is increased knee flexion, a heel Most of the time, crossing over of the knees whip will appear if children have persistent internal rotation. This heel is due to internal rotation of the hips, often whip clearly adds to children’s poor coordination during running. Treat- secondary to increased femoral anteversion ment of increased internal rotation is a derotation femoral osteotomy, and not caused by primary increased hip which will improve the foot progression angle. Usually, this external rotation is associated with hypotonia and may be part of a progressive anterior hip subluxation syndrome (Case 7. Typically, these children start losing functional am- bulatory ability as the hip increases its external rotation at the same time the anterior subluxation is increasing. The treatment is to correct the hip joint pathology.

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