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Venous insufficiency

2014-10-04T19:48:55Z

Bobby Schwartz:

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Image = Venous Insufficiency.jpg|
Caption = Venous insufficiency|
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OMIM = |
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{{SI}}

'''Editor-in-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.]; Michael Traurig, M.D., Vein Centers of Excellence, Greenville, SC; {{AOEIC}}: [[C. Michael Gibson, M.S., M.D.]]; {{CZ}}

==Overview==
'''Venous insufficiency''' is a condition in which the veins do not efficiently return blood from the lower limbs back to the heart. Venous insufficiency involves one or more veins.

==Normal Anatomy and Function==

* The '''superficial veins''' lie in the subcutaneous fatty layer of the body just beneath the skin and superficial to the deep fascia enveloping the body musculature. The principal veins in the legs are the great and lesser saphenous veins and their tributaries; in the arms they are the basilic and cephalic veins and their tributaries.

* The '''deep veins''' accompany arteries and bear the same name as the arteries they parallel. It is common in the extremities for there to be two or more veins accompanying a small to medium sized artery.

* The '''perforating veins''' penetrate the deep fascia and connect the superficial veins to the deep veins. Those along the inner (medial) side of the lower leg play a major role in the pathogenesis of the postphlebitic leg.

* The '''intramuscular sinusoidal veins''' are large, very thin walled, valveless veins within skeletal muscle. They connect directly with the deep veins.

<gallery>
Image:Great_saphenous_vein.png|Great saphenous vein
Image:Gray582.png|Small saphenous vein and its tributaries.
Image:Gray584.png|The femoral vein and its tributaries.
</gallery>

===Function===
[[Image:Veincrosssection.png|thumb|100px|left|Cross section of a vein showing a valve which prevents backflow]]
Veins serve to return blood from organs to the heart.

In [[systemic circulation]] oxygenated blood is pumped by the [[left ventricle]] through the [[artery|arteries]] to the muscles and organs of the body, where its nutrients and gases are exchanged at [[capillary|capillaries]], entering the veins filled with cellular waste and [[carbon dioxide]].

The de-[[oxygen]]ated blood is taken by veins to the [[right atrium]] of the heart, which transfers the blood to the [[right ventricle]], where it is then pumped to the pulmonary arteries and eventually the [[lung]]s.

In [[pulmonary circulation]] the [[pulmonary vein]]s return oxygenated blood from the lungs to the [[left atrium]], which empties into the left ventricle, completing the cycle of blood circulation. Normal venous flow is dependent on four factors:

* Dynamic Flow: The heart related flow (dynamics / spontaneous flow). Flow in the arterial system is dependent on the pumping action of the heart and the elasticity and muscular activity of the arteries.
* Phasic Flow: The breathing-related intra-abdominal pressure changes lead to respiratory fluctuation of venous flow with faster flow during expiration due to lower intraabdominal pressure (upward movement of [[diaphragm]]) and slower flow during inspiration due to higher intraabdominal pressure (downward movement of [[diaphragm]]). This pressure dependent flow pattern is transmitted through the upper leg veins into the major deep veins in the distal lower leg and into the major superficial veins (great and small [[saphenous vein]]s) in the recumbent patient.
* The muscle pump or the venous pump: The muscle pump mechanism is highly developed in the calf muscles. Large venous sinusoids located in these muscles. As they contract, the force helps to emptying the below veins. Contractions of the calf muscles can produce a sufficient pressure to empty the sinusoids into the deep veins. The deep veins are affected with the similar compressing force due to a strong fascial structure. As a result, with each muscle contraction venous blood is pumped towards to the heart.
* The valves: The valves are prevent retrograde flow. They prevent retrograde flow from heart to veins and from deep veins to superfacial veins.

==Classification==

===CEAP Classification: '''''C'''''linical Presentation, '''''E'''''tiology, '''''A'''''natomical Localization, '''''P'''''athophysiological Dysfunction===

* According to Clinical Presentation
:* Asymptomatic
:* Symptomatic
* According to Etiology
:* Congenital
:* Primary
:* Secondary)
* According to Anatomical Localization / Distribution
:* Superficial
:* Deep
:* Perforator
:* Alone
:* In combination
* According to Pathophysiological Dysfunction
:* Reflux
:* Obstruction
:* Alone
:* In combination

===Evaluation===

* Class 0: No evidence of venous disease.
* Class 1: Telangiectasia (Superficial spider veins), reticular veins, malleolar flare
* Class 2: Simple varicose veins only
* Class 3: Ankle oedema of venous origin (not foot edema)
* Class 4: Skin pigmentation in the gaiter area (lipodermatosclerosis)
* Class 5: Dermatological changes with a healed venous ulcer
* Class 6: Dermatological changes with an open (active) venous ulcer

==Pathophysiology==
[[Image:18094.jpg|left|300px|thumb|The valves in the veins usually channel the flow of blood toward the heart. When these valves are damaged, blood leaks and pools in the legs and feet. Venous insufficiency is a condition in which the veins fail to return blood efficiently to the heart. This condition usually involves one or more veins. Symptoms include swelling of the legs and pain in the extremities such as a dull aching, heaviness, or cramping.]]

Disturbed venous return from peripheral veins) can have the following causes:

* Impairment of the calf muscle pump
* Obstruction of the deep veins
* Valve incompetence of the epifascial veins
* Valve incompetence of the perforating veins
* Valve incompetence of the subfascial veins
<br clear="left"/>

==Causes of Venous Insufficiency==
* [[Deep vein thrombosis]]
* [[Phlebitis]]
* [[Pregnancy]]
* [[Varicose vein]]s

==Risk Factors==
* [[Ageing]]
* [[Family history]]
* Female hormones
* Gravitational hydrostatic forces (exacerbated during pregnancy)
* Hydrostatic muscular compartment force
* [[Sedentary lifestyle]]

==Diagnosis==

Clinical manifestations of venous insufficiency include various conditions such as telangiectasias, varicose veins, and axial incompetence. These are easily treated. In contrast, venous insufficiency may be refractory to treatment as in the severely damaged postthrombotic limb which manifests segmental occlusion in combination with universal venous reflux. Venous Duplex Ultrasonography is commonly used to diagnose venous reflux.

===Signs and Symptoms===

* Leg discomfort and / or pain: Complains may include dull aching, heaviness, or cramping. Venous claudication may mimic arterial intermittent claudication, though it typically takes longer to subside after stopping exercise.
* Skin pigmentation and discoloration of the skin. Venous insufficiency is characterized by a dark bluish / purple discoloration. Over time, long standing stasis of blood leads to the deposition of [[hemosiderin]], giving the skin a dark, speckled appearance. If the leg is placed in a dependent position, the bluish/purple discoloration may darken dramatically, further suggestive of venous insufficiency. This occurs as a result of gravity working against an already ineffective blood return system. Patients with severe arterial insufficiency, on the other hand, may have relatively pale skin as a result of under perfusion. When their legs are placed in a dependent position, gravity enhances arterial inflow and the skin may become more red as maximally dilated arterioles attempt to bring blood to otherwise starved tissues. In cases of severe ischemia, the affected areas (usually involving the most distal aspect of the foot), can appear whitish or mottled, giving the leg a marbleized appearance. Dead tissue turns black (a.k.a. [[gangrene]]). [[Cellulitis]] (infection in the skin) will cause the skin to appear bright red. These changes can be difficult to detect in people of color.
* Ulceration: Non-healing ulcers especially around the [[medial malleolus]]
* Lipodermatosclerosis: LDS or liposclerosis refers to a thickening in the tissues underneath the skin.
* Varicose eczema: the skin becomes red, wet and scaly.
* Leg swelling

===Physical Examination===

* Auscultation findings of arteriovenous fistulas may be present
* Increased skin temperature may found
* Thin skin: Sign of poor skin nutrition.

<gallery>
Image:Venous Insufficiency.jpg|Venous insufficiency
Image:Cellulitis.jpg|[[Cellulitis]]
Image:Assymetric Leg, Swelling secondary to Deep Venous Thrombosis in Right Leg.jpg|Assymetric Leg, Swelling secondary to [[Deep Venous Thrombosis]] in Right Leg
Image:Venous Stasis Ulcer.jpg|Venous Stasis Ulcer
Image:Edema of Right Foot.jpg|Edema of Right Foot
Image:Massive edema.jpg|Massive [[edema]]
</gallery>
===Tourniquet tests===

Performing a Tourniquet test is necessary to determine the level of valvular incompetence in the superficial system and to ascertain whether deep venous system involvement is present. Tourniquet test is developed by Brody and later on modified by Trendelenburg.

The patient should wait in a supine position with the limb elevated for at least one minute before starting to perform the Tourniquet test. This maneuver empties the veins by reducing venous congestion in the superficial venous system. Four tourniquets are then placed at the upper thigh, lower thigh, calf, and upper ankle.

Then ask to patient to stand. If the superficial veins of the calf segment fill, perforating vein incompetence is usually present. The tourniquets are then removed from the bottom upward. If removing the ankle tourniquet fills the superficial venous system, presence of perforating vein incompetence is suspected.

If after removal of the below-knee tourniquet the lesser saphenous system fills, then presence of lesser saphenous incompetence is most likely. In following step, the above-knee tourniquet is removed to assess the competence of the [[Hunter's canal]] perforator. At the end, if the superficial venous system remains empty, then the high thigh tourniquet is removed to detect saphenofemoral incompetence.

===Trendelenburg test===

A '''Trendelenburg test''' determines the competency of the valves in communicating veins between the [[Superficial vein|superficial]] and [[deep vein]]s of the leg. The leg is raised above heart level until the veins become empty, then the leg is quickly lowered. Superficial veins of the leg normally empty into deep veins, however retrograde filling occurs when valves are incompetent, leading to [[varicose veins]].

The Trendelenburg test is often confused with [[Trendelenburg's sign]], which is related to conditions affecting the hip and femur.

===Perthes test===

The '''Perthes test''' is a clinical test for assessing the patency of the deep femoral vein prior to varicose vein surgery. It is named after German surgeon Georg Perthes.

The limb is elevated and an elastic bandage is applied firmly from the toes to the upper 1/3 of the thigh to obliterate the superficial veins only.

With the bandage applied the patient is asked to walk for 5 minutes. If deep system is competent, the blood will go through and back to the heart. If the deep system is incompetent, the patient will feel pain in the leg.

This test is sometimes referred to as the Delbet-Mocquot test, named after French physicians Pierre Delbet and Pierre Mocquot.

==== Modified Perthes test ====

The test in done by applying a tourniquet at the level of the saphenofemoral junction to occlude the superficial pathway, and then the patient is asked to move in situ. If the deep veins are occluded, the dilated veins increase in prominence and pain occurs.

This is a more reliable test as it does not depend on patient's pain threshold.

===Ultrasonography===

====Gray scale ultrasonography (Compress ultrasonography)====

====Color Doppler Ultrasonography====

Duplex scanning of the deep and superficial veins can detect obstruction. In addition, the function of valves in each segment of the evaluated veins can be assessed by determining the direction of blood-flow using Doppler ultrasound. Function of the proximal valves is evaluated during [[Valsalva maneuver]] in the recumbent patient and Doppler sampling in the common and superficial [[femoral vein]]s during increased abdominal pressure.

The examination is often done in the upright position, as this is the best way to evaluate valve function.

'''Landmarks for venous reflux examination:'''

* Common femoral vein
* [[Femoral vein]]
:* Upper third part
:* Distal third part
* [[Popliteal vein]]
* Gastrocnemius veins
* Saphenofemoral junction
* [[Saphenous vein]] (above the knee)
* [[Saphenous vein]] (below the knee)
* Saphenopopliteal junction
* Mode of termination, short saphenous vein

Therapeutic decision depends on color flow duplex ultrasound evaluation results. Following an examination there are four main levels of venous pathology:

* Superficial venous reflux only
* Deep venous reflux only
* Mixed superficial and deep venous reflux
* Occluded deep venous system

===Photoplethysmography (PPG)===

===Air Plethysmography (APG)===

===Mercury Strain-gauge Plethysmography===

===Real-Time Digital Phlebography===

===Light Reflection Rheography===

===MRI===

MRI provides sagittal, coronal, and cross-sectional views and is able to detect acute occlusion.

===Computed Tomography===

===Phlebography===

* Ascending
* Descending

===Thermography===

[[Thermography]] provides an infrared map of cutaneous temperature and can be used to help identify suferficial and perforating veins.
==Treatment==

===Conservative treatment===

The symptoms of varicose veins can be controlled to an extent with the following:
*Elevating the legs often provides temporary symptomatic relief.
*"Advice about regular exercise sounds sensible but is not supported by any evidence."<ref>BMJ 2006;333:287-292 (5 August), Varicose veins and their management, Bruce Campbell [http://www.bmj.com/cgi/content/full/333/7562/287 (subscription)]</ref>
*The wearing of graduated [[compression stockings]] with a pressure of 30–40 mmHg has been shown to correct the swelling, nutritional exchange, and improve the microcirculation in legs affected by varicose veins.<ref>Curri SB et al. Changes of cutaneous microcirculation from elasto-compression in chronic venous insufficiency. In Davy A and Stemmer R, editors: Phlebology '89, Montrouge, France, 1989, John Libbey Eurotext.</ref> They also often provide relief from the discomfort associated with this disease. Caution should be exercised in their use in patients with concurrent arterial disease.
*Anti-inflammatory medication such as [[ibuprofen]] or [[aspirin]] can be used as part of treatment for superficial thrombophlebitis along with graduated compression hosiery – but there is a risk of intestinal bleeding. In extensive superficial thrombophlebitis, consideration should be given to anti-coagulation, thrombectomy or sclerotherapy of the involved vein.
*[[Diosmin 95]] is a dietary supplement distributed in the U.S. by Nutratech, Inc. The U.S. Food and Drug Administration does not approve dietary supplements, and concluded that there was an "inadequate basis for reasonable expectation of safety." <ref>New Dietary Ingredients in Dietary Supplements, U.S. Food and Drug Administration, Center for Food Safety and Applied Nutrition Office of Nutritional Products, Labeling, and Dietary Supplements
February 2001 (Updated September 10, 2001), http://www.cfsan.fda.gov/~dms/ds-ingrd.html</ref> <ref>Memorandum
[http://www.fda.gov/ohrms/dockets/dockets/95s0316/rpt0083_01.pdf]</ref>
*Lumbrokinase (Bolouke) is another dietary supplement. It has phase II and III clinical trials that demonstrate its effectiveness as a fibrinolytic agent. Lumbrokinase has been used successfully in cases of venous insufficiency where "cleaning of the valves" might be of help in restoring valve function and anatomy [http://www.canadarna.com/]
*More aggresive thrombolytic therapy with injectable low molecular weight heparins (such as lovenox or arixtra) can also reduce fibrin formation and has been successfully clinically to reduce the signs and symptoms of venous insufficiency [http://wehelpwhathurts.homestead.com/thrombolytictherapy.html].

===Compression Therapy: External banding to restore saphenous competence===

* Graduated compression stockings
:* Custom made
:* Standard size
:* Knee length
:* Thigh length
:* Compression tights
* Bandages
:* Single component
:* Multiple components
:* Inelastic
:* Elastic
* Intermittent pneumatic compression
:* Single chamber
:* Sequential chambers
:* Foot-pump
:* Lower leg
:* Full leg & trunk

===Stent Application===

Self-expanding metallic stents are used in venous stenting.

=== Hemodynamic correction of varicose veins (CHIVA)===

CHIVA is the acronym for '''C'''onservative and '''H'''emodynamic cure of '''I'''ncompetent '''V'''aricose veins in '''A'''mbulatory patients translated from the French cure Conservatrice et Hémodynamique de l'Insuffisance Veineuse en Ambulatoire<ref>Claude Franceschi, Cure CHIVA, 1988, Editions de L'Armançon, 21390 Precy-Sous-Thil France</ref> published in France in 1988.
;Pathophysiological principles
CHIVA relies on an hemodynamic impairment assessed by data and evidences depicted through Ultrasound dynamic venous investigations. According to this new concept, the clinical symptoms of venous insufficiency are not the cause but the consequence of various abnormalities of the venous system. For example,a varicose vein being overloaded, may be dilated not only because of valvular incompetence (the most frequent) but because of a venous block (thombosis) or arterio-venous fistula, and so the treatment has to be tailored according the hemodynamic feature.
;Procedure and outcomes
It generally consists in 1 to 4 small incisions under local anesthesia in order to disconnect the varicose veins from the abnormal flow due to valvular incompetence which dilates them.<ref>[http://www.dailymotion.com/3d4050d0c5d14ae36f61e4639/video/9617821]</ref> The patient is dismissed the same day. This method leads to an improvement of the venous function in order to:
* Cure the symptoms of venous insufficiency as varicose veins, legs swelling, ulcers.<ref>Maeso and all, Comparison of clinical outcome of Stripping and CHIVA for Treatment of varicose veins in Lower Extremities, Ann Vasc Surg 2001; 15: 661-665 </ref> <ref>Zamboni and all: Minimally Invasive Surgical management of primary Venous Ulcers vs Compression Treatment: a randomized Clinical Trial. Eur J Vasc Endovsc Surg 00, 1-6 (2003)</ref>
* Prevent varicose recurrence due to progressive enlargement of collateral veins which replace and overtake the destroyed veins: CHIVA vs Stripping: varicose recurrence divided by 2 to 5 at 10 years.<ref>Varicose Vein Stripping vs. Hemodynamic Correction (C.H.I.V.A.): a Long Term Randomised Trial
S. Carandina and all; Eur J Vasc Endovasc Surg xx, 1e8 (2007) doi:10.1016/j.ejvs.2007.09.011, online http://www.sciencedirect.com</ref>
* Preserve the superficial venous capital for unpredictable but possible need for coronary or leg artery vital by-pass which increases with ageing.
;Consequences to be achieved properly, CHIVA method needs a comprehensive knowledge of both hemodynamics and Ultrasound venous investigation.

===Surgery===

* Superficial Venous Stripping: Stripping consists in a removal of all the saphena vein main trunk from the groin down to the ankle.The complications include deep vein thrombosis (5.3%),<ref>van Rij AM et al. Incidence of Deep Venous Thrombosis after Varicose Vein Surgery, Br J Surg 2004 Dec; 91(12):1582-5</ref> pulmonary embolism (0.06%), and wound complications including infection (2.2%). For traditional surgery, reported recurrence rates, which have been tracked for 10 years, range from 5-60%. In addition, since stripping removes the saphenous main trunks, they are no longer availlable for venous by-pass in the future (coronary and/or leg artery vital disease)<ref>Hammarsten J, Pedersen P, Cederlund CG, Campanello M. Department of Surgery and Radiology, Hospital of Varberg, Sweden Long saphenous vein saving surgery for varicose veins. A long-term follow-up. Eur J Vasc Surg. 1990 Aug;4(4):361-4.</ref>
* Conventional surgery: Conventional surgery for varicose veins does relieve symptoms and has a role on the prevention of chronic venous ulceration.
* Valve repair techniques
:* Techniques with Phlebotomy
::* Internal Valvuloplasty
::* Venous Segment Transfer
::* Vein Valve Transplantation
::* Neo Valve
::* Allograft Cryopreserved Valve
:* Techniques without Phlebotomy
::* Wrapping, Banding, Cuffing, and External Stenting
::* External Valvuloplasty
::* Transmural Valvuloplasty
::* Transcommissural Valvuloplasty
::* Angioscopy-Assisted External Valve Repair
* Percutaneously placed device
:* The Portland valve

===Sclerotherapy===

* Conventional Sclerotherapy
* Foam Sclerotherapy

A commonly performed non-surgical treatment for varicose and "spider" leg veins is [[sclerotherapy]]. It has been used in the treatment of varicose veins for over 150 years.<ref>Goldman M, Sclerotherapy Treatment of varicose and telangiectatic leg vein, Hardcover Text, 2nd Ed, 1995</ref> Sclerotherapy is often used for telangiectasias (spider veins) and varicose veins that persist or recur after vein stripping.<ref>"Veins & Lymphatics," L. K. Pak et al, ''in'' Lange's Current Surgical Diagnosis & Treatment, 11th ed., McGraw-Hill, </ref><ref>Tisi PV, Beverley C, Rees A. Injection sclerotherapy for varicose veins. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD001732.</ref> Sclerotherapy can also be performed using microfoam sclerosants under ultrasound guidance to treat larger varicose veins, including the greater and short saphenous veins.<ref>Paul Thibault, Sclerotherapy and Ultrasound-Guided Sclerotherapy, The Vein Book / editor, John J. Bergan, 2007.</ref><ref>Padbury A, Benveniste G L, Foam echosclerotherapy of the small saphenous vein, Australian and New Zealand Journal of Phlebology Vol 8, Number 1 (December 2004)</ref> A study by Kanter and Thibault in 1996 reported a 76% success rate at 24 months in treating saphenofemoral junction and great saphenous vein incompetence with STS 3% solution.<ref>Kanter A, Thibault P. Saphenofemoral junction incompetence treated by ultrasound-guided sclerotherapy, Dermatol Surg. 1996. 22: 648-652.</ref> A Cochrane Collaboration review<ref>http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001732/abstract.html</ref> concluded sclerotherapy was better than surgery in the short term (1 year) for its treatment success, complication rate and cost, but surgery was better after 5 years, although the research is weak.<ref>Rigby KA, Palfreyman SJ, Beverley C, Michaels JA. Surgery versus sclerotherapy for the treatment of varicose veins. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD004980. [http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004980/abstract.html]</ref>

A Health Technology Assessment found that sclerotherapy provided less benefit than surgery, but is likely to provide a small benefit in varicose veins without reflux.<ref>Michaels JA, Campbell WB, Brazier JE, MacIntyre JB, Palfreyman SJ, Ratcliffe J, et al. Randomized clinical trial, observational study and assessment of cost-effectiveness of the treatment of varicose veins (REACTIV trial). Health Technol Assess 2006;10(13). [http://www.hta.ac.uk/fullmono/mon1013.pdf] This Health Technology Assessment monograph includes reviews of the epidemiology, assessment, and treatment of varicose veins, as well as a study on clinical and cost effectiveness of surgery and sclerotherapy</ref> Complications of sclerotherapy are rare but can include blood clots and ulceration. [[Anaphylaxis|Anaphylactic]] reactions are "extraordinarily rare but can be life-threatening," and doctors should have resuscitation equipment ready.<ref>William R. Finkelmeier, Sclerotherapy, Ch. 12, ACS Surgery: Principles & Practice, 2004, WebMD (hardcover book)</ref> There has been one reported case of stroke after ultrasound guided sclerotherapy when an unusually large dose of sclerosant foam was injected.

===Endovenous Ablation (Saphenous Venous Ablation - Closure)===

* Endovenous laser ablation (EVLA) is a relatively simple and quick technique which can be performed under a local anesthetic. Endovenous laser techniques employ an 810 nm-diode laser to heat the long or short [[saphenous vein]] (or major tributaries), inducing a combination of endothelial damage, focal coagulative necrosis, shrinkage of the vein and thrombotic occlusion.
* Radiofrequency ablation

The Australian Medical Services Advisory Committee (MSAC) in 2008 has determined that endovenous laser treatment for varicose veins "appears to be more effective in the short term, and at least as effective overall, as the comparative procedure of junction ligation and vein stripping for the treatment of varicose veins."<ref>Medical Services Advisory Committee, Endovenous laser therapy (ELT) for varicose veins. MSAC application 1113, Dept of Health and Ageing, Commonwealth of Australia, 2008. http://www.msac.gov.au/internet/msac/publishing.nsf/Content/2E0BACBB8704139ACA25745E001C2F21/$File/1113report.pdf</ref> It also found in its assessment of available literature, that "occurrence rates of more severe complications such as DVT, nerve injury and paraesthesia, post-operative infections and haematomas, appears to be greater after ligation and stripping than after EVLT". Complications for endovenous laser treatment include minor skin burns (0.4%)<ref name="Elmore"> Elmore FA and Lackey D, Effectiveness of laser treatment in eliminating superficial venous reflux, Phlebology 2008 :23 :21-31</ref> and temporary paraesthesia (2.1%).<ref name="Elmore"/> The longest study of endovenous laser ablation is 39 months.

Two prospective randomized trials found speedier recovery and fewer complications after radiofrequency obliteration (AKA radiofrequency ablation) compared to open surgery.<ref>Rautio, T, et al., Endovenous oblitration versus conventional stripping operation in the treatment of primary varicose veins, J Vasc Surg 2002:35:958-65</ref><ref>Lurie F, et al., Prospective randomized study of endovenous radiofrequency oblitration (closure) versus ligation and vein stripping (EVOLVeS: two-year follow-up. Eur J Vasc Endovasc Surg 2005;29:67-73</ref> Myers<ref>Kenneth Myers, An opinion —surgery for small saphenous reflux is obsolete!" Australian and New Zealand Journal of Phlebology, Vol 8, Number 1 (December 2004)</ref> wrote that open surgery for [[small saphenous vein]] reflux is obsolete. Myers said these veins should be treated with endovenous techniques, citing high recurrence rates after surgical management, and risk of nerve damage up to 15%. In comparison, radiofrequency ablation has been shown to control 80% of cases of small saphenous vein reflux at 4 years, said Myers. Complications for radiofrequency ablation include burns, paraesthesia, clinical phlebitis, and slightly higher rates of deep vein thrombosis (0.57%) and pulmonary embolism (0.17%).One 3-year study compared radiofrequency, with a recurrence rate of 33%, to open surgery, which had a recurrence rate of 23%.

==References==
{{Reflist|2}}

==Additional Resources==

* Haimovici's vascular surgery. Editor-in-chief: Ascher, Enrico 5th ed. 2004 ISBN 0632044586

*[http://www.piedmontpmr.com/treatment-for-burning-itching-swollen-painful-legs-2/ Venous Insufficiency]

==See Also==
* [[Deep vein thrombosis]]
* [[Pulmonary embolism]]
* [[Thromboembolism]]
* [[Varicose veins]]
* [[Veins]]

{{Veins}}

[[Category:Cardiology]]
[[Category:Physical examination]]
[[Category:Signs and symptoms]]

{{WH}}
{{WS}}

Thoracic outlet syndrome

2014-10-04T19:44:14Z

Bobby Schwartz: /* Overview */

{{DiseaseDisorder infobox |
Name = Thoracic outlet syndrome |
ICD10 = {{ICD10|G|54|0|g|50}} |
ICD9 = {{ICD9|353.0}} |
ICDO = |
Image = Gray808.png |
Caption = The right brachial plexus with its short branches, viewed from in front. |
OMIM = |
MedlinePlus = 001434 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = 13039 |
MeshID = D013901 |
}}
{{SI}}

'''For patient information click [[{{PAGENAME}} (patient information)|here]]'''

'''Editor(s)-In-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.]; '''Associate Editor(s)-In-Chief:''' {{CZ}}

==Overview==

'''Thoracic outlet syndrome''' (TOS) consists of a group of distinct [[disease|disorders]] that affect the [[nerve]]s in the [[brachial plexus]] (nerves that pass into the [[arm]]s from the [[neck]]) and various nerves and [[blood vessel]]s between the base of the neck and [[axilla]] ([[armpit]]). While traditionally thought of as a sensory-motor neurovascular disorder that is due to a mechanical or compressive source clinical evidence also exits that suggests the sympathetic portion of the nervous system is frequently involved. This is at least one explanation for the poor outcomes seen with a surgical treatment approach.

==Epidemiology==

TOS is more common in women. The onset of symptoms usually occurs between 20 and 50 years of age.

==Causes==

For the most part, these disorders are thought to be produced by compression of the components of the brachial plexus (the large cluster of nerves that pass from the neck to the arm), the [[subclavian artery]], the [[subclavian vein]] or are sympathetically mediated. These subtypes are referred to as [[Nervous system|neurogenic]] TOS, arterial TOS, and venous TOS, respectively. The compression may be positional (caused by movement of the clavicle (collarbone) and shoulder girdle on arm movement) or static (caused by abnormalities or enlargement of the various muscles surrounding the arteries, veins and brachial plexus).

The neurogenic form of TOS accounts for 95 to 98% of all cases of TOS. The sympathetic nervous system is felt to be the most common neurogenic source.

It is known from pathological studies of cadavers, and from surgical studies of patients with TOS, that there are numerous anomalies of the scalene muscles and the other muscles that surround the arteries, veins and brachial plexus. TOS may result from these anomalies of the [[scalene muscle]]s or from enlargement ([[hypertrophy]]) of the scalene muscles. One common cause of hypertrophy is [[Physical trauma|trauma]], as may occur in motor vehicle accidents.

The two groups of people most likely to develop TOS are those suffering neck injuries in motor vehicle accidents and those who use computers in non-ergonomic postures for extended periods of time. Young overhead athletes (such as swimmers, volleyball players and baseball pitchers) and musicians may also develop thoracic outlet syndrome, but significantly less frequently than the two large groups above.

==Classification==
===Old Classification===
The following taxonomy of TOS is used in [[ICD|ICD-9-CM]] and other sources:
* Scalenus anticus syndrome (compression on [[brachial plexus]] and/or [[subclavian artery]] caused by muscle growth) - diagnosed by using [[Adson's sign]] with patient's head turned outward
* Cervical rib syndrome (compression on [[brachial plexus]] and/or [[subclavian artery]] caused by bone growth) - diagnosed by using [[Adson's sign]] with patient's head turned inward
* Costoclavicular syndrome (narrowing between the [[clavicle]] and the first [[rib]]) -- diagnosed with costoclavicular maneuver<ref>{{FPnotebook|ORT63}}</ref>
===New Classification===

* Neurogenic TOS has a characteristic sign, called the Gilliatt-Sumner hand, in which there is severe wasting in the fleshy base of the thumb. There may be numbness along the underside of the hand and forearm, or dull aching pain in the neck, shoulder, and armpit. When the sympathetic nervous system is involved, there may be skin temperature and skin color changes. Findings are most predominant in the medial aspect of the arm, all the way down to the fifth finger.

* Vascular TOS features pallor, a weak or absent pulse in the affected arm, which also may be cool to the touch and appear paler than the unaffected arm. Symptoms may include numbness, tingling, aching, and heaviness.

* Non-specific TOS most prominently features a dull, aching pain in the neck, shoulder, and armpit that gets worse with activity. Non-specific TOS is frequently triggered by a traumatic event such as a car accident or a work related injury. It also occurs in athletes, including weight lifters, swimmers, tennis players, and baseball pitchers.

==Symptoms==

* Arterial thoracic outlet syndrome can present with pallor, coldness, pain, and paresthesias of the fingers due to severe ischemia.
* Venous form (aka '''Paget-Schroetter syndrome''', '''Effort thrombosis''' and '''thoracic inlet syndrome''') presents with arm swelling and pain.

==Diagnosis of Thoracic Outlet Syndrome should be Distinguished from==

* [[Acute coronary syndrome]]
* Brachial plexitis
* [[Carpal tunnel syndrome]]
* Cervical disc disorders (e.g., cervical spondylitis)
* [[Complex regional pain syndrome]]
* [[Reflex Sympathetic Dystrophy]]
* [[Fibromyalgia]]
* Mediastinal venous obstruction (e.g., [[Pancoast tumor]])
* [[Multiple sclerosis]]
* Postural palsy
* [[Raynaud's disease]]
* [[Rotator cuff|Rotator cuff injuries]]
* Spinal cord injuries
* Spinal cord neoplasms
* [[thrombophlebitis|Superficial thrombophlebitis]]
* Trauma
* Tumors of the syrinx
* [[Ulnar nerve]] compression at the elbow
* [[Vasculitis]]
* Vasospastic disorder

==Diagnosis==

* Adson's sign and the costoclavicular maneuver are notoriously inaccurate, and may be a small part of a comprehensive history and physical examination of a patient with TOS. There is currently no single clinical sign that makes the diagnosis of TOS with certainty.
* Cervical radiography
* Chest radiography is helpful to evaluate:
:* Presence of cervical or first rib
:* Clavicle deformity
:* Pulmonary disease
:* Pancoast tumor
* Color flow duplex scanning
* Nerve conduction studies, electromyography, or imaging studies are recommended to confirm or rule out a diagnosis of TOS.
:* Nerve conduction evaluation via root stimulation and F wave is the best direct approach to evaluation of neurologic TOS.
:* Electromyography (EMG) is unreliable and does not provide objective evidence of TOS, however it is frequently used to rule out other disorders such as C8 radiculopathy.
* Cervical myelogram
* CT scan
* MRI <ref>Stepansky F, Hecht EM, Rivera R, Hirsh LE, Taouli B, Kaur M, Lee VS. Dynamic MR angiography of upper extremity vascular disease: pictorial review. Radiographics. 2008 Jan-Feb;28(1):e28. Epub 2007 Oct 29. PMID 17967936 </ref>
* [[Arteriography]], while only rarely used to evaluate thoracic outlet syndrome, may be used if a surgery is being planned to correct an arterial TOS.<ref>[http://www.mountsinai.org/Other/Diseases/Thoracic%20outlet%20syndrome Thoracic outlet syndrome]
Mount Sinai Hospital, New York</ref>
:* Arteriography indications:
::* Evidence of peripheral emboli in the upper extremity
::* Suspected subclavian stenosis or aneurysm (e.g., bruit or abnormal supraclavicular pulsation)
::* Blood pressure differential greater than 20 mmHg
::* Obliteration of radial pulse during EAST
* Venography
:* Venography indications:
::*Persistent or intermittent edema of the hand or arm
::*Peripheral unilateral cyanosis
::*Prominent venous pattern over the arm, shoulder, or chest
*[[Thermography]][http://www.piedmontpmr.com/thoracic-outlet-syndrome-tos-robert-g-schwartz-greenville-sc-2]
:*Thermography indications:
::*Vasomotor or sudomotor instability
::*Weather sensitivity
::*Cold limb in a shawl or C8 distribution
::*Thermography may be one of the most sensitive tests to objectify the presence of thoracic outlet syndrome, especially if it is felt to be sympathetic in origin

==Diagnostic Findings==

MRV demonstrates severe focal stenosis of the [[subclavian vein|left subclavian vein]] only when the patient's arm is overhead.

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Thoracic outlet syndrome MRI 003.jpg|MIP
Image:Thoracic outlet syndrome MRI 001.jpg|3D MRV
Image:Thoracic outlet syndrome MRI 004.jpg|MIP
Image:Thoracic outlet syndrome MRI 002.jpg|3D MRV
</gallery>

==Treatment==

Often, continued and active postural changes along with physiotherapy, massage therapy, chiropractic or [[Osteopathic manipulative medicine|osteopathic manipulation]], will suffice. The recovery process however is long term, and a few days of poor posture can often set one back. Various anesthetic injections, such as cervical plexus block and stellate ganglion block can provide significant relief.

About 10 to 15% of patients undergo surgical decompression following an appropriate trial of conservative therapy, most often specific physical therapy directed towards the treatment of thoracic outlet syndrome, and usually lasting between 6 and 12 months. Surgical treatment may include removal of anomalous muscles, removal of the native anterior and/or middle scalene muscles, removal of the first rib or, if present, a cervical rib, or neurolysis (removal of fibrous tissue from the brachial plexus).

In general;

* Treatment of arterial thoracic outlet syndrome is surgical intervention. Treatment is required to treat or prevent acute thromboembolic events.
* Treatment of venous thoracic outlet syndrome depends primarily on the presence and extent of associated venous thrombosis and may include anticoagulation, thrombolysis, or surgical decompression.

===Noninvasive===
* [[Stretching]]<br />The goal of self stretching is to relieve compression in the thoracic cavity, reduce blood vessel and nerve impingement, and realign the bones, muscles, ligaments, and tendons causing the problem.
** Moving shoulders forward (hunching) then back to neutral, followed by extending them back (arching) then back to neutral, followed by lifting shoulders then back to neutral.
** Tilting and extending neck opposite to the side of injury while keeping the injured arm down or wrapped around the back.
* Nerve Gliding<br />This syndrome causes a compression of a large cluster of nerves, resulting in the impairment of nerves throughout the arm. By performing nerve gliding exercises one can stretch and mobilize the nerve fibers. Chronic and intermittent nerve compression has been studied in animal models, and has a well-described pathophysiology, as described by Susan Mackinnon, MD, currently at Washington University in St. Louis. Nerve gliding exercises have been studied by several authorities, including David Butler in Australia.
** Extend your injured arm with fingers directly outwards to the side. Tilt your head to the otherside, and/or turn your head to the other side. A gentle pulling feeling is generally felt throughout the injured side. Initially, only do this and repeat. Once this exercise has been mastered and no extreme pain is felt, begin stretching your fingers back. Repeat with different variations, tilting your hand up, backwards, or downwards.
* [[Posture]]<br />TOS is rapidly aggravated by poor posture. Active breathing exercises and [[ergonomic]] desk setup can both help maintain active posture. Often the muscles in the back become weak due to prolonged (years) hunching.
* Ice/Heat<br />Ice can be used to decrease inflammation of sore or injured muscles. Heat can also aid in relieving sore muscles by improving circulation to them. While the whole arm generally feels painful, some relief can be seen when ice/heat is applied to the thoracic region (collar bone, armpit, or shoulder blades).

===Invasive===
* [[Cortisone]]<br />Injected into a joint or muscle, cortisone can help relief and lower inflammation.
* [[Botox]] injections<br />Short for Botulinum Toxin A, Botox binds nerve endings and prevents the release of neurotransmitters that activate muscles. A small amount of Botox injected into the tight or spastic muscles found in TOS sufferers often provides months of relief while the muscles is temporarily paralyzed. This noncosmetic treatment is unfortunately not covered by most medical plans and costs upwards of $400. Botox is VERY long-lasting, and its use will probably be based on results of ongoing research. Serious side effects have been reported, and are similarly long-lasting, so improved understanding of the mechanism of a 'scalene block' is vital to determining the benefit and risk of using Botox.
* Surgical approaches have also been used.<ref name="pmid17985565">{{cite journal |author=Rochkind S, Shemesh M, Patish H, ''et al'' |title=Thoracic outlet syndrome: a multidisciplinary problem with a perspective for microsurgical management without rib resection |journal=Acta Neurochir. Suppl. |volume=100 |issue= |pages=145–7 |year=2007 |pmid=17985565 |doi=}}</ref>
* Provocative test: The injection of a short-acting anesthetic such as xylocaine into the anterior scalene, subclavius, or pectoralis minor muscles as a provocative test to assist in the diagnosis of thoracic outlet syndrome. This is referred to as a 'scalene block'. If the patient experiences symptomatic relief for approximately 15 minutes following this procedure, surgical decompression is more likely to be successful in leading to the same level of symptomatic relief. However, this is not considered a 'treatment', as the relief is expected to wear off within an hour or two, at a maximum. Active research continues into the accuracy and risks of this provocative test.

==Prognosis==

The outcome for individuals with TOS varies according to type. The majority of individuals with TOS will improve with exercise and physical therapy. Vascular TOS, and true neurogenic TOS often require surgery to relieve pressure on the affected vessel or nerve.

==References==
{{Reflist|2}}

{{PNS diseases of the nervous system}}
[[nl:Thoracic outlet syndrome]]

==External Links==
*[http://www.piedmontpmr.com/thoracic-outlet-syndrome-tos-robert-g-schwartz-greenville-sc-2 TOS-Thoracic Outlet Syndrome]

{{WH}}
{{WikiDoc Sources}}

Thoracic outlet syndrome

2014-10-04T19:42:02Z

Bobby Schwartz: /* Overview */

{{DiseaseDisorder infobox |
Name = Thoracic outlet syndrome |
ICD10 = {{ICD10|G|54|0|g|50}} |
ICD9 = {{ICD9|353.0}} |
ICDO = |
Image = Gray808.png |
Caption = The right brachial plexus with its short branches, viewed from in front. |
OMIM = |
MedlinePlus = 001434 |
eMedicineSubj = |
eMedicineTopic = |
DiseasesDB = 13039 |
MeshID = D013901 |
}}
{{SI}}

'''For patient information click [[{{PAGENAME}} (patient information)|here]]'''

'''Editor(s)-In-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.]; '''Associate Editor(s)-In-Chief:''' {{CZ}}

==Overview==

'''Thoracic outlet syndrome''' (TOS) consists of a group of distinct [[disease|disorders]] that affect the [[nerve]]s in the [[brachial plexus]] (nerves that pass into the [[arm]]s from the [[neck]]) and various nerves and [[blood vessel]]s between the base of the neck and [[axilla]] ([[armpit]]). While traditionally thought of as a sensory-motor neurovascular disorder due to mechanical or compressive source clinical evidence exits that suggest that the sympathetic portion of the system is frequently involved. This is at least one explanation for the poor outcomes seen with a surgical treatment approach.

==Epidemiology==

TOS is more common in women. The onset of symptoms usually occurs between 20 and 50 years of age.

==Causes==

For the most part, these disorders are thought to be produced by compression of the components of the brachial plexus (the large cluster of nerves that pass from the neck to the arm), the [[subclavian artery]], the [[subclavian vein]] or are sympathetically mediated. These subtypes are referred to as [[Nervous system|neurogenic]] TOS, arterial TOS, and venous TOS, respectively. The compression may be positional (caused by movement of the clavicle (collarbone) and shoulder girdle on arm movement) or static (caused by abnormalities or enlargement of the various muscles surrounding the arteries, veins and brachial plexus).

The neurogenic form of TOS accounts for 95 to 98% of all cases of TOS. The sympathetic nervous system is felt to be the most common neurogenic source.

It is known from pathological studies of cadavers, and from surgical studies of patients with TOS, that there are numerous anomalies of the scalene muscles and the other muscles that surround the arteries, veins and brachial plexus. TOS may result from these anomalies of the [[scalene muscle]]s or from enlargement ([[hypertrophy]]) of the scalene muscles. One common cause of hypertrophy is [[Physical trauma|trauma]], as may occur in motor vehicle accidents.

The two groups of people most likely to develop TOS are those suffering neck injuries in motor vehicle accidents and those who use computers in non-ergonomic postures for extended periods of time. Young overhead athletes (such as swimmers, volleyball players and baseball pitchers) and musicians may also develop thoracic outlet syndrome, but significantly less frequently than the two large groups above.

==Classification==
===Old Classification===
The following taxonomy of TOS is used in [[ICD|ICD-9-CM]] and other sources:
* Scalenus anticus syndrome (compression on [[brachial plexus]] and/or [[subclavian artery]] caused by muscle growth) - diagnosed by using [[Adson's sign]] with patient's head turned outward
* Cervical rib syndrome (compression on [[brachial plexus]] and/or [[subclavian artery]] caused by bone growth) - diagnosed by using [[Adson's sign]] with patient's head turned inward
* Costoclavicular syndrome (narrowing between the [[clavicle]] and the first [[rib]]) -- diagnosed with costoclavicular maneuver<ref>{{FPnotebook|ORT63}}</ref>
===New Classification===

* Neurogenic TOS has a characteristic sign, called the Gilliatt-Sumner hand, in which there is severe wasting in the fleshy base of the thumb. There may be numbness along the underside of the hand and forearm, or dull aching pain in the neck, shoulder, and armpit. When the sympathetic nervous system is involved, there may be skin temperature and skin color changes. Findings are most predominant in the medial aspect of the arm, all the way down to the fifth finger.

* Vascular TOS features pallor, a weak or absent pulse in the affected arm, which also may be cool to the touch and appear paler than the unaffected arm. Symptoms may include numbness, tingling, aching, and heaviness.

* Non-specific TOS most prominently features a dull, aching pain in the neck, shoulder, and armpit that gets worse with activity. Non-specific TOS is frequently triggered by a traumatic event such as a car accident or a work related injury. It also occurs in athletes, including weight lifters, swimmers, tennis players, and baseball pitchers.

==Symptoms==

* Arterial thoracic outlet syndrome can present with pallor, coldness, pain, and paresthesias of the fingers due to severe ischemia.
* Venous form (aka '''Paget-Schroetter syndrome''', '''Effort thrombosis''' and '''thoracic inlet syndrome''') presents with arm swelling and pain.

==Diagnosis of Thoracic Outlet Syndrome should be Distinguished from==

* [[Acute coronary syndrome]]
* Brachial plexitis
* [[Carpal tunnel syndrome]]
* Cervical disc disorders (e.g., cervical spondylitis)
* [[Complex regional pain syndrome]]
* [[Reflex Sympathetic Dystrophy]]
* [[Fibromyalgia]]
* Mediastinal venous obstruction (e.g., [[Pancoast tumor]])
* [[Multiple sclerosis]]
* Postural palsy
* [[Raynaud's disease]]
* [[Rotator cuff|Rotator cuff injuries]]
* Spinal cord injuries
* Spinal cord neoplasms
* [[thrombophlebitis|Superficial thrombophlebitis]]
* Trauma
* Tumors of the syrinx
* [[Ulnar nerve]] compression at the elbow
* [[Vasculitis]]
* Vasospastic disorder

==Diagnosis==

* Adson's sign and the costoclavicular maneuver are notoriously inaccurate, and may be a small part of a comprehensive history and physical examination of a patient with TOS. There is currently no single clinical sign that makes the diagnosis of TOS with certainty.
* Cervical radiography
* Chest radiography is helpful to evaluate:
:* Presence of cervical or first rib
:* Clavicle deformity
:* Pulmonary disease
:* Pancoast tumor
* Color flow duplex scanning
* Nerve conduction studies, electromyography, or imaging studies are recommended to confirm or rule out a diagnosis of TOS.
:* Nerve conduction evaluation via root stimulation and F wave is the best direct approach to evaluation of neurologic TOS.
:* Electromyography (EMG) is unreliable and does not provide objective evidence of TOS, however it is frequently used to rule out other disorders such as C8 radiculopathy.
* Cervical myelogram
* CT scan
* MRI <ref>Stepansky F, Hecht EM, Rivera R, Hirsh LE, Taouli B, Kaur M, Lee VS. Dynamic MR angiography of upper extremity vascular disease: pictorial review. Radiographics. 2008 Jan-Feb;28(1):e28. Epub 2007 Oct 29. PMID 17967936 </ref>
* [[Arteriography]], while only rarely used to evaluate thoracic outlet syndrome, may be used if a surgery is being planned to correct an arterial TOS.<ref>[http://www.mountsinai.org/Other/Diseases/Thoracic%20outlet%20syndrome Thoracic outlet syndrome]
Mount Sinai Hospital, New York</ref>
:* Arteriography indications:
::* Evidence of peripheral emboli in the upper extremity
::* Suspected subclavian stenosis or aneurysm (e.g., bruit or abnormal supraclavicular pulsation)
::* Blood pressure differential greater than 20 mmHg
::* Obliteration of radial pulse during EAST
* Venography
:* Venography indications:
::*Persistent or intermittent edema of the hand or arm
::*Peripheral unilateral cyanosis
::*Prominent venous pattern over the arm, shoulder, or chest
*[[Thermography]][http://www.piedmontpmr.com/thoracic-outlet-syndrome-tos-robert-g-schwartz-greenville-sc-2]
:*Thermography indications:
::*Vasomotor or sudomotor instability
::*Weather sensitivity
::*Cold limb in a shawl or C8 distribution
::*Thermography may be one of the most sensitive tests to objectify the presence of thoracic outlet syndrome, especially if it is felt to be sympathetic in origin

==Diagnostic Findings==

MRV demonstrates severe focal stenosis of the [[subclavian vein|left subclavian vein]] only when the patient's arm is overhead.

[http://www.radswiki.net Images courtesy of RadsWiki]

<gallery perRow="2">
Image:Thoracic outlet syndrome MRI 003.jpg|MIP
Image:Thoracic outlet syndrome MRI 001.jpg|3D MRV
Image:Thoracic outlet syndrome MRI 004.jpg|MIP
Image:Thoracic outlet syndrome MRI 002.jpg|3D MRV
</gallery>

==Treatment==

Often, continued and active postural changes along with physiotherapy, massage therapy, chiropractic or [[Osteopathic manipulative medicine|osteopathic manipulation]], will suffice. The recovery process however is long term, and a few days of poor posture can often set one back. Various anesthetic injections, such as cervical plexus block and stellate ganglion block can provide significant relief.

About 10 to 15% of patients undergo surgical decompression following an appropriate trial of conservative therapy, most often specific physical therapy directed towards the treatment of thoracic outlet syndrome, and usually lasting between 6 and 12 months. Surgical treatment may include removal of anomalous muscles, removal of the native anterior and/or middle scalene muscles, removal of the first rib or, if present, a cervical rib, or neurolysis (removal of fibrous tissue from the brachial plexus).

In general;

* Treatment of arterial thoracic outlet syndrome is surgical intervention. Treatment is required to treat or prevent acute thromboembolic events.
* Treatment of venous thoracic outlet syndrome depends primarily on the presence and extent of associated venous thrombosis and may include anticoagulation, thrombolysis, or surgical decompression.

===Noninvasive===
* [[Stretching]]<br />The goal of self stretching is to relieve compression in the thoracic cavity, reduce blood vessel and nerve impingement, and realign the bones, muscles, ligaments, and tendons causing the problem.
** Moving shoulders forward (hunching) then back to neutral, followed by extending them back (arching) then back to neutral, followed by lifting shoulders then back to neutral.
** Tilting and extending neck opposite to the side of injury while keeping the injured arm down or wrapped around the back.
* Nerve Gliding<br />This syndrome causes a compression of a large cluster of nerves, resulting in the impairment of nerves throughout the arm. By performing nerve gliding exercises one can stretch and mobilize the nerve fibers. Chronic and intermittent nerve compression has been studied in animal models, and has a well-described pathophysiology, as described by Susan Mackinnon, MD, currently at Washington University in St. Louis. Nerve gliding exercises have been studied by several authorities, including David Butler in Australia.
** Extend your injured arm with fingers directly outwards to the side. Tilt your head to the otherside, and/or turn your head to the other side. A gentle pulling feeling is generally felt throughout the injured side. Initially, only do this and repeat. Once this exercise has been mastered and no extreme pain is felt, begin stretching your fingers back. Repeat with different variations, tilting your hand up, backwards, or downwards.
* [[Posture]]<br />TOS is rapidly aggravated by poor posture. Active breathing exercises and [[ergonomic]] desk setup can both help maintain active posture. Often the muscles in the back become weak due to prolonged (years) hunching.
* Ice/Heat<br />Ice can be used to decrease inflammation of sore or injured muscles. Heat can also aid in relieving sore muscles by improving circulation to them. While the whole arm generally feels painful, some relief can be seen when ice/heat is applied to the thoracic region (collar bone, armpit, or shoulder blades).

===Invasive===
* [[Cortisone]]<br />Injected into a joint or muscle, cortisone can help relief and lower inflammation.
* [[Botox]] injections<br />Short for Botulinum Toxin A, Botox binds nerve endings and prevents the release of neurotransmitters that activate muscles. A small amount of Botox injected into the tight or spastic muscles found in TOS sufferers often provides months of relief while the muscles is temporarily paralyzed. This noncosmetic treatment is unfortunately not covered by most medical plans and costs upwards of $400. Botox is VERY long-lasting, and its use will probably be based on results of ongoing research. Serious side effects have been reported, and are similarly long-lasting, so improved understanding of the mechanism of a 'scalene block' is vital to determining the benefit and risk of using Botox.
* Surgical approaches have also been used.<ref name="pmid17985565">{{cite journal |author=Rochkind S, Shemesh M, Patish H, ''et al'' |title=Thoracic outlet syndrome: a multidisciplinary problem with a perspective for microsurgical management without rib resection |journal=Acta Neurochir. Suppl. |volume=100 |issue= |pages=145–7 |year=2007 |pmid=17985565 |doi=}}</ref>
* Provocative test: The injection of a short-acting anesthetic such as xylocaine into the anterior scalene, subclavius, or pectoralis minor muscles as a provocative test to assist in the diagnosis of thoracic outlet syndrome. This is referred to as a 'scalene block'. If the patient experiences symptomatic relief for approximately 15 minutes following this procedure, surgical decompression is more likely to be successful in leading to the same level of symptomatic relief. However, this is not considered a 'treatment', as the relief is expected to wear off within an hour or two, at a maximum. Active research continues into the accuracy and risks of this provocative test.

==Prognosis==

The outcome for individuals with TOS varies according to type. The majority of individuals with TOS will improve with exercise and physical therapy. Vascular TOS, and true neurogenic TOS often require surgery to relieve pressure on the affected vessel or nerve.

==References==
{{Reflist|2}}

{{PNS diseases of the nervous system}}
[[nl:Thoracic outlet syndrome]]

==External Links==
*[http://www.piedmontpmr.com/thoracic-outlet-syndrome-tos-robert-g-schwartz-greenville-sc-2 TOS-Thoracic Outlet Syndrome]

{{WH}}
{{WikiDoc Sources}}

Stem cell

2014-10-04T19:36:49Z

Bobby Schwartz: /* Treatments */

{{SI}}
'''For The WikiDoc Living Textbook Of Stem Cell Therapy Directory click [[The WikiDoc Living Textbook Of Stem Cell Therapy|here]]'''
[[Image:Mouse embryonic stem cells.jpg|right|thumb|300px|[[Mus musculus|Mouse]] [[Mammalian embryogenesis|embryo]]nic stem cells with fluorescent marker.]]
[[Image:Human embryonic stem cell colony phase.jpg|right|thumb|300px|Human Embryonic Stem cell colony on mouse embryonic fibroblast feeder layer.]]
'''Editor-in-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.];

==Overview==
'''Stem cells''' are [[Cell (biology)|cells]] found in most, if not all, multi-cellular [[organisms]]. They are characterized by the ability to renew themselves through [[Mitosis|mitotic]] [[cell division]] and [[Cellular differentiation|differentiating]] into a diverse range of specialized cell types. Research in the stem cell field grew out of findings by [[Canada|Canadian]] scientists [[Ernest McCulloch|Ernest A. McCulloch]] and [[James Till|James E. Till]] in the 1960s.<ref>{{cite journal | author = Becker AJ, McCulloch EA, Till JE | title = Cytological demonstration of the clonal nature of spleen colonies derived from transplanted mouse marrow cells | journal = Nature | volume = 197 | pages = 452-4 | year = 1963 | pmid = 13970094 | doi=10.1038/197452a0 }}</ref><ref>{{cite journal | author = Siminovitch L, McCulloch EA, Till JE | title = The distribution of colony-forming cells among spleen colonies | journal = Journal of Cellular and Comparative Physiology | volume = 62| pages = 327-36 | year = 1963 | id = PMID 14086156 | doi = 10.1002/jcp.1030620313 }}</ref>
The two broad types of mammalian stem cells are: '''[[embryonic stem cell]]s''' that are found in [[blastocyst]]s, and '''[[adult stem cell]]s''' that are found in adult tissues. In a developing [[embryo]], stem cells can differentiate into all of the specialized embryonic tissues. In [[adult]] organisms, stem cells and [[progenitor cell]]s act as a repair system for the body, replenishing specialized cells, but also maintain the normal turnover of regenerative organs, such as blood, skin or intestinal tissues.

As stem cells can be grown and transformed into specialized cells with characteristics consistent with cells of various tissues such as muscles or nerves through [[cell culture]], their use in [[Cell therapy|medical therapies]] has been proposed. In particular, embryonic [[cell line]]s, [[autologous]] embryonic stem cells generated through [[therapeutic cloning]], and highly plastic adult stem cells from the [[umbilical cord blood]] or [[bone marrow]] are touted as promising candidates.<ref>{{cite journal | author=Tuch BE | title=Stem cells--a clinical update | journal=Australian family physician | volume=35 | issue=9 | pages=719-21 | year=2006 | pmid=16969445}}</ref>

==Properties of stem cells==
The classical definition of a stem cell requires that it possess two properties:
* '''''Self-renewal''''' - the ability to go through numerous [[cell cycle|cycles]] of [[cell division]] while maintaining the undifferentiated state.
* '''''Potency''''' - the capacity to differentiate into specialized cell types. In the strictest sense, this requires stem cells to be either '''[[totipotency|totipotent]]''' or '''[[pluripotency|pluripotent]]''' - to be able to give rise to any mature cell type, although '''[[multipotent]]''' or '''[[unipotent cell|unipotent]]''' [[progenitor cell]]s are sometimes referred to as stem cells.

===Potency definitions===
[[Image:Stem cells diagram.png|400px|thumb|right|Pluripotent, embryonic stem cells originate as inner mass cells within a blastocyst. The stem cells can become any tissue in the body, excluding a placenta. Only the morula's cells are totipotent, able to become all tissues and a placenta.]]
''Potency'' specifies the differentiation potential (the potential to differentiate into different cell types) of the stem cell.

* '''[[Totipotency|Totipotent]]''' stem cells are produced from the fusion of an egg and sperm cell. Cells produced by the first few divisions of the fertilized egg are also totipotent. These cells can differentiate into embryonic and extraembryonic cell types.

* '''[[Pluripotent]]''' stem cells are the descendants of totipotent cells and can differentiate into cells derived from any of the three [[germ layer]]s.

* '''[[Multipotent]]''' stem cells can produce only cells of a closely related family of cells (e.g. [[hematopoietic stem cell]]s differentiate into red blood cells, white blood cells, platelets, etc.).

* '''[[Unipotency|Unipotent]]''' cells can produce only one cell type, but have the property of self-renewal which distinguishes them from non-stem cells (e.g. muscle stem cells).

===Identifying stem cells===
The practical definition of a stem cell is the functional definition - the ability to regenerate tissue over a lifetime. For example, the gold standard test for a bone marrow or hematopoietic stem cell (HSC) is the ability to transplant one cell and save an individual without HSCs. In this case, a stem cell must be able to produce new blood cells and immune cells over a long term, demonstrating potency. It should also be possible to isolate stem cells from the transplanted individual, which can themselves be transplanted into another individual without HSCs, demonstrating that the stem cell was able to self-renew.

Properties of stem cells can be illustrated ''[[in vitro]]'', using methods such as [[mesenchymal stem cell|clonogenic assay]]s, where single cells are characterized by their ability to differentiate and self-renew.<ref>{{cite journal | author = Friedenstein AJ, Deriglasova UF, Kulagina NN, Panasuk AF, Rudakowa SF, Luria EA, Ruadkow IA | title = Precursors for fibroblasts in different populations of hematopoietic cells as detected by the ''in vitro'' colony assay method | journal = Exp Hematol | volume = 2| issue = 2 | pages = 83-92 | year = 1974| pmid = 4455512 }}</ref><ref>{{cite journal | author = Friedenstein AJ, Gorskaja JF, Kulagina NN | title = Fibroblast precursors in normal and irradiated mouse hematopoietic organs | journal = Exp Hematol | volume = 4 | issue = 5 | pages = 267-74 | year = 1976 | pmid = 976387 }}</ref> As well, stem cells can be isolated based on a distinctive set of cell surface markers. However, ''in vitro'' culture conditions can alter the behavior of cells, making it unclear whether the cells will behave in a similar manner ''[[in vivo]]''. Considerable debate exists whether some proposed adult cell populations are truly stem cells.

==Embryonic stem cells==
{{main|Embryonic stem cell}}

'''Embryonic stem cell lines''' (ES cell lines) are cultures of cells derived from the [[epiblast]] tissue of the [[inner cell mass]] (ICM) of a [[blastocyst]] or earlier [[morula]] stage embryos.<ref>[http://www.foxnews.com/story/0,2933,210078,00.html FOXNews.com - New Stem-Cell Procedure Doesn't Harm Embryos, Company Claims - Biology | Astronomy | Chemistry | Physics]</ref> A blastocyst is an early stage [[embryo]]—approximately four to five days old in humans and consisting of 50–150 cells. ES cells are [[pluripotent]] and give rise during development to all derivatives of the three primary [[germ layer]]s: ectoderm, endoderm and mesoderm. In other words, they can develop into each of the more than 200 cell types of the adult [[human body|body]] when given sufficient and necessary stimulation for a specific cell type. They do not contribute to the extra-embryonic membranes or the [[placenta]].

Nearly all research to date has taken place using mouse embryonic stem cells (mES) or human embryonic stem cells (hES). Both have the essential stem cell characteristics, yet they require very different environments in order to maintain an undifferentiated state. Mouse ES cells are grown on a layer of gelatin and require the presence of Leukemia Inhibitory Factor (LIF).<ref>[https://catalog.invitrogen.com/index.cfm?fuseaction=iProtocol.unitSectionTree&treeNodeID=9E662600C6C10276D8E040E99EA33BB0] , Mouse Embryonic Stem (ES) Cell Culture-Current Protocols in Molecular Biology </ref> Human ES cells are grown on a feeder layer of mouse embryonic [[fibroblasts]] (MEFs) and require the presence of basic Fibroblast Growth Factor (bFGF or FGF-2).<ref>[http://stemcells.nih.gov/research/NIHresearch/scunit/culture.asp], Culture of Human Embryonic Stem Cells (hESC) NIH</ref> Without optimal culture conditions or genetic manipulation,<ref>{{cite journal |author=Chambers I, Colby D, Robertson M, ''et al'' |title=Functional expression cloning of Nanog, a pluripotency sustaining factor in embryonic stem cells |journal=Cell |volume=113 |issue=5 |pages=643-55 |year=2003 |pmid=12787505 |doi=10.1016/S0092-8674(03)00392-1}}</ref> embryonic stem cells will rapidly differentiate.

A human embryonic stem cell is also defined by the presence of several transcription factors and cell surface proteins. The transcription factors [[Oct-4]], [[Nanog]], and [[SOX2]] form the core regulatory network that ensures the suppression of genes that lead to differentiation and the maintenance of pluripotency.<ref>{{cite journal |author=Boyer LA, Lee TI, Cole MF, ''et al'' |title=Core transcriptional regulatory circuitry in human embryonic stem cells |journal=Cell |volume=122 |issue=6 |pages=947-56 |year=2005 |pmid=16153702 |doi=10.1016/j.cell.2005.08.020}}</ref> The cell surface antigens most commonly used to identify hES cells are the glycolipids SSEA3 and SSEA4 and the keratan sulfate antigens Tra-1-60 and Tra-1-81. The molecular definition of a stem cell includes many more proteins and continues to be a topic of research.<ref>{{cite journal |author=Adewumi O, Aflatoonian B, Ahrlund-Richter L, ''et al'' |title=Characterization of human embryonic stem cell lines by the International Stem Cell Initiative |journal=Nat. Biotechnol. |volume=25 |issue=7 |pages=803-16 |year=2007 |pmid=17572666 |doi=10.1038/nbt1318}}</ref>

After twenty years of research, there are no approved treatments or human trials using embryonic stem cells. ES cells, being totipotent cells, require specific signals for correct differentiation - if injected directly into the body, ES cells will differentiate into many different types of cells, causing a [[teratoma]]. Differentiating ES cells into usable cells while avoiding transplant rejection are just a few of the hurdles that embryonic stem cell researchers still face.<ref>{{cite journal |author=Wu DC, Boyd AS, Wood KJ |title=Embryonic stem cell transplantation: potential applicability in cell replacement therapy and regenerative medicine |journal=Front. Biosci. |volume=12 |issue= |pages=4525-35 |year=2007 |pmid=17485394 |doi=10.2741/2407}}</ref> Many nations currently have [[moratoria]] on either ES cell research or the production of new ES cell lines. Because of their combined abilities of unlimited expansion and pluripotency, embryonic stem cells remain a theoretically potential source for regenerative medicine and tissue replacement after injury or disease.

== Adult stem cells ==
{{main|Adult stem cell}}

[[Image:Stem cell division and differentiation.svg|thumb|160px|'''Stem cell division and differentiation.''' A - stem cell; B - progenitor cell; C - differentiated cell; 1 - symmetric stem cell division; 2 - asymmetric stem cell division; 3 - progenitor division; 4 - terminal differentiation]]

The term '''adult stem cell''' refers to any cell which is found in a developed organism that has two properties: the ability to divide and create another cell like itself and also divide and create a cell more differentiated than itself. Also known as '''[[somatic]]''' (from Greek Σωματικóς, "of the body") stem cells and '''germline''' (giving rise to gametes) stem cells, they can be found in children, as well as adults.<ref>{{cite journal |author=Jiang Y, Jahagirdar BN, Reinhardt RL, ''et al'' |title=Pluripotency of mesenchymal stem cells derived from adult marrow |journal=Nature |volume=418 |issue=6893 |pages=41-9 |year=2002 |pmid=12077603 |doi=10.1038/nature00870}}</ref> Pluripotent adult stem cells are rare and generally small in number but can be found in a number of tissues including umbilical cord blood.<ref>{{cite journal |author=Ratajczak MZ, Machalinski B, Wojakowski W, Ratajczak J, Kucia M |title=A hypothesis for an embryonic origin of pluripotent Oct-4(+) stem cells in adult bone marrow and other tissues |journal=Leukemia |volume=21 |issue=5 |pages=860-7 |year=2007 |pmid=17344915 |doi=10.1038/sj.leu.2404630}}</ref> Most adult stem cells are lineage-restricted ([[multipotent]]) and are generally referred to by their tissue origin ([[mesenchymal stem cell]], adipose-derived stem cell, [[endothelial stem cell]], etc.).<ref>{{cite journal |author=Barrilleaux B, Phinney DG, Prockop DJ, O'Connor KC |title=Review: ex vivo engineering of living tissues with adult stem cells |journal=Tissue Eng. |volume=12 |issue=11 |pages=3007-19 |year=2006 |pmid=17518617 |doi=10.1089/ten.2006.12.3007}}</ref><ref>{{cite journal |author=Gimble JM, Katz AJ, Bunnell BA |title=Adipose-derived stem cells for regenerative medicine |journal=Circ. Res. |volume=100 |issue=9 |pages=1249-60 |year=2007 |pmid=17495232 |doi=10.1161/01.RES.0000265074.83288.09}}</ref>

A great deal of adult stem cell research has focused on clarifying their capacity to divide or self-renew indefinitely and their differentiation potential.<ref>{{cite journal | author = Gardner RL | title = Stem cells: potency, plasticity and public perception | journal = Journal of Anatomy | volume = 200 | issue = 3 | pages = 277-82 | year = 2002 | pmid = 12033732 | doi=10.1046/j.1469-7580.2002.00029.x}}</ref> In mice, pluripotent stem cells are directly generated from adult fibroblast cultures.<ref>{{cite journal |author=Takahashi K, Yamanaka S |title=Induction of pluripotent stem cells from mouse embryonic and adult fibroblast cultures by defined factors |journal=Cell |volume=126 |issue=4 |pages=663-76 |year=2006 |pmid=16904174 |doi=10.1016/j.cell.2006.07.024}}</ref>

While embryonic stem cell potential remains untested, adult stem cell treatments have been used for many years to treat successfully leukemia and related bone/blood cancers through bone marrow transplants.<ref>[http://www.ucsfhealth.org/childrens/medical_services/cancer/bmt/treatments/leukemia.html], Bone Marrow Transplant</ref> The use of adult stem cells in research and therapy is not as [[Stem cell controversy|controversial]] as [[embryonic stem cell]]s, because the production of adult stem cells does not require the destruction of an [[embryo]]. Consequently, more US government funding is being provided for adult stem cell research.<ref>[http://www.hhs.gov/news/press/2004pres/20040714b.html],USDHHS Stem Cell FAQ 2004</ref>

==Lineage==
{{main|Stem cell line}}
To ensure self-renewal, stem cells undergo two types of cell division (see ''Stem cell division and differentiation'' diagram). Symmetric division gives rise to two identical daughter cells both endowed with stem cell properties. Asymmetric division, on the other hand, produces only one stem cell and a [[progenitor cell]] with limited self-renewal potential. Progenitors can go through several rounds of cell division before terminally [[cell differentiation|differentiating]] into a mature cell. It is possible that the molecular distinction between symmetric and asymmetric divisions lies in differential segregation of cell membrane proteins (such as [[Receptor (biochemistry)|receptors]]) between the daughter cells.<ref>{{cite journal |author=Beckmann J, Scheitza S, Wernet P, Fischer JC, Giebel B |title=Asymmetric cell division within the human hematopoietic stem and progenitor cell compartment: identification of asymmetrically segregating proteins |journal=Blood |volume=109 |issue=12 |pages=5494-501 |year=2007 |pmid=17332245 |doi=10.1182/blood-2006-11-055921}}</ref>

An alternative theory is that stem cells remain undifferentiated due to environmental cues in their particular niche. Stem cells differentiate when they leave that niche or no longer receive those signals. Studies in ''Drosophila'' germarium have identified the signals dpp and adherins junctions that prevent germarium stem cells from differentiating.<ref>{{cite journal | author = Xie T, Spradling A | title = decapentaplegic is essential for the maintenance and division of germline stem cells in the Drosophila ovary | journal = Cell | volume = 94 | issue = 2 | pages = 251-60 | year = 1998 | pmid = 9695953 | doi = 10.1016/S0092-8674(00)81424-5}}</ref><ref>{{cite journal | author = Song X, Zhu C, Doan C, Xie T | title = Germline stem cells anchored by adherens junctions in the Drosophila ovary niches. | journal = Science | volume = 296 | issue = 5574 | pages = 1855-7 | year = 2002 | pmid = 12052957 | doi=10.1126/science.1069871}}</ref>

{{main|Induced pluripotent stem cell}}
The signals that lead to reprogramming of cells to an embryonic-like state are also being investigated. These signal pathways include several [[transcription factor]]s including the [[oncogene]] [[Myc|c-Myc]]. Initial studies indicate that transformation of mice cells with a combination of these anti-differentiation signals can reverse differentiation and may allow adult cells to become pluripotent.<ref>{{cite journal | author = Takahashi K, Yamanaka S | title = Induction of pluripotent stem cells from mouse embryonic and adult fibroblast cultures by defined factors | journal = Cell | volume = 126 | issue = 4 | pages = 663-76 | year = 2006 | pmid = 16904174 | doi=10.1016/j.cell.2006.07.024}}</ref> However, the need to transform these cells with an oncogene may prevent the use of this approach in therapy.

==Treatments==
{{main|Stem cell treatments}}
Medical researchers believe that stem cell therapy has the potential to dramatically change the treatment of human disease. A number of adult stem cell therapies already exist, particularly [[bone marrow transplant]]s that are used to treat [[leukemia]].<ref>{{cite journal |author=Gahrton G, Björkstrand B |title=Progress in haematopoietic stem cell transplantation for multiple myeloma | journal=J Intern Med |volume=248 |issue=3 |pages=185-201 |year=2000 | pmid= 10971785 | doi=10.1046/j.1365-2796.2000.00706.x}}</ref> In the future, medical researchers anticipate being able to use technologies derived from stem cell research to treat a wider variety of diseases including [[cancer]], [[Parkinson's disease]], [[spinal cord injuries]], and [[muscle]] damage, amongst a number of other impairments and conditions.<ref>{{cite journal |author=Lindvall O |title=Stem cells for cell therapy in Parkinson's disease |journal=Pharmacol Res |volume=47 |issue=4 |pages=279-87 |year=2003 |pmid = 12644384 | doi=10.1016/S1043-6618(03)00037-9}}</ref><ref>{{cite journal |author=Goldman S, Windrem M |title=Cell replacement therapy in neurological disease |journal=Philos Trans R Soc Lond B Biol Sci |volume=361 |issue=1473 |pages=1463-75 |year=2006 |pmid = 16939969 | doi=10.1098/rstb.2006.1886}}</ref>

Stem Cell treatments are becoming more widely available, especially for musculoskeletal, peripheral vascular, and peripheral neuropathy indications. Most clinical applications use autologous stem cells and do not involve manipulation of the cells in between harvesting and implantation [http://www.piedmontpmr.com/adipose-mesenchyme-and-bone-marrow-derived-stem-cell-regenerative-therapy-3]. Several factors influence the selection of autologus stem cell harvest site and type. In those cases where autologous harvest does not make sense then placental derived cells is a viable alternative.

Other uses for stem cell are still surrounded scientific uncertainty but are gaining in acceptance. While stem cells are already used extensively in research some scientists do not see cell therapy as the first goal of the research, but see the investigation of stem cells as a goal worthy in itself.<ref>{{cite web | author = Wade N | title = Some Scientists See Shift in Stem Cell Hopes | publisher = New York Times | url=http://www.nytimes.com/2006/08/14/washington/14stem.html | date=2006-08-14 | accessdate=2006-12-28}}</ref>

==Controversy surrounding human embryonic stem cell research==
{{main|Stem cell controversy}}
There exists a widespread controversy over human embryonic stem cell research that emanates from the techniques used in the creation and usage of stem cells. [[Embryonic stem cell|Human embryonic stem cell]] research is controversial because, with the present state of technology, starting a [[stem cell line]] requires the destruction of a [[embryo|human embryo]] and/or [[therapeutic cloning]]. However, recently, it has been shown in principle that embryonic stem cell lines can be generated using a single-cell biopsy similar to that used in [[preimplantation genetic diagnosis]] that may allow stem cell creation without embryonic destruction.<ref>[http://www.npr.org/templates/story/story.php?storyId=5696557 Firm Creates Stem Cells Without Hurting Embryos : NPR]</ref> It is not the entire field of stem cell research, but the specific field of human embryonic stem cell research that is at the centre of an ethical debate.

Opponents of the research argue that embryonic stem cell technologies are a [[slippery slope]] to [[reproductive cloning]] and can fundamentally devalue human life. Those in the [[pro-life]] movement argue that a human embryo is a human life and is therefore entitled to protection.

Contrarily, supporters of embryonic stem cell research argue that such research should be pursued because the resultant treatments could have significant medical potential. It is also noted that excess embryos created for [[invitro fertilisation|in vitro fertilisation]] could be donated with consent and used for the research.

The ensuing debate has prompted authorities around the world to seek regulatory frameworks and highlighted the fact that stem cell research represents a [[social]] and [[ethical]] challenge.

==Key stem cell research events==
* '''1960s''' - [[Joseph Altman]] and Gopal Das present scientific evidence of adult [[neurogenesis]], ongoing stem cell activity in the brain; their reports contradict [[Santiago Ramón y Cajal|Cajal]]'s "no new neurons" dogma and are largely ignored.
* '''1963''' - [[Ernest McCulloch|McCulloch]] and [[James Till|Till]] illustrate the presence of self-renewing cells in mouse bone marrow.
* '''1968''' - [[Bone marrow]] [[Organ transplant|transplant]] between two siblings successfully treats [[Severe combined immunodeficiency|SCID]].
* '''1978''' - [[Haematopoietic stem cell]]s are discovered in human [[cord blood]].
* '''1981''' - Mouse [[embryonic stem cell]]s are derived from the [[inner cell mass]] by scientists [[Martin Evans]], [[Matthew Kaufman]], and [[Gail R. Martin]]. Gail Martin is attributed for coining the term "Embryonic Stem Cell".
* '''1992''' - Neural stem cells are cultured ''[[in vitro]]'' as neurospheres.
* '''1997''' - Leukemia is shown to originate from a haematopoietic stem cell, the first direct evidence for [[cancer stem cell]]s.
* '''1998''' - [[James Thomson (cell biologist)|James Thomson]] and coworkers derive the first human embryonic [[stem cell line]] at the [[University of Wisconsin-Madison]].
* '''2000s''' - Several reports of [[adult stem cell]] plasticity are published.
* '''2001''' - Scientists at [[Advanced Cell Technology]] clone first early (four- to six-cell stage) human embryos for the purpose of generating embryonic stem cells.<ref>[http://www.sciam.com/article.cfm?articleID=0008B8F9-AC62-1C75-9B81809EC588EF21&pageNumber=4&catID=4 The First Human Cloned Embryo: Scientific American]</ref>
* '''2003''' - Dr. Songtao Shi of NIH discovers new source of adult stem cells in children's primary teeth.<ref>{{cite journal | author=Shostak S | title=(Re)defining stem cells | journal=Bioessays | year=2006 | pages=301-8 | volume=28 | issue=3 | pmid = 16479584 | doi=10.1002/bies.20376}}</ref>
* '''2004-2005''' - Korean researcher [[Hwang Woo-Suk]] claims to have created several human [[embryonic stem cell]] lines from unfertilised human [[oocyte]]s. The lines were later shown to be fabricated.
* '''2005''' - Researchers at [[Kingston University]] in [[England]] claim to have discovered a third category of stem cell, dubbed cord-blood-derived embryonic-like stem cells (CBEs), derived from umbilical cord blood. The group claims these cells are able to differentiate into more types of tissue than adult stem cells.
*'''August 2006''' - Rat '''[[Induced pluripotent stem cell]]s''': the journal [[Cell (journal)|''Cell'']] publishes Kazutoshi Takahashi and Shinya Yamanaka, [http://www.cell.com/content/article/fulltext?uid=PIIS0092867406009767 "Induction of Pluripotent Stem Cells from Mouse Embryonic and Adult Fibroblast Cultures by Defined Factors"].
*'''October 2006''' - Scientists in England create the first ever artificial liver cells using umbilical cord blood stem cells.<ref>[http://discovermagazine.com/2007/mar/good-news-for-alcoholics Good News for Alcoholics | Biotechnology | DISCOVER Magazine]</ref><ref>[http://news.scotsman.com/health.cfm?id=1608072006 Scotsman.com News]</ref>
* '''January 2007''' - Scientists at [[Wake Forest University]] led by Dr. [[Anthony Atala]] and [[Harvard University]] report discovery of a new type of stem cell in [[amniotic fluid]].[http://www.nature.com/nbt/journal/v25/n1/abs/nbt1274.html] This may potentially provide an alternative to embryonic stem cells for use in research and therapy.<ref>[http://www.boston.com/news/local/massachusetts/articles/2007/01/07/amniotic_fluid_yields_stem_cells_harvard_researchers_report/ Amniotic fluid yields stem cells, Harvard researchers report - Boston.com]</ref>
*'''June 2007''' - Research reported by three different groups shows that normal skin cells can be reprogrammed to an embryonic state in mice.<ref>{{cite journal | author=Cyranoski D | title=Simple switch turns cells embryonic | journal=Nature | year=2007 | pages=618-9 | volume=447 | issue=7145 | pmid = 17554270 | doi = 10.1038/447618a }}</ref> In the same month, scientist Shoukhrat Mitalipov reports the first successful creation of a primate stem cell line through [[somatic cell nuclear transfer]]<ref>{{cite journal | author=Mitalipov SM, Zhou Q, Byrne JA, Ji WZ, Norgren RB, Wolf DP | title=Reprogramming following somatic cell nuclear transfer in primates is dependent upon nuclear remodeling | journal=Hum Reprod | year=2007 | pages=2232-42 | volume=22 | issue=8 | pmid = 17562675 | doi = 10.1093/humrep/dem136 }}</ref>
*'''October 2007''' - [[Mario Capecchi]], [[Martin Evans]], and [[Oliver Smithies]] win the 2007 [[Nobel Prize for Physiology or Medicine]] for their work on embryonic stem cells from mice using gene targeting strategies producing genetically engineered mice (known as [[knockout mice]]) for gene research.<ref name = "Nobel 2007">{{cite web
|url = http://nobelprize.org/nobel_prizes/medicine/laureates/2007/index.html
|title = The Nobel Prize in Physiology or Medicine 2007
|accessdaymonth = 8 October|accessyear = 2007|publisher = Nobelprize.org}}</ref>
*'''November 2007''' - Human '''[[Induced pluripotent stem cell]]s''': Two similar papers released by their respective journals prior to formal publication: in [[Cell (journal)|''Cell'']] by [[Kazutoshi Takahashi]] and [[Shinya Yamanaka]], [http://images.cell.com/images/Edimages/Cell/IEPs/3661.pdf "Induction of Pluripotent Stem Cells from Adult Human Fibroblasts by Defined Factors"], and in ''Science'' by Junying Yu, et al., from the research group of [[James Thomson (cell biologist)|James Thomson]], [http://www.sciencemag.org/cgi/content/abstract/1151526 "Induced Pluripotent Stem Cell Lines Derived from Human Somatic Cells"]: pluripotent stem cells generated from mature human fibroblasts. It is possible now to produce a stem cell from almost any other human cell instead of using embryos as needed previously, albeit the risk of [[tumorigenesis]] due to [[c-myc]] and [[Gene therapy#Retroviruses| retroviral gene transfer]] remains to be determined.
*'''January 2008''' - Human embryonic stem cell lines were generated without destruction of the embryo<ref>[http://www.cellstemcell.com/content/article/abstract?uid=PIIS193459090700330X Cell Stem Cell - Chung et al]</ref>
*'''January 2008''' - Development of human cloned blastocysts following [[somatic cell nuclear transfer]] with adult fibroblasts<ref>http://stemcells.alphamedpress.org/cgi/reprint/2007-0252v1.pdf</ref>
*'''February 2008''' - Generation of Pluripotent Stem Cells from Adult Mouse Liver and Stomach: these iPS cells seem to be more similar to embryonic stem cells than the previous developed iPS cells and not tumorigenic, moreover genes that are required for iPS cells do not need to be inserted into specific sites, which encourages the development of non-viral reprogramming techniques. <ref>[http://www.ncbi.nlm.nih.gov/pubmed/18276851?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Generation of Pluripotent Stem Cells from Adult Mo...[Science. 2008] - PubMed Result]</ref><ref>[http://blogs.nature.com/reports/theniche/2008/02/adult_cell_types_besides_skin.html The Niche: Adult cell types besides skin are reprogrammed]</ref>

==Stem cell funding & policy debate in the US==
* '''1993''' - As per the National Institutes of Health Revitalization Act, Congress and President [[Bill Clinton]] give the NIH direct authority to fund human embryo research for the first time.<ref>[http://www.pbs.org/wgbh/nova/sciencenow/dispatches/050413.html Dispatches: The Politics of Stem Cells] [[PBS]]</ref>
* '''1995''' - The U.S. Congress enacts into law an appropriations bill attached to which is the [[Dickey Amendment]] which prohibited federally appropriated funds to be used for research where human embryos would be either created or destroyed. This predates the creation of the first human embryonic stem cell lines.
* '''1999''' - After the creation of the first human embryonic stem cell lines in 1998 by James Thomson of the University of Wisconsin, Harriet Rabb, the top lawyer at the Department of Health and Human Services, releases a legal opinion that would set the course for Clinton Administration policy. Federal funds, obviously, could not be used to derive stem cell lines (because derivation involves embryo destruction). However, she concludes that because human embryonic stem cells "are not a human embryo within the statutory definition," the Dickey-Wicker Amendment does not apply to them. The NIH was therefore free to give federal funding to experiments involving the cells themselves. President Clinton strongly endorses the new guidelines, noting that human embryonic stem cell research promised "potentially staggering benefits." And with the guidelines in place, the NIH begins accepting grant proposals from scientists.<ref>[http://www.pbs.org/wgbh/nova/sciencenow/dispatches/050413.html Dispatches: The Politics of Stem Cells] [[PBS]]</ref>
* '''02 November, 2004''' - [[California]] voters approve [[Proposition 71]], which provides $3 billion in state funds over ten years to human embryonic stem cell research.
* '''2001-2006''' - U.S. [[President]] [[George W. Bush]] signs an executive order which restricts federally-funded stem cell research on embryonic stem cells to the already derived cell lines. He supports federal funding for embryonic stem cell research on the already existing lines of approximately $100 million and $250 million for research on adult and animal stem cells.
* '''5 May, 2006''' - Senator [[Rick Santorum]] introduces bill number S. 2754, or the Alternative Pluripotent Stem Cell Therapies Enhancement Act, into the [[United States Senate|U.S. Senate]].
* '''18 July, 2006''' - The U.S. Senate passes the Stem Cell Research Enhancement Act H.R. 810 and votes down Senator Santorum's S. 2754.
* '''19 July, 2006''' - [[President]] [[George W. Bush]] vetoes H.R. 810 ([[Stem Cell Research Enhancement Act]]), a bill that would have reversed the Gingrich-era appropriations amendment which made it illegal for federal money to be used for research where stem cells are derived from the destruction of an embryo.
* '''07 November, 2006''' - The people of the U.S. state of [[Missouri]] passed [[Missouri Constitutional Amendment 2 (2006)|Amendment 2]], which allows usage of any stem cell research and therapy allowed under federal law, but prohibits human reproductive cloning.<ref>[http://www.sos.mo.gov/elections/2006petitions/ppStemCell.asp Full-text of Missouri Constitution Amendment 2]</ref>
*'''16 February, 2007''' – The California Institute for Regenerative Medicine became the biggest financial backer of human embryonic stem cell research in the United States when they awarded nearly $45 million in research grants.<ref>[http://www.cbsnews.com/stories/2007/02/17/ap/national/mainD8NB4T002.shtml Calif. Awards $45M in Stem Cell Grants] [[Associated Press]], Feb. 17, 2007.</ref>

==Related Chapters==
*[[The American Society for Cell Biology]]
*[[California Institute for Regenerative Medicine]]
*[[Genetics Policy Institute]]
*[[Cancer stem cells]]
*[[Induced pluripotent stem cell]] (iPS Cell)
*[[Odontis]]

==References==
{{reflist|2}}

==External links==

;General
*[http://www.tellmeaboutstemcells.org/ Tell Me About Stem Cells: Quick and simple guide explaining the science behind stem cells]
*[http://stemcells.nih.gov/info/basics/ Stem Cell Basics]
*[http://www.nature.com/stemcells Nature Reports Stem Cells: Introductory material, research advances and debates concerning stem cell research.]
*[http://dels.nas.edu/bls/stemcells/booklet.shtml Understanding Stem Cells: A View of the Science and Issues from the National Academies]
*[http://www.sciam.com/article.cfm?chanID=sa006&articleID=000DFA43-04B1-10AA-84B183414B7F0000 Scientific American Magazine (June 2004 Issue) The Stem Cell Challenge]
*[http://www.sciam.com/article.cfm?chanID=sa006&articleID=000B1BED-0C0A-1498-8C0A83414B7F0000 Scientific American Magazine (July 2006 Issue) Stem Cells: The Real Culprits in Cancer?]
*[http://stemcells.nih.gov/ National Institutes of Health]
*[http://www.scrfi.org Stem Cell Research Forum of India ]
*{{sep entry|stem-cells|Ethics of Stem Cell Research|Andrew Siegel}}

;Peer-reviewed journals
*[http://www.stemcells.com STEM CELLS®]
*[http://www.tandf.co.uk/journals/titles/14653249.asp Cytotherapy]
*[http://www.liebertpub.com/publication.aspx?pub_id=9 Cloning and Stem Cells]
*[http://www.liebertpub.com/publication.aspx?pub_id=125 Stem Cells and Development]
*[http://www.futuremedicine.com/loi/rme Regenerative Medicine]
*[http://www.nature.com/nbt/journal/v25/n1/abs/nbt1274.html Isolation of amniotic stem cell lines with potential for therapy]

{{Stem cells}}
{{embryology}}

[[Category:Stem cells| ]]
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[[Category:Developmental biology]]
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Sports injury

2014-10-04T19:30:56Z

Bobby Schwartz: /* Treatment */

{{SI}}

'''Editor-In-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.]

==Overview==
[[Image:JJInjury.jpg|thumb|250px|left|A Tennis injury]]
[[Image:Women's tackle.jpg|thumb|250px|left|Tackles like this one in Women's Australian rules football can cause injuries.]]
[[Image:RyanMillerhurt.jpg|thumb|250px|left|Ryan Miller of the Buffalo Sabres suffers an ankle sprain.]]
'''Sports injuries''' are [[Injury|injuries]] that occur to athletes in major sporting events. In many cases, these types of injuries are due to [[:Category:Overuse injuries|overuse]] of a part of the body when participating in a certain activity. For example, [[Chondromalacia patellae|runner's knee]] is a painful condition generally associated with [[running]], while [[tennis elbow]] is a form of [[repetitive stress injury]] at the [[Elbow-joint|elbow]], although it does not often occur with tennis players. Other types of injuries can be caused by a hard contact with something. This can often cause a broken bone or torn ligament or tendon

Injuries are a common occurrence in professional sports and most teams have a staff of Athletic Trainers and close connections to the [[Sports medicine|medical community]]. Controversy has arisen at times when teams have made decisions that could threaten a players long-term health for short term gain.

== Classification ==

Sports injuries can be broadly classified as either traumatic or overuse injuries. Traumatic injuries account for most injuries in contact sports such as Football, Rugby, Australian rules football, Gaelic football and American football because of the dynamic and high collision nature of these sports. These injuries range from bruises and muscle strains, to fractures and head injuries.

A bruise or [[contusion]] is damage to small blood vessels which causes bleeding within the tissues. A [[muscle strain]] is a small tear of muscle fibers and a [[ligament]] [[sprain]] is a small tear of ligament tissue. The body’s response to these sports injuries is the same in the initial five day period immediately following the traumatic incident - inflammation.

== Signs and symptoms ==
Inflammation is characterized by pain, localized swelling, heat, redness and a loss of function.

== Mechanism ==

All of these traumatic injuries cause damage to the cells that make up the soft tissues. The dead and damaged cells release chemicals, which initiate an inflammatory response. Small blood vessels are damaged and opened up, producing bleeding within the tissue. In the body’s normal reaction, a small blood clot is formed in order to stop this bleeding and from this clot special cells (called fibroblasts) begin the healing process by laying down scar tissue.

The inflammatory stage is therefore the first phase of healing. However, too much of an inflammatory response in the early stage can mean that the healing process takes longer and a return to activity is delayed. The sports injury treatments are intended to minimize the inflammatory phase of an injury, so that the overall healing process is accelerated.
==Diagnosis==

Diagnosing the underlying cause of sports injuries is usually done by a [[medical doctor]], osteopathic physican, physiotherapist (physical therapist) or by a chiropractor.

===History and Physical Examination===
A thorough medical history and physical exam can usually identify any dangerous conditions or family history that may be associated with the pain. The patient describes the onset, site, and severity of the pain; duration of symptoms and any limitations in movement; and history of previous episodes or any health conditions that might be related to the pain. The physician will examine the back and conduct neurologic tests to determine the cause of pain and appropriate treatment. Blood tests may also be ordered. Imaging tests may be necessary to diagnose tumors or other possible sources of the pain.

A variety of diagnostic methods are available to confirm the presence of sports injuries:

===X-Ray===
[[X-ray]] imaging includes conventional and enhanced methods that can help diagnose the cause and site of pain. A conventional x-ray, often the first imaging technique used, looks for broken bones or an injured vertebra. A technician passes a concentrated beam of low-dose ionized radiation through the back and takes pictures that, within minutes, clearly show the bony structure and any misalignment or fractures. Tissue masses such as injured muscles and ligaments or painful conditions such as a bulging disc are not visible on conventional x-rays. This fast, noninvasive, painless procedure is usually performed in a doctor’s office or at a clinic.

===Ultrasound imaging===
[[Diagnostic musculoskeletal ultrasound]] imaging, also called ultrasound scanning or sonography, uses high-frequency sound waves to obtain images inside the body. The sound wave echoes are recorded and displayed as a real-time visual image. Ultrasound imaging can show tears in ligaments, muscles, tendons, and other soft tissue masses in the limbs, parvertebral soft tissues and to image various internal organs.

===Electrodiagnostic procedures===
Electrodiagnostic procedures include electromyography ([[EMG]]), nerve conduction studies, and evoked potential (EP) studies. EMG assesses the electrical activity in a nerve and can detect if muscle weakness results from injury or a problem with the nerves that control the muscles. Very fine needles are inserted in muscles to measure electrical activity transmitted from the brain or spinal cord to a particular area of the body. With nerve conduction studies the doctor uses two sets of electrodes (similar to those used during an electrocardiogram) that are placed on the skin over the muscles. The first set gives the patient a mild shock to stimulate the nerve that runs to a particular muscle. The second set of electrodes is used to make a recording of the nerve’s electrical signals, and from this information the doctor can determine if there is nerve damage. EP tests also involve two sets of electrodes — one set to stimulate a sensory nerve and the other set on the scalp to record the speed of nerve signal transmissions to the brain.

===Computerized tomography===
]]Computerized tomography]](CT) is a quick and painless process used when internal organ or spinal pathology is suspected. X-rays are passed through the body at various angles and are detected by a computerized scanner to produce two-dimensional slices (1 mm each) of internal structures under study. This diagnostic exam is generally conducted at an imaging center or hospital.

===Magnetic resonance imaging===
[[Magnetic resonance imaging]] (MRI) is used to evaluate for bone degeneration or injury or disease in tissues and nerves, muscles, ligaments, and blood vessels. MRI scanning equipment creates a magnetic field around the body strong enough to temporarily realign water molecules in the tissues. Radio waves are then passed through the body to detect the “relaxation” of the molecules back to a random alignment and trigger a resonance signal at different angles within the body. A computer processes this resonance into either a three-dimensional picture or a two-dimensional “slice” of the tissue being scanned, and differentiates between bone, soft tissues and fluid-filled spaces by their water content and structural properties. This noninvasive procedure is often used to identify a condition requiring prompt surgical treatment.

===Bone scans===
[[Bone scan]] is used to diagnose and monitor infection, fracture, or disorders in the bone. A small amount of radioactive material is injected into the bloodstream and will collect in the bones, particularly in areas with some abnormality. Scanner-generated images are sent to a computer to identify specific areas of irregular bone metabolism or abnormal blood flow, as well as to measure levels of joint disease.

===Thermography===
[[Thermography]] involves the use of infrared sensing devices to measure small temperature changes between the two sides of the body or the temperature of a specific organ. Thermography may be used to detect the presence or absence of sympathetic nerve involvement (unusual pain, swelling and weather sensitivity.

== Treatment ==
For the vast majority of patients, sports injuries can be treated with non-surgical care. More recently regenerative techniques such as [[Stem cell|Stem cell]], [[Platelet rich plasma|Platelet rich plasma]], and [[Prolotherapy|Prolotherapy]] have become more readily available for those seeing aggressive non-surgical care. For those with acute, short-term pain, certain home remedies may be effective.

Sports injuries can be treated and managed by using the P.R.I.C.E.R... DR. ABC and T.O.T.A.P.S regimes:
* '''P''' - Protect
* '''R''' - Rest
* '''I''' - Ice
* '''C''' - Compression
* '''E''' - Elevation
* '''R''' - Referral

* '''D''' - Danger
* '''R''' - Response
* '''A''' - Airway
* '''B''' - Breathing
* '''C''' - Circulation

* '''T''' - Talk
* '''O''' - Observe
* '''T''' - Touch
* '''A''' - Active movement
* '''P''' - Passive movement
* '''S''' - Skills test

The inflammatory stage typically lasts around 5 days and all treatment during this time is designed to address the cardinal signs of inflammation – pain, swelling, redness, heat and a loss of function.

Most sports injuries can be treated without surgery. Treatment involves using analgesics, reducing inflammation, restoring proper function and strength, and preventing recurrence of the injury. Most patients recover without residual functional loss. Patients should contact a doctor if there is not a noticeable reduction in pain and inflammation after 72 hours of self-care.

Although ice and heat (the use of cold and hot compresses) have never been scientifically proven to quickly resolve injury, compresses may help reduce pain and inflammation and allow greater mobility for some individuals.<ref name="pmid16437495">{{cite journal |author=French SD, Cameron M, Walker BF, Reggars JW, Esterman AJ |title=Superficial heat or cold for low back pain |journal=Cochrane Database Syst Rev |volume= |issue=1 |pages=CD004750 |year=2006 |pmid=16437495 |doi=10.1002/14651858.CD004750.pub2 |url=}}</ref> As soon as possible following trauma, patients should apply a cold pack or a cold compress (such as a bag of ice or bag of frozen vegetables wrapped in a towel) to the tender spot several times a day for up to 20 minutes. After 2 to 3 days of cold treatment, they should then apply heat (such as a heating lamp or hot pad) for brief periods to relax muscles and increase blood flow. Warm baths may also help relax muscles. Patients should avoid sleeping on a heating pad, which can cause burns and lead to additional tissue damage.

Exercise may be the most effective way to speed recovery and help strengthen muscles. Maintaining and building muscle strength is particularly important for persons with skeletal irregularities. Doctors and physical therapists can provide a list of gentle exercises that help keep muscles moving and speed the recovery process. A routine of healthy activities may include stretching exercises, swimming, walking, and movement therapy to improve coordination and develop proper posture and muscle balance. Yoga is another way to gently stretch muscles and ease pain. Any mild discomfort felt at the start of these exercises should disappear as muscles become stronger. But if pain is more than mild and lasts more than 15 minutes during exercise, patients should stop exercising and contact a doctor.

Medications are often used to treat acute and chronic pain. Effective pain relief may involve a combination of prescription drugs and over-the-counter remedies. Patients should always check with a doctor before taking drugs for pain relief. Certain medicines, even those sold over the counter, are unsafe during pregnancy, may conflict with other medications, may cause side effects including drowsiness, or may lead to liver damage.

* Over-the-counter analgesics, including nonsteroidal anti-inflammatory drugs are taken orally to reduce stiffness, swelling, and inflammation and to ease mild to moderate low back pain. Counter-irritants applied topically to the skin as a cream or spray stimulate the nerve endings in the skin to provide feelings of warmth or cold and dull the sense of pain. Topical analgesics can also reduce inflammation and stimulate blood flow. Many of these compounds contain salicylates, the same ingredient found in oral pain medications containing aspirin.
* [[Muscle relaxant]]s for acute<ref name="pmid16973062">{{cite journal |author=Koes B, van Tulder M |title=Low back pain (acute) |journal=Clin Evid |volume= |issue=15 |pages=1619–33 |year=2006 |month=June |pmid=16973062 |doi= |url=}}</ref> or chronic<ref name="pmid16973063">{{cite journal |author=van Tulder M, Koes B |title=Low back pain (chronic) |journal=Clin Evid |volume= |issue=15 |pages=1634–53 |year=2006 |month=June |pmid=16973063 |doi= |url=}}</ref> pain.
* Opioids such as codeine, oxycodone, hydrocodone, and morphine are often prescribed to manage severe acute pain but should be used only for a short period of time and under a physician’s supervision. Side effects can include drowsiness, decreased reaction time, impaired judgment, and potential for addiction. Many specialists are convinced that chronic use of these drugs is detrimental to the patient, adding to depression and even increasing pain. <ref name="pmid17636781">{{cite journal |author=Deshpande A, Furlan A, Mailis-Gagnon A, Atlas S, Turk D |title=Opioids for chronic low-back pain |journal=Cochrane database of systematic reviews (Online) |volume= |issue=3 |pages=CD004959 |year=2007 |pmid=17636781 |doi=10.1002/14651858.CD004959.pub3}}</ref>

Spinal manipulation is literally a "hands-on" approach in which professionally licensed specialists (doctors of chiropractic care) use leverage and a series of exercises to adjust spinal structures and restore back mobility.<ref name="pmid16973062"/> or chronic<ref name="pmid16973063"/> pain. A [[clinical prediction rule]] can guide who is most likely to respond to manipulation.<ref name="pmid15611489">{{cite journal |author=Childs JD, Fritz JM, Flynn TW, ''et al'' |title=A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study |journal=Ann. Intern. Med. |volume=141 |issue=12 |pages=920-8 |year=2004 |pmid=15611489 |doi=}} [http://www.annals.org/cgi/content/full/141/12/920/T1 Summary of the rule]</ref>

When pain does not respond to more conventional approaches, patients may consider the following options:

Acupuncture<ref name="pmid16973063"/> involves the insertion of needles the width of a human hair along precise points throughout the body. Practitioners believe this process triggers the release of naturally occurring painkilling molecules called peptides and keeps the body’s normal flow of energy unblocked. Clinical studies are measuring the effectiveness of acupuncture in comparison to more conventional procedures in the treatment of acute low back pain.<ref name="pmid17893311">{{cite journal |author=Haake M, Müller HH, Schade-Brittinger C, ''et al'' |title=German Acupuncture Trials (GERAC) for Chronic Low Back Pain: Randomized, Multicenter, Blinded, Parallel-Group Trial With 3 Groups |journal=Arch. Intern. Med. |volume=167 |issue=17 |pages=1892–8 |year=2007 |pmid=17893311 |doi=10.1001/archinte.167.17.1892}}</ref>

Interventional therapy can ease pain by blocking nerve conduction between specific areas of the body and the brain. Approaches range from injections of local anesthetics, steroids or proliferative agents ([[Prolotherapy]]) into affected soft tissues, joints, or nerve roots. Chronic use of steroid injections may lead to increased functional impairment.

Traction involves the use of weights to apply constant or intermittent force to gradually “pull” the skeletal structure into better alignment. Traction is not recommended for treating acute low back symptoms.

Transcutaneous electrical nerve stimulation (TENS) is administered by a battery-powered device that sends mild electric pulses along nerve fibers to block pain signals to the brain. Small electrodes placed on the skin at or near the site of pain generate nerve impulses that block incoming pain signals from the peripheral nerves. TENS may also help stimulate the brain’s production of endorphins (chemicals that have pain-relieving properties).

* [[Muscle Energy Technique]] (MET) may help (PMID 14524509 - small study)<ref name="pmid14524509"> {{cite journal |author=Wilson E, Payton O, Donegan-Shoaf L, Dec K |title=Muscle energy technique in patients with acute low back pain: a pilot clinical trial |journal=J Orthop Sports Phys Ther |volume=33 |issue=9 |pages=502–12 |year=2003 |month=September |pmid=14524509 |doi= |url=}}</ref>

Ultrasound is a noninvasive therapy used to warm the body’s internal tissues, which causes muscles to relax. Sound waves pass through the skin and into the injured muscles and other soft tissues.

[[Image:HyperbaricDive_Chamber_1.jpg|thumb|250px|left|Portable Mild Hyperbaric Chamber 40" diameter]] Although not proven some professional athletes use hyperbaric chambers to speed healing. Hines Ward of the Steelers sent his personal hyperbaric chamber,(similar to the one pictured), to his hotel to sleep in believing it would help heal his sprained medial collateral ligament he suffered in their playoff win against the Ravens. Hines went on to play in Super Bowl XLIII.

In the most serious cases, when the condition does not respond to other therapies, surgery can be an affective approach for serious musculoskeletal injuries. Some surgical procedures may be performed in a doctor’s office under local anesthesia ([http://www.piedmontpmr.com/ultrasound-guided-percutaneous-tenotomy-3 such as ultrasound guided percutaneous tenotomy]), some are performed as an outpatient (such as arthroscopy) and others require hospitalization. It may be months following surgery before the patient is fully healed, and he or she may suffer permanent loss of flexibility.

== Prevention ==
A comprehensive [[Warming up|warm-up]] programme has been found to decrease injuries in soccer.<ref>{{cite journal |author=Soligard T, Myklebust G, Steffen K, ''et al'' |title=Comprehensive warm-up programme to prevent injuries in young female footballers: cluster randomised controlled trial |journal=BMJ |volume=337 |issue= |pages=a2469 |year=2008 |pmid=19066253 |doi=10.1136/bmj.a2469 |url=}}</ref> Many athletes will partake in HGH Treatment for Athletic Enhancement as a way to prevent injuries.

[[Compression sportswear]] is becoming very popular with both professional and amateur athletes. These garments are thought to both reduce the risk of muscle injury and speed up muscle recovery.
==References==
{{reflist|colwidth=30em}}

==See also==
*[[Concussion grading systems]]
*[[Sports medicine]]
*[[Prolotherapy]]
*[[Diagnostic musculoskeletal ultrasonography]]

== External links ==
* [http://www.sportsinjuryinfo.com/ Sports Injury Info ]
* [http://www.mindef.gov.sg/imindef/mindef_websites/topics/elifestyle/articles/exercise_and_physical/sports_injuries.html Videos on Prevention and Management of Sports Injuries]
*[http://www.nasm.org NASM]
* [http://sportsvl.com/rest/sportsinjuries.htm Sport injuries links]
*[http://wehelpwhathurts.homestead.com/healthsportsandfitness.html Empowering The Athelete in Motion]

[[Category:Injuries]]
[[Category:Sports medicine]]

[[ja:スポーツ障害]]
[[no:Idrettsskade]]
[[sv:Idrottsskada]]

{{WH}}
{{WS}}

Sports injury

2014-10-04T19:29:26Z

Bobby Schwartz: /* Treatment */

{{SI}}

'''Editor-In-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.]

==Overview==
[[Image:JJInjury.jpg|thumb|250px|left|A Tennis injury]]
[[Image:Women's tackle.jpg|thumb|250px|left|Tackles like this one in Women's Australian rules football can cause injuries.]]
[[Image:RyanMillerhurt.jpg|thumb|250px|left|Ryan Miller of the Buffalo Sabres suffers an ankle sprain.]]
'''Sports injuries''' are [[Injury|injuries]] that occur to athletes in major sporting events. In many cases, these types of injuries are due to [[:Category:Overuse injuries|overuse]] of a part of the body when participating in a certain activity. For example, [[Chondromalacia patellae|runner's knee]] is a painful condition generally associated with [[running]], while [[tennis elbow]] is a form of [[repetitive stress injury]] at the [[Elbow-joint|elbow]], although it does not often occur with tennis players. Other types of injuries can be caused by a hard contact with something. This can often cause a broken bone or torn ligament or tendon

Injuries are a common occurrence in professional sports and most teams have a staff of Athletic Trainers and close connections to the [[Sports medicine|medical community]]. Controversy has arisen at times when teams have made decisions that could threaten a players long-term health for short term gain.

== Classification ==

Sports injuries can be broadly classified as either traumatic or overuse injuries. Traumatic injuries account for most injuries in contact sports such as Football, Rugby, Australian rules football, Gaelic football and American football because of the dynamic and high collision nature of these sports. These injuries range from bruises and muscle strains, to fractures and head injuries.

A bruise or [[contusion]] is damage to small blood vessels which causes bleeding within the tissues. A [[muscle strain]] is a small tear of muscle fibers and a [[ligament]] [[sprain]] is a small tear of ligament tissue. The body’s response to these sports injuries is the same in the initial five day period immediately following the traumatic incident - inflammation.

== Signs and symptoms ==
Inflammation is characterized by pain, localized swelling, heat, redness and a loss of function.

== Mechanism ==

All of these traumatic injuries cause damage to the cells that make up the soft tissues. The dead and damaged cells release chemicals, which initiate an inflammatory response. Small blood vessels are damaged and opened up, producing bleeding within the tissue. In the body’s normal reaction, a small blood clot is formed in order to stop this bleeding and from this clot special cells (called fibroblasts) begin the healing process by laying down scar tissue.

The inflammatory stage is therefore the first phase of healing. However, too much of an inflammatory response in the early stage can mean that the healing process takes longer and a return to activity is delayed. The sports injury treatments are intended to minimize the inflammatory phase of an injury, so that the overall healing process is accelerated.
==Diagnosis==

Diagnosing the underlying cause of sports injuries is usually done by a [[medical doctor]], osteopathic physican, physiotherapist (physical therapist) or by a chiropractor.

===History and Physical Examination===
A thorough medical history and physical exam can usually identify any dangerous conditions or family history that may be associated with the pain. The patient describes the onset, site, and severity of the pain; duration of symptoms and any limitations in movement; and history of previous episodes or any health conditions that might be related to the pain. The physician will examine the back and conduct neurologic tests to determine the cause of pain and appropriate treatment. Blood tests may also be ordered. Imaging tests may be necessary to diagnose tumors or other possible sources of the pain.

A variety of diagnostic methods are available to confirm the presence of sports injuries:

===X-Ray===
[[X-ray]] imaging includes conventional and enhanced methods that can help diagnose the cause and site of pain. A conventional x-ray, often the first imaging technique used, looks for broken bones or an injured vertebra. A technician passes a concentrated beam of low-dose ionized radiation through the back and takes pictures that, within minutes, clearly show the bony structure and any misalignment or fractures. Tissue masses such as injured muscles and ligaments or painful conditions such as a bulging disc are not visible on conventional x-rays. This fast, noninvasive, painless procedure is usually performed in a doctor’s office or at a clinic.

===Ultrasound imaging===
[[Diagnostic musculoskeletal ultrasound]] imaging, also called ultrasound scanning or sonography, uses high-frequency sound waves to obtain images inside the body. The sound wave echoes are recorded and displayed as a real-time visual image. Ultrasound imaging can show tears in ligaments, muscles, tendons, and other soft tissue masses in the limbs, parvertebral soft tissues and to image various internal organs.

===Electrodiagnostic procedures===
Electrodiagnostic procedures include electromyography ([[EMG]]), nerve conduction studies, and evoked potential (EP) studies. EMG assesses the electrical activity in a nerve and can detect if muscle weakness results from injury or a problem with the nerves that control the muscles. Very fine needles are inserted in muscles to measure electrical activity transmitted from the brain or spinal cord to a particular area of the body. With nerve conduction studies the doctor uses two sets of electrodes (similar to those used during an electrocardiogram) that are placed on the skin over the muscles. The first set gives the patient a mild shock to stimulate the nerve that runs to a particular muscle. The second set of electrodes is used to make a recording of the nerve’s electrical signals, and from this information the doctor can determine if there is nerve damage. EP tests also involve two sets of electrodes — one set to stimulate a sensory nerve and the other set on the scalp to record the speed of nerve signal transmissions to the brain.

===Computerized tomography===
]]Computerized tomography]](CT) is a quick and painless process used when internal organ or spinal pathology is suspected. X-rays are passed through the body at various angles and are detected by a computerized scanner to produce two-dimensional slices (1 mm each) of internal structures under study. This diagnostic exam is generally conducted at an imaging center or hospital.

===Magnetic resonance imaging===
[[Magnetic resonance imaging]] (MRI) is used to evaluate for bone degeneration or injury or disease in tissues and nerves, muscles, ligaments, and blood vessels. MRI scanning equipment creates a magnetic field around the body strong enough to temporarily realign water molecules in the tissues. Radio waves are then passed through the body to detect the “relaxation” of the molecules back to a random alignment and trigger a resonance signal at different angles within the body. A computer processes this resonance into either a three-dimensional picture or a two-dimensional “slice” of the tissue being scanned, and differentiates between bone, soft tissues and fluid-filled spaces by their water content and structural properties. This noninvasive procedure is often used to identify a condition requiring prompt surgical treatment.

===Bone scans===
[[Bone scan]] is used to diagnose and monitor infection, fracture, or disorders in the bone. A small amount of radioactive material is injected into the bloodstream and will collect in the bones, particularly in areas with some abnormality. Scanner-generated images are sent to a computer to identify specific areas of irregular bone metabolism or abnormal blood flow, as well as to measure levels of joint disease.

===Thermography===
[[Thermography]] involves the use of infrared sensing devices to measure small temperature changes between the two sides of the body or the temperature of a specific organ. Thermography may be used to detect the presence or absence of sympathetic nerve involvement (unusual pain, swelling and weather sensitivity.

== Treatment ==
For the vast majority of patients, sports injuries can be treated with non-surgical care. More recently regenerative techniques such as [[Stem cell|Stem cell]] | [[Platelet rich plasma|Platelet rich plasms]] | and [[Prolotherapy|Prolotherapy]] have become more readily available for those seeing aggressive non-surgical care.

For those with acute, short-term pain, certain home remedies may be effective.
Sports injuries can be treated and managed by using the P.R.I.C.E.R... DR. ABC and T.O.T.A.P.S regimes:
* '''P''' - Protect
* '''R''' - Rest
* '''I''' - Ice
* '''C''' - Compression
* '''E''' - Elevation
* '''R''' - Referral

* '''D''' - Danger
* '''R''' - Response
* '''A''' - Airway
* '''B''' - Breathing
* '''C''' - Circulation

* '''T''' - Talk
* '''O''' - Observe
* '''T''' - Touch
* '''A''' - Active movement
* '''P''' - Passive movement
* '''S''' - Skills test

The inflammatory stage typically lasts around 5 days and all treatment during this time is designed to address the cardinal signs of inflammation – pain, swelling, redness, heat and a loss of function.

Most sports injuries can be treated without surgery. Treatment involves using analgesics, reducing inflammation, restoring proper function and strength, and preventing recurrence of the injury. Most patients recover without residual functional loss. Patients should contact a doctor if there is not a noticeable reduction in pain and inflammation after 72 hours of self-care.

Although ice and heat (the use of cold and hot compresses) have never been scientifically proven to quickly resolve injury, compresses may help reduce pain and inflammation and allow greater mobility for some individuals.<ref name="pmid16437495">{{cite journal |author=French SD, Cameron M, Walker BF, Reggars JW, Esterman AJ |title=Superficial heat or cold for low back pain |journal=Cochrane Database Syst Rev |volume= |issue=1 |pages=CD004750 |year=2006 |pmid=16437495 |doi=10.1002/14651858.CD004750.pub2 |url=}}</ref> As soon as possible following trauma, patients should apply a cold pack or a cold compress (such as a bag of ice or bag of frozen vegetables wrapped in a towel) to the tender spot several times a day for up to 20 minutes. After 2 to 3 days of cold treatment, they should then apply heat (such as a heating lamp or hot pad) for brief periods to relax muscles and increase blood flow. Warm baths may also help relax muscles. Patients should avoid sleeping on a heating pad, which can cause burns and lead to additional tissue damage.

Exercise may be the most effective way to speed recovery and help strengthen muscles. Maintaining and building muscle strength is particularly important for persons with skeletal irregularities. Doctors and physical therapists can provide a list of gentle exercises that help keep muscles moving and speed the recovery process. A routine of healthy activities may include stretching exercises, swimming, walking, and movement therapy to improve coordination and develop proper posture and muscle balance. Yoga is another way to gently stretch muscles and ease pain. Any mild discomfort felt at the start of these exercises should disappear as muscles become stronger. But if pain is more than mild and lasts more than 15 minutes during exercise, patients should stop exercising and contact a doctor.

Medications are often used to treat acute and chronic pain. Effective pain relief may involve a combination of prescription drugs and over-the-counter remedies. Patients should always check with a doctor before taking drugs for pain relief. Certain medicines, even those sold over the counter, are unsafe during pregnancy, may conflict with other medications, may cause side effects including drowsiness, or may lead to liver damage.

* Over-the-counter analgesics, including nonsteroidal anti-inflammatory drugs are taken orally to reduce stiffness, swelling, and inflammation and to ease mild to moderate low back pain. Counter-irritants applied topically to the skin as a cream or spray stimulate the nerve endings in the skin to provide feelings of warmth or cold and dull the sense of pain. Topical analgesics can also reduce inflammation and stimulate blood flow. Many of these compounds contain salicylates, the same ingredient found in oral pain medications containing aspirin.
* [[Muscle relaxant]]s for acute<ref name="pmid16973062">{{cite journal |author=Koes B, van Tulder M |title=Low back pain (acute) |journal=Clin Evid |volume= |issue=15 |pages=1619–33 |year=2006 |month=June |pmid=16973062 |doi= |url=}}</ref> or chronic<ref name="pmid16973063">{{cite journal |author=van Tulder M, Koes B |title=Low back pain (chronic) |journal=Clin Evid |volume= |issue=15 |pages=1634–53 |year=2006 |month=June |pmid=16973063 |doi= |url=}}</ref> pain.
* Opioids such as codeine, oxycodone, hydrocodone, and morphine are often prescribed to manage severe acute pain but should be used only for a short period of time and under a physician’s supervision. Side effects can include drowsiness, decreased reaction time, impaired judgment, and potential for addiction. Many specialists are convinced that chronic use of these drugs is detrimental to the patient, adding to depression and even increasing pain. <ref name="pmid17636781">{{cite journal |author=Deshpande A, Furlan A, Mailis-Gagnon A, Atlas S, Turk D |title=Opioids for chronic low-back pain |journal=Cochrane database of systematic reviews (Online) |volume= |issue=3 |pages=CD004959 |year=2007 |pmid=17636781 |doi=10.1002/14651858.CD004959.pub3}}</ref>

Spinal manipulation is literally a "hands-on" approach in which professionally licensed specialists (doctors of chiropractic care) use leverage and a series of exercises to adjust spinal structures and restore back mobility.<ref name="pmid16973062"/> or chronic<ref name="pmid16973063"/> pain. A [[clinical prediction rule]] can guide who is most likely to respond to manipulation.<ref name="pmid15611489">{{cite journal |author=Childs JD, Fritz JM, Flynn TW, ''et al'' |title=A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study |journal=Ann. Intern. Med. |volume=141 |issue=12 |pages=920-8 |year=2004 |pmid=15611489 |doi=}} [http://www.annals.org/cgi/content/full/141/12/920/T1 Summary of the rule]</ref>

When pain does not respond to more conventional approaches, patients may consider the following options:

Acupuncture<ref name="pmid16973063"/> involves the insertion of needles the width of a human hair along precise points throughout the body. Practitioners believe this process triggers the release of naturally occurring painkilling molecules called peptides and keeps the body’s normal flow of energy unblocked. Clinical studies are measuring the effectiveness of acupuncture in comparison to more conventional procedures in the treatment of acute low back pain.<ref name="pmid17893311">{{cite journal |author=Haake M, Müller HH, Schade-Brittinger C, ''et al'' |title=German Acupuncture Trials (GERAC) for Chronic Low Back Pain: Randomized, Multicenter, Blinded, Parallel-Group Trial With 3 Groups |journal=Arch. Intern. Med. |volume=167 |issue=17 |pages=1892–8 |year=2007 |pmid=17893311 |doi=10.1001/archinte.167.17.1892}}</ref>

Interventional therapy can ease pain by blocking nerve conduction between specific areas of the body and the brain. Approaches range from injections of local anesthetics, steroids or proliferative agents ([[Prolotherapy]]) into affected soft tissues, joints, or nerve roots. Chronic use of steroid injections may lead to increased functional impairment.

Traction involves the use of weights to apply constant or intermittent force to gradually “pull” the skeletal structure into better alignment. Traction is not recommended for treating acute low back symptoms.

Transcutaneous electrical nerve stimulation (TENS) is administered by a battery-powered device that sends mild electric pulses along nerve fibers to block pain signals to the brain. Small electrodes placed on the skin at or near the site of pain generate nerve impulses that block incoming pain signals from the peripheral nerves. TENS may also help stimulate the brain’s production of endorphins (chemicals that have pain-relieving properties).

* [[Muscle Energy Technique]] (MET) may help (PMID 14524509 - small study)<ref name="pmid14524509"> {{cite journal |author=Wilson E, Payton O, Donegan-Shoaf L, Dec K |title=Muscle energy technique in patients with acute low back pain: a pilot clinical trial |journal=J Orthop Sports Phys Ther |volume=33 |issue=9 |pages=502–12 |year=2003 |month=September |pmid=14524509 |doi= |url=}}</ref>

Ultrasound is a noninvasive therapy used to warm the body’s internal tissues, which causes muscles to relax. Sound waves pass through the skin and into the injured muscles and other soft tissues.

[[Image:HyperbaricDive_Chamber_1.jpg|thumb|250px|left|Portable Mild Hyperbaric Chamber 40" diameter]] Although not proven some professional athletes use hyperbaric chambers to speed healing. Hines Ward of the Steelers sent his personal hyperbaric chamber,(similar to the one pictured), to his hotel to sleep in believing it would help heal his sprained medial collateral ligament he suffered in their playoff win against the Ravens. Hines went on to play in Super Bowl XLIII.

In the most serious cases, when the condition does not respond to other therapies, surgery can be an affective approach for serious musculoskeletal injuries. Some surgical procedures may be performed in a doctor’s office under local anesthesia ([http://www.piedmontpmr.com/ultrasound-guided-percutaneous-tenotomy-3 such as ultrasound guided percutaneous tenotomy]), some are performed as an outpatient (such as arthroscopy) and others require hospitalization. It may be months following surgery before the patient is fully healed, and he or she may suffer permanent loss of flexibility.

== Prevention ==
A comprehensive [[Warming up|warm-up]] programme has been found to decrease injuries in soccer.<ref>{{cite journal |author=Soligard T, Myklebust G, Steffen K, ''et al'' |title=Comprehensive warm-up programme to prevent injuries in young female footballers: cluster randomised controlled trial |journal=BMJ |volume=337 |issue= |pages=a2469 |year=2008 |pmid=19066253 |doi=10.1136/bmj.a2469 |url=}}</ref> Many athletes will partake in HGH Treatment for Athletic Enhancement as a way to prevent injuries.

[[Compression sportswear]] is becoming very popular with both professional and amateur athletes. These garments are thought to both reduce the risk of muscle injury and speed up muscle recovery.
==References==
{{reflist|colwidth=30em}}

==See also==
*[[Concussion grading systems]]
*[[Sports medicine]]
*[[Prolotherapy]]
*[[Diagnostic musculoskeletal ultrasonography]]

== External links ==
* [http://www.sportsinjuryinfo.com/ Sports Injury Info ]
* [http://www.mindef.gov.sg/imindef/mindef_websites/topics/elifestyle/articles/exercise_and_physical/sports_injuries.html Videos on Prevention and Management of Sports Injuries]
*[http://www.nasm.org NASM]
* [http://sportsvl.com/rest/sportsinjuries.htm Sport injuries links]
*[http://wehelpwhathurts.homestead.com/healthsportsandfitness.html Empowering The Athelete in Motion]

[[Category:Injuries]]
[[Category:Sports medicine]]

[[ja:スポーツ障害]]
[[no:Idrettsskade]]
[[sv:Idrottsskada]]

{{WH}}
{{WS}}

Prolotherapy

2014-10-04T19:24:51Z

Bobby Schwartz: /* Overview */

{{SI}}

'''Editors-In-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.]; Dean Reeves, M.D., Clinical assistant professor at the University of Kansas Medical School, Dept of Physical Medicine and Rehabilitation; Felix Linetsky, M.D., Clinical Associate Professor, Department of Osteopathic Principles and Practice, Nova Southeastern College of Osteopathic Medicine [mailto:flinetsky@me.com]

{{EJ}}

==Overview==
'''Prolotherapy''' ("Proliferative Injection Therapy") involves injecting an otherwise non-[[Pharmacology|pharmacological]] and non-[[Biological activity|active]] proliferant or irritant solution into the body, generally in the region of [[tendons]] or [[ligaments]] for the purpose of strengthening weakened connective tissue and alleviating musculoskeletal [[pain]]. Prolotherapy has enjoyed increased acceptance within the medical community, especially in light of the focus being given to regenerative medicine as a discipline.

Prolotherapy can be distinguished from [[sclerotherapy]]. Sclerotherapy is the use of injections of caustics into the veins, in vascular surgery and dermatology, to remove [[varicose veins]] and other vascular irregularities. Prolotherapy is the use of injections in tendons or ligaments to correct connective tissue weakness and reduce musculoskeletal pain. Prolotherapy is also called "proliferation therapy" and "regenerative injection therapy."

Prolotherapy is often used as an alternative to invasive [[arthroscopic surgery]]. This is an important alternative, especially when ligamentous structures are involved. The unique role of prolotherapy is highlighted when taking into consideration the effectiveness of arthroscopy. A double-blind placebo-controlled study on arthroscopic surgery for [[osteoarthritis]] of the knee was published in the [[New England Journal of Medicine]] in July 2002 and concluded that the group that received actual arthroscopic surgery did not report better function or pain than the placebo group."<ref>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12110735 "A controlled trial of arthroscopic surgery for osteoarthritis of the knee" N Engl J Med 2002 Jul 11;347(2):81-8, Moseley JB; O'Malley K; Petersen NJ; Menke TJ; Brody BA; Kuykendall DH; Hollingsworth JC; Ashton CM; Wray NP</ref>

Arthroscopic surgery of the knee is, however, rarely performed for the indication of osteoarthritis, but rather for mechanical tears or disruptions of cartilaginous tissue. Prolotherapy is not intended to address this type of problem. Doctors and surgeons have given numerous accounts of successful treatment for knee injuries, shoulder separation, and typical injuries to golfers ([[epicondylitis]], shoulder strain, lower back strain and injury, hip and knee injury)<ref>{{cite web|url=http://www.prolotherapy-hhf.org/Prolotherapy_insert%202006.pdf
|title=Second Annual Prolotherapy Research Forum}}</ref><ref>March Darrow, Prolotherapy: Living Pain Free, Protex Press, ISBN-13: 978-0971450325</ref><ref>Ross A. Hauser, Marion A. Hauser, Prolo Your Pain Away, Beulah Land Press, ISBN-13: 978-0966101096</ref>.

As of April 2005, doctors at the [[Mayo Clinic]] began supporting prolotherapy. Robert D. Sheeler, MD (Medical Editor, ''Mayo Clinic Health letter'') first learned of prolotherapy through [[C. Everett Koop]]’s interest in the treatment. Mayo Clinic doctors list the areas that are most likely to benefit from prolotherapy treatment: ankles, knees, elbows, and sacroiliac joint in the low back. They report that "unlike [[corticosteroid]] injections — which may provide temporary relief — prolotherapy involves improving the injected tissue by stimulating tissue growth."<ref name="Mayo">{{cite journal| journal = Mayo Clinic Health Letter| volume = 23| issue = 4| year = 2005| pages = | title = Alternative treatments: Dealing with chronic pain| last = Mayo Clinic | first = | url = | format = | accessdate = }}</ref>

While identifing a clearly delinated population of back pain patients in the literature can be quite challenging, an [[evidence-based medicine]] review<ref name="CochraneCollaboration">[http://www.cochrane.org/reviews/en/ab004059.html] Cochrane Collaboration</ref> of prolotherapy for [[low back pain]] concluded: "There is conflicting evidence regarding the efficacy of prolotherapy injections for patients with chronic low-back pain. If used alone, prolotherapy injections do not have a role in the treatment of chronic low-back pain. When combined with other treatments, they may give prolonged partial relief of pain and disability." More studies are currently underway (see '''[[#Ongoing Study|Ongoing study]]''' section below).

==Prolotherapy in clinical practice==

Prolotherapy involves the injection of either an irritant or proliferant solution into the area where connective tissue has been weakened or damaged through injury or strain. Many solutions are used, including [[Dextrose]], [[Lidocaine]] (a commonly used local anesthetic), [[Phenol]] (an alcohol), [[Glycerine]], [[Cod Liver Oil]] extract or Sodium Morrhuate . The injection is placed onto ligament, into joint capsules or where [[tendon]] connects to bone. Many points may require injection. The Injected solution causes the body to heal itself through the process of [[inflammation]] and repair. In the case of weakened or torn connective tissue, induced inflammation and release of growth factor at the site of injury may result in a 40% strengthening of the attachment points.

Most clinicians say that at least three injections, done at 2-3 week intervals, are required to accomplish this result. In addition, patients may receive treatment beyond the initial three injections until treatments are required only every several years, if at all.<ref name="RationalForProlotherapy">{{cite web|url= http://www.prolotherapy.com/articles/banks.htm |title=A Rationale for Prolotherapy}}</ref> Allen R Banks, Ph.D., has described in detail the theory behind prolotherapy in "A Rationale for Prolotherapy".<ref name="RationalForProlotherapy"/> Robert G. Schwartz, MD has also published a biochemical literature review on the topic "Prolotherapy: A Literature Review and Retrospective Study"[http://www.piedmontpmr.com/prolotherapy-treatment-for-ligament-pain].

===History===
Injections of irritant solutions were performed in the late 1800’s to repair hernias and in the early 1900’s for jaw pain due to temporomandibular (jaw) joint laxity. Dr. George Hackett, MD developed the technique of prolotherapy in the 1940’s. Dr. Gustav Hemwall was a pioneer, beginning his studies and treatments in the 1950s and continuing until the mid 1990s. In his study of almost 10,000 prolotherapy cases, Dr. Hackett found that over 99 percent of the patients found relief from their chronic pain. <ref name=history>{{cite web |url=http://getprolo.com/the_history_of_prolotherapy.htm |title=The History of Prolotherapy. |accessdate=2007-08-26 |quote=In 1955, at an American Medical Association meeting, Dr. Gustav Hemwall was astonished to see so many doctors at one particular exhibit. The presenter was talking about a very successful treatment for chronic low back pain. Nothing was worse at the time for Dr. Hemwall than having a chronic low back pain patient come to him, because the treatments he was able to offer were not very successful. The doctor doing the presentation was George S. Hackett, M.D., and he was discussing the technique of Prolotherapy. Once the crowd diminished, Dr. Hemwall asked Dr. Hackett how he could learn the treatment described in his book, Ligament and Tendon Relaxation Treated by Prolotherapy. Dr. Hemwall went to Dr. Hackett's office in Canton, Ohio, to learn the technique. Dr. Hemwall became so proficient at administering the technique that Dr. Hackett would later refer patients to him. Prolotherapy owes a great debt to Dr. Hemwall. Between 1955 until his retirement in 1996, he was the main instructor and proponent of Prolotherapy in the United States. He was not a researcher but a clinician, and perhaps the world's greatest Prolotherapist. He treated more than 10,000 patients world wide and collected data on 8,000 of these patients. In 1974, Dr. Hemwall presented his largest survey of 2,007 Prolotherapy patients to the Prolotherapy Association. |publisher= }}</ref>

===Guidelines used by practitioners as indicators for prolotherapy===
* Recurrent swelling or fullness involving a joint or muscular region
* Popping, clicking, grinding, or catching sensations with movement
* A sensation of the “leg giving way” with associated back pain
* Temporary benefit from chiropractic manipulation or manual mobilization that fails to ultimately resolve the pain
* Distinct tender points and “jump signs” along the bone at tendon or ligament attachments
* Numbness, tingling, aching, or burning, referred into an upper or lower extremity
* Recurrent headache, face pain, jaw pain, ear pain
* Chest pain with tenderness along the rib attachments on the spine or along the front of the chest
* Spine pain that does not respond to surgery, or whose origin is not clear or consistent based on extensive studies

==Evidence based medicine==

A [[Cochrane Collaboration|Cochrane review]] of the medical literature as of January 2004 on the efficacy of prolotherapy injections in adults with chronic low-back pain<ref name="CochraneCollaboration">[http://www.cochrane.org/reviews/en/ab004059.html] Cochrane collaboration</ref> found four [[controlled trials]], all measuring pain and disability levels at six months. The review concluded:

:"There is conflicting evidence regarding the efficacy of prolotherapy injections in reducing pain and disability in patients with chronic low-back pain. Conclusions are confounded by clinical heterogeneity amongst studies and by the presence of co-interventions." "... in the presence of co-interventions, prolotherapy injections were more effective than control injections, more so when both injections and co-interventions were controlled concurrently."

The review also noted: "[m]inor side effects from the treatment, such as increased back pain and stiffness, were common but short-lived." ("Stiffness" is an expected short-lived side effect, as the goal is to cause irritation and the corresponding body reaction of temporary inflammation and repair.)

More recently Lyftogt J. [Prolotherapy for recalcitrant lumbago. Australasia Musculoskeletal Med. 2008; 13 (5):18-20] published that ninety percent of patients with recalcitrant lumbago reported more then 50% improvement after prolotherapy. Long term follow up results were not stated. In addition, Rabago et al. [A systematic review of prolotherapy for chronic musculoskeletal pain. Clin J Sport Med. 2005 Sep;15(5):376-80] noted: "Two [randomized controlled trials] on osteoarthritis reported decreased pain, increased range of motion, and increased patellofemoral cartilage thickness after prolotherapy."

==Criticism==
While many major [[medical insurance]] policies cover the treatment, not all do. Twenty years ago (After a 1999 review of the medical evidence) Medicare declined prolotherapy coverage for chronic low back pain (citing that prolotherapy "was last examined for coverage by the Health Care Financing Administration (HCFA) in September 1992").<ref>[http://www.quackwatch.org/01QuackeryRelatedTopics/prolo.html] HCFA Decision Memorandum</ref>

===Ongoing Study===
====Knee injuries====
A randomized, [[double-blind]], [[placebo]] control study is currently recruiting patients to determine whether prolotherapy can decrease pain and disability from knee [[osteoarthritis]]. This study is Sponsored by the National Center for Complementary and Alternative Medicine ([[NCCAM]]).<ref>[http://clinicaltrials.gov/show/NCT00085722] Clinicaltrials.Gov, Joint Injections for Osteoarthritic Knee Pain, web page last updated October 16, 2006</ref>

====Tennis elbow====
A randomized, [[double-blind]], [[placebo]] control study is currently recruiting patients to determine whether prolotherapy can be an effective treatment for lateral epicondylitis (tennis elbow).<ref>http://clinicaltrials.gov/ct2/show?cond=%22Tennis+Elbow%22&rank=3 Clinicaltrials.Gov, Efficacy Study of Prolotherapy vs Corticosteroid for Tennis Elbow</ref>

==See also==
*[[Pin firing]]
*Gustav Hemwall

==References==
{{Reflist|2}}

== External links ==
* [http://www.prolotherapy.org Prolotherapy.org] is a source for extensive articles, diagrams and other resources related to prolotherapy.
* [http://prolotherapy.com/ Prolotherapy.com] - a source for information on nonsurgical ligament reconstruction
* [http://www.aaomed.org American Association of Orthopaedic Medicine] is a non-profit organization that promotes prolotherapy.
*{{cite web
| title = CAM Prolotherapy Project
| date = 2006-08-06
| url = http://www.camresearch.com
| accessdate = 2006-08-06 }}

{{SIB}}

[[Category:Orthopedics]]
[[Category:Inflammations]]
[[Category:Alternative medicine]]

{{WH}}
{{WS}}

Prolotherapy

2014-10-04T19:23:38Z

Bobby Schwartz:

{{SI}}

'''Editors-In-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.]; Dean Reeves, M.D., Clinical assistant professor at the University of Kansas Medical School, Dept of Physical Medicine and Rehabilitation; Felix Linetsky, M.D., Clinical Associate Professor, Department of Osteopathic Principles and Practice, Nova Southeastern College of Osteopathic Medicine [mailto:flinetsky@me.com]

{{EJ}}

==Overview==
'''Prolotherapy''' ("Proliferative Injection Therapy") involves injecting an otherwise non-[[Pharmacology|pharmacological]] and non-[[Biological activity|active]] proliferant or irritant solution into the body, generally in the region of [[tendons]] or [[ligaments]] for the purpose of strengthening weakened connective tissue and alleviating musculoskeletal [[pain]]. Prolotherapy has enjoyed increasing acceptance within the medical community, especially in light of the increased focus being given to regenerative medicine as a discipline.

Prolotherapy can be distinguished from [[sclerotherapy]]. Sclerotherapy is the use of injections of caustics into the veins, in vascular surgery and dermatology, to remove [[varicose veins]] and other vascular irregularities. Prolotherapy is the use of injections in tendons or ligaments to correct connective tissue weakness and reduce musculoskeletal pain. Prolotherapy is also called "proliferation therapy" and "regenerative injection therapy."

Prolotherapy is often used as an alternative to invasive [[arthroscopic surgery]]. This is an important alternative, especially when ligamentous structures are involved. The unique role of prolotherapy is highlighted when taking into consideration the effectiveness of arthroscopy. A double-blind placebo-controlled study on arthroscopic surgery for [[osteoarthritis]] of the knee was published in the [[New England Journal of Medicine]] in July 2002 and concluded that the group that received actual arthroscopic surgery did not report better function or pain than the placebo group."<ref>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12110735 "A controlled trial of arthroscopic surgery for osteoarthritis of the knee" N Engl J Med 2002 Jul 11;347(2):81-8, Moseley JB; O'Malley K; Petersen NJ; Menke TJ; Brody BA; Kuykendall DH; Hollingsworth JC; Ashton CM; Wray NP</ref>

Arthroscopic surgery of the knee is, however, rarely performed for the indication of osteoarthritis, but rather for mechanical tears or disruptions of cartilaginous tissue. Prolotherapy is not intended to address this type of problem. Doctors and surgeons have given numerous accounts of successful treatment for knee injuries, shoulder separation, and typical injuries to golfers ([[epicondylitis]], shoulder strain, lower back strain and injury, hip and knee injury)<ref>{{cite web|url=http://www.prolotherapy-hhf.org/Prolotherapy_insert%202006.pdf
|title=Second Annual Prolotherapy Research Forum}}</ref><ref>March Darrow, Prolotherapy: Living Pain Free, Protex Press, ISBN-13: 978-0971450325</ref><ref>Ross A. Hauser, Marion A. Hauser, Prolo Your Pain Away, Beulah Land Press, ISBN-13: 978-0966101096</ref>.

As of April 2005, doctors at the [[Mayo Clinic]] began supporting prolotherapy. Robert D. Sheeler, MD (Medical Editor, ''Mayo Clinic Health letter'') first learned of prolotherapy through [[C. Everett Koop]]’s interest in the treatment. Mayo Clinic doctors list the areas that are most likely to benefit from prolotherapy treatment: ankles, knees, elbows, and sacroiliac joint in the low back. They report that "unlike [[corticosteroid]] injections — which may provide temporary relief — prolotherapy involves improving the injected tissue by stimulating tissue growth."<ref name="Mayo">{{cite journal| journal = Mayo Clinic Health Letter| volume = 23| issue = 4| year = 2005| pages = | title = Alternative treatments: Dealing with chronic pain| last = Mayo Clinic | first = | url = | format = | accessdate = }}</ref>

While identifing a clearly delinated population of back pain patients in the literature can be quite challenging, an [[evidence-based medicine]] review<ref name="CochraneCollaboration">[http://www.cochrane.org/reviews/en/ab004059.html] Cochrane Collaboration</ref> of prolotherapy for [[low back pain]] concluded: "There is conflicting evidence regarding the efficacy of prolotherapy injections for patients with chronic low-back pain. If used alone, prolotherapy injections do not have a role in the treatment of chronic low-back pain. When combined with other treatments, they may give prolonged partial relief of pain and disability." More studies are currently underway (see '''[[#Ongoing Study|Ongoing study]]''' section below).

==Prolotherapy in clinical practice==

Prolotherapy involves the injection of either an irritant or proliferant solution into the area where connective tissue has been weakened or damaged through injury or strain. Many solutions are used, including [[Dextrose]], [[Lidocaine]] (a commonly used local anesthetic), [[Phenol]] (an alcohol), [[Glycerine]], [[Cod Liver Oil]] extract or Sodium Morrhuate . The injection is placed onto ligament, into joint capsules or where [[tendon]] connects to bone. Many points may require injection. The Injected solution causes the body to heal itself through the process of [[inflammation]] and repair. In the case of weakened or torn connective tissue, induced inflammation and release of growth factor at the site of injury may result in a 40% strengthening of the attachment points.

Most clinicians say that at least three injections, done at 2-3 week intervals, are required to accomplish this result. In addition, patients may receive treatment beyond the initial three injections until treatments are required only every several years, if at all.<ref name="RationalForProlotherapy">{{cite web|url= http://www.prolotherapy.com/articles/banks.htm |title=A Rationale for Prolotherapy}}</ref> Allen R Banks, Ph.D., has described in detail the theory behind prolotherapy in "A Rationale for Prolotherapy".<ref name="RationalForProlotherapy"/> Robert G. Schwartz, MD has also published a biochemical literature review on the topic "Prolotherapy: A Literature Review and Retrospective Study"[http://www.piedmontpmr.com/prolotherapy-treatment-for-ligament-pain].

===History===
Injections of irritant solutions were performed in the late 1800’s to repair hernias and in the early 1900’s for jaw pain due to temporomandibular (jaw) joint laxity. Dr. George Hackett, MD developed the technique of prolotherapy in the 1940’s. Dr. Gustav Hemwall was a pioneer, beginning his studies and treatments in the 1950s and continuing until the mid 1990s. In his study of almost 10,000 prolotherapy cases, Dr. Hackett found that over 99 percent of the patients found relief from their chronic pain. <ref name=history>{{cite web |url=http://getprolo.com/the_history_of_prolotherapy.htm |title=The History of Prolotherapy. |accessdate=2007-08-26 |quote=In 1955, at an American Medical Association meeting, Dr. Gustav Hemwall was astonished to see so many doctors at one particular exhibit. The presenter was talking about a very successful treatment for chronic low back pain. Nothing was worse at the time for Dr. Hemwall than having a chronic low back pain patient come to him, because the treatments he was able to offer were not very successful. The doctor doing the presentation was George S. Hackett, M.D., and he was discussing the technique of Prolotherapy. Once the crowd diminished, Dr. Hemwall asked Dr. Hackett how he could learn the treatment described in his book, Ligament and Tendon Relaxation Treated by Prolotherapy. Dr. Hemwall went to Dr. Hackett's office in Canton, Ohio, to learn the technique. Dr. Hemwall became so proficient at administering the technique that Dr. Hackett would later refer patients to him. Prolotherapy owes a great debt to Dr. Hemwall. Between 1955 until his retirement in 1996, he was the main instructor and proponent of Prolotherapy in the United States. He was not a researcher but a clinician, and perhaps the world's greatest Prolotherapist. He treated more than 10,000 patients world wide and collected data on 8,000 of these patients. In 1974, Dr. Hemwall presented his largest survey of 2,007 Prolotherapy patients to the Prolotherapy Association. |publisher= }}</ref>

===Guidelines used by practitioners as indicators for prolotherapy===
* Recurrent swelling or fullness involving a joint or muscular region
* Popping, clicking, grinding, or catching sensations with movement
* A sensation of the “leg giving way” with associated back pain
* Temporary benefit from chiropractic manipulation or manual mobilization that fails to ultimately resolve the pain
* Distinct tender points and “jump signs” along the bone at tendon or ligament attachments
* Numbness, tingling, aching, or burning, referred into an upper or lower extremity
* Recurrent headache, face pain, jaw pain, ear pain
* Chest pain with tenderness along the rib attachments on the spine or along the front of the chest
* Spine pain that does not respond to surgery, or whose origin is not clear or consistent based on extensive studies

==Evidence based medicine==

A [[Cochrane Collaboration|Cochrane review]] of the medical literature as of January 2004 on the efficacy of prolotherapy injections in adults with chronic low-back pain<ref name="CochraneCollaboration">[http://www.cochrane.org/reviews/en/ab004059.html] Cochrane collaboration</ref> found four [[controlled trials]], all measuring pain and disability levels at six months. The review concluded:

:"There is conflicting evidence regarding the efficacy of prolotherapy injections in reducing pain and disability in patients with chronic low-back pain. Conclusions are confounded by clinical heterogeneity amongst studies and by the presence of co-interventions." "... in the presence of co-interventions, prolotherapy injections were more effective than control injections, more so when both injections and co-interventions were controlled concurrently."

The review also noted: "[m]inor side effects from the treatment, such as increased back pain and stiffness, were common but short-lived." ("Stiffness" is an expected short-lived side effect, as the goal is to cause irritation and the corresponding body reaction of temporary inflammation and repair.)

More recently Lyftogt J. [Prolotherapy for recalcitrant lumbago. Australasia Musculoskeletal Med. 2008; 13 (5):18-20] published that ninety percent of patients with recalcitrant lumbago reported more then 50% improvement after prolotherapy. Long term follow up results were not stated. In addition, Rabago et al. [A systematic review of prolotherapy for chronic musculoskeletal pain. Clin J Sport Med. 2005 Sep;15(5):376-80] noted: "Two [randomized controlled trials] on osteoarthritis reported decreased pain, increased range of motion, and increased patellofemoral cartilage thickness after prolotherapy."

==Criticism==
While many major [[medical insurance]] policies cover the treatment, not all do. Twenty years ago (After a 1999 review of the medical evidence) Medicare declined prolotherapy coverage for chronic low back pain (citing that prolotherapy "was last examined for coverage by the Health Care Financing Administration (HCFA) in September 1992").<ref>[http://www.quackwatch.org/01QuackeryRelatedTopics/prolo.html] HCFA Decision Memorandum</ref>

===Ongoing Study===
====Knee injuries====
A randomized, [[double-blind]], [[placebo]] control study is currently recruiting patients to determine whether prolotherapy can decrease pain and disability from knee [[osteoarthritis]]. This study is Sponsored by the National Center for Complementary and Alternative Medicine ([[NCCAM]]).<ref>[http://clinicaltrials.gov/show/NCT00085722] Clinicaltrials.Gov, Joint Injections for Osteoarthritic Knee Pain, web page last updated October 16, 2006</ref>

====Tennis elbow====
A randomized, [[double-blind]], [[placebo]] control study is currently recruiting patients to determine whether prolotherapy can be an effective treatment for lateral epicondylitis (tennis elbow).<ref>http://clinicaltrials.gov/ct2/show?cond=%22Tennis+Elbow%22&rank=3 Clinicaltrials.Gov, Efficacy Study of Prolotherapy vs Corticosteroid for Tennis Elbow</ref>

==See also==
*[[Pin firing]]
*Gustav Hemwall

==References==
{{Reflist|2}}

== External links ==
* [http://www.prolotherapy.org Prolotherapy.org] is a source for extensive articles, diagrams and other resources related to prolotherapy.
* [http://prolotherapy.com/ Prolotherapy.com] - a source for information on nonsurgical ligament reconstruction
* [http://www.aaomed.org American Association of Orthopaedic Medicine] is a non-profit organization that promotes prolotherapy.
*{{cite web
| title = CAM Prolotherapy Project
| date = 2006-08-06
| url = http://www.camresearch.com
| accessdate = 2006-08-06 }}

{{SIB}}

[[Category:Orthopedics]]
[[Category:Inflammations]]
[[Category:Alternative medicine]]

{{WH}}
{{WS}}

Osteoarthritis

2014-10-04T19:16:02Z

Bobby Schwartz: /* Treatment */

__NOTOC__
'''For patient information click [[{{PAGENAME}} (patient information)|here]]'''
{{Infobox_Disease |
Name = Osteoarthritis |
Image = Gonarthrose-Knorpelaufbrauch.jpg |
Caption = |
DiseasesDB = 9313 |
ICD10 = {{ICD10|M|15||m|15}}-{{ICD10|M|19||m|15}}, {{ICD10|M|47||m|45}} |
ICD9 = {{ICD9|715}} |
ICDO = |
OMIM = 165720 |
MedlinePlus = 000423 |
MeshID = D010003 |
}}
{{Osteoarthritis}}
'''Editor-In-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.]

{{SK}} OA; osteoarthrosis; degenerative arthritis; degenerative joint disease; DJD; arthrosis; hypertrophic osteoarthritis; arthritis, degenerative; osteoarthrosis deformans
==[[Osteoarthritis overview|Overview]]==
==[[Osteoarthritis classification|Classification]]==
==[[Osteoarthritis pathophysiology|Pathophysiology]]==

==[[Osteoarthritis causes|Causes]]==

==[[Osteoarthritis differential diagnosis|Differentiating Diabetic nephropathy from other Diseases]]==

==[[Osteoarthritis epidemiology and demographics|Epidemiology and Demographics]]==

==[[Osteoarthritis risk factors|Risk Factors]]==

==[[Osteoarthritis natural history, complications and prognosis|Natural History, Complications and Prognosis]]==

==Diagnosis==
[[Osteoarthritis history and symptoms|History and Symptoms]] | [[Osteoarthritis physical examination|Physical Examination]] | [[Osteoarthritis laboratory findings|Laboratory Findings]] | [[Osteoarthritis x ray|X Ray]] | [[Osteoarthritis MRI|MRI]] | [[Osteoarthritis other diagnostic studies|Other Diagnostic Studies]]

==Treatment==
[[Osteoarthritis medical therapy|Medical Therapy]] | [[Osteoarthritis surgery|Surgery]] | [[Osteoarthritis primary prevention|Primary Prevention]] | [[Osteoarthritis cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Osteoarthritis future or investigational therapies|Future or Investigational Therapies]] | [[Stem cell|Stem cell]]

==Case Studies==
:[[Osteoarthritis case study one|Case #1]]

==Related Chapters==
*[[Back pain]]
*[[Chronic pain]]
*[[Osteoimmunology]]

== External links ==
* [http://www.nlm.nih.gov/medlineplus/osteoarthritis.html MedlinePlus:Osteoarthritis at National Institutes of Health]

{{Diseases of the musculoskeletal system and connective tissue}}

[[Category:Arthritis]]
[[Category:General practice]]
[[Category:Rheumatology]]

[[bg:Артроза]]
[[ca:Artrosi]]
[[cs:Osteoartróza]]
[[de:Arthrose]]
[[es:Artrosis]]
[[fr:Arthrose]]
[[he:דלקת מפרקים ניוונית]]
[[lt:Osteoartritas]]
[[nl:Artrose]]
[[no:Artrose]]
[[pl:Choroba zwyrodnieniowa stawów]]
[[pt:Osteoartrite]]
[[ru:Остеоартроз]]
[[sv:Artros]]

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

Osteoarthritis

2014-10-04T19:14:55Z

Bobby Schwartz: /* Treatment */

__NOTOC__
'''For patient information click [[{{PAGENAME}} (patient information)|here]]'''
{{Infobox_Disease |
Name = Osteoarthritis |
Image = Gonarthrose-Knorpelaufbrauch.jpg |
Caption = |
DiseasesDB = 9313 |
ICD10 = {{ICD10|M|15||m|15}}-{{ICD10|M|19||m|15}}, {{ICD10|M|47||m|45}} |
ICD9 = {{ICD9|715}} |
ICDO = |
OMIM = 165720 |
MedlinePlus = 000423 |
MeshID = D010003 |
}}
{{Osteoarthritis}}
'''Editor-In-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.]

{{SK}} OA; osteoarthrosis; degenerative arthritis; degenerative joint disease; DJD; arthrosis; hypertrophic osteoarthritis; arthritis, degenerative; osteoarthrosis deformans
==[[Osteoarthritis overview|Overview]]==
==[[Osteoarthritis classification|Classification]]==
==[[Osteoarthritis pathophysiology|Pathophysiology]]==

==[[Osteoarthritis causes|Causes]]==

==[[Osteoarthritis differential diagnosis|Differentiating Diabetic nephropathy from other Diseases]]==

==[[Osteoarthritis epidemiology and demographics|Epidemiology and Demographics]]==

==[[Osteoarthritis risk factors|Risk Factors]]==

==[[Osteoarthritis natural history, complications and prognosis|Natural History, Complications and Prognosis]]==

==Diagnosis==
[[Osteoarthritis history and symptoms|History and Symptoms]] | [[Osteoarthritis physical examination|Physical Examination]] | [[Osteoarthritis laboratory findings|Laboratory Findings]] | [[Osteoarthritis x ray|X Ray]] | [[Osteoarthritis MRI|MRI]] | [[Osteoarthritis other diagnostic studies|Other Diagnostic Studies]]

==Treatment==
[[Osteoarthritis medical therapy|Medical Therapy]] | [[Osteoarthritis surgery|Surgery]] | [[Osteoarthritis primary prevention|Primary Prevention]] | [[Osteoarthritis cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Osteoarthritis future or investigational therapies|Future or Investigational Therapies]] | [[Stem Cell|Stem Cell]]

==Case Studies==
:[[Osteoarthritis case study one|Case #1]]

==Related Chapters==
*[[Back pain]]
*[[Chronic pain]]
*[[Osteoimmunology]]

== External links ==
* [http://www.nlm.nih.gov/medlineplus/osteoarthritis.html MedlinePlus:Osteoarthritis at National Institutes of Health]

{{Diseases of the musculoskeletal system and connective tissue}}

[[Category:Arthritis]]
[[Category:General practice]]
[[Category:Rheumatology]]

[[bg:Артроза]]
[[ca:Artrosi]]
[[cs:Osteoartróza]]
[[de:Arthrose]]
[[es:Artrosis]]
[[fr:Arthrose]]
[[he:דלקת מפרקים ניוונית]]
[[lt:Osteoartritas]]
[[nl:Artrose]]
[[no:Artrose]]
[[pl:Choroba zwyrodnieniowa stawów]]
[[pt:Osteoartrite]]
[[ru:Остеоартроз]]
[[sv:Artros]]

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

Musculoskeletal problems of the foot

2014-10-04T19:12:49Z

Bobby Schwartz: /* Overview */

{{SI}}

'''Editors-In-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.]; [[User:Michael Tollison|Michael Tollison, M.D.]] [mailto:Tollison864@charter.net], Piedmont Orthopaedic Associates, Greenville, SC

==Overview==
[[Image:Foot & ankle kinesiology.jpg‎|thumb|left|Foot & ankle kinesiology]]
Foot and ankle pain is a very common condition. Anomalies range from [[osteoarthritis]], ligamentous strain [http://www.piedmontpmr.com/ligament-pain-stretched-torn-or-strained], nerve entrapment and peripheral [[neuropathy]] [http://www.piedmontpmr.com/peripheral-neuropathy-treatment-options-for-diabetic-and-small-fiber-types], to mechanical and postural induced abnormalities. Most cases respond to conservative care including physical therapy, orthotics, local injection and percutaneous tenotomy [http://www.piedmontpmr.com/ultrasound-guided-percutaneous-tenotomy-3]. In more recalcitrant cases surgical intervention is required.

==Associated Conditions==
It is not at all uncommon for someone to present with foot or ankle pain even when the primary problem is coming from nerve root irritation in the back [http://www.piedmontpmr.com/low-back-pain-getting-to-the-root-cause], venous reflux [http://www.piedmontpmr.com/treatment-for-burning-itching-swollen-painful-legs-2] or peripheral arterial disease [http://www.piedmontpmr.com/peripheral-arterial-disease-2]. It is therefor important to keep in mind that not all foot and ankle problems arise from the foot or ankle itself. If pain persists beyond a few weeks, it is wise to get a doctors opinion.

== History and Symptoms ==
The history of present illness (the facts that surround the onset of pain) and the symptoms associated with the chief complaint, can provide valuable clues as to its source. Examples of several conditions are listed below.

=== Acute Traumatic Injury ===
* '''Fracture of Proximal Phalanx of Great Toe'''
*:* Usually via direct trauma or toe-stubbing injury
*:* Usually minimal displacement; can by treated conservatively
* '''Fracture of Metatarsals 1-4'''
*:* Usually via direct blow to top of foot
*:* Midfoot pain, inability to bear weight, direct tenderness
*:* Nondisplaced
*:*:* Can be treated conservatively
*:* Displaced
*:*:* Require surgical reduction
* '''Fracture of 5<sup>th</sup> Metatarsal (MT)'''
*:* Dancer’s Fracture
*:*:* Severe inversion injury--avulsion of bone from proximal metatarsal
*:*:* Occurs at site of peroneus brevis insertion
*:*:* Can be treated conservatively (immobilization)
*:* Jones’ Fracture
*:*:* Fracture of proximal tuberosity of base of metatarsal
*:* Transverse fracture of shaft
*:*:* Can be managed conservatively, but high rate nonunion
* '''Calcaneal Fracture'''
*:* Most commonly fractured tarsal bone
*:* Usually via vertical falls or twisting injuries
*:* Intra-articular Fractures
*:*:* All require orthopedics referral; unpredictable healing
*:*:* May be complicated by chronic joint pain, arthritis, nerve entrapment
*:* Extra-articular Fractures
*:*:* Most can be treated without surgery
*:*:* Ortho referral for displaced posterior process fractures (Achilles disruption)
*:*:* Ortho referral for nonunion of anterior process fracture
[[Image:Xray osteoporotic heel2.jpg|thumb|left|Xray osteoporotic heel]]
=== Nontraumatic ===
* '''Great toe'''
*:* Hallux valgus (bunion)
*:*:* Metatarso-phalangeal osteoarthritis (MTP OA)--painful swelling of dorsomedial aspect of 1st metatarsal head
*:*:* Hallux valgus deformity associated (toe angulates laterally)
*:*:* Hyperpronation (flat feet) and poor footwear contribute
*:*:* Arthritic flares or bursitis can occur with ongoing pressure at medial joint line
*:* Adventitial bursitis
*:*:* Inflammation of bursal sac over medial 1st MTP joint due to friction/pressure
*:*:* Dramatic erythema, edema and tenderness
*:* Gout (podagra):
*:*:* Dramatic inflammatory response to monosodium urate (MSU) crystal deposition
*:*:* Can also affect tenosynovial sheaths (enthesitis) and other small joints of foot
*:* Sesamoid disorders
*:*:* Two sesamoids (medial and lateral) articulate on plantar aspect of 1st metatarsal (MT)
*:*:* Inflammation or fracture can occur with chronic stress (runners, dancers)
*:*:* Localized pain and swelling at plantar aspect of 1st
* '''Forefoot'''
*:* Metatarsalgia
*:*:* Pain at any of the 2nd-5th metatarsal heads with weight-bearing
*:*:* Can be related to inflammatory deformity with subluxation of MT head (right anterior)
*:* Morton’s neuroma
*:*:* Chronic irritation of digital nerve running between metatarsal heads
*:*:* Most commonly occurs between 3rd and 4th toes
*:*:* Burning pain btwn toes; cramping; numbness along sides of 2 adjacent toes
*:*:* Typically associated with poorly padded shoes, improves with forefoot massage
*:* Metatarsal stress fracture
*:*:* Microfracture of metatarsal after prolonged walking/standing (“march fracture”)
*:*:* Usually 2nd or 3rd metatarsal
*:*:* Sudden onset of pain, often without history of trauma
*:*:* Military recruits, athletes, osteoporotic patients at risk
* '''Hindfoot – Plantar Region'''
*:* Plantar fasciitis
*:*:* One of most common causes adult foot pain
*:*:* Heel pain worse with initiation of walking/standing after inactivity
*:*:* Results from strain of plantar fascia after jumping, prolonged standing
*:*:* Predisposing factors
*:*:*:* Obesity
*:*:*:* Flat feet (pes planus) or high arches (pes cavus)
*:*:*:* Excessive pronation
*:*:*:* Short Achilles tendons
*:*:* Can be an inflammatory process associated with systemic disease (rheumatoid arthritis (RA), Reiter’s)
*:*:* Calcaneal spurs may coexist or develop due to inflammation (but usually asymptomatic)
*:* Infracalcaneal bursitis
*:*:* Inflammation of bursa beneath calcaneus
*:*:* Pain/ache in mid-plantar aspect of calcaneus
*:*:* Symptoms increase with duration of weight-bearing
*:* Calcaneal periostitis
*:*:* Bilateral pain along plantar and lateral aspects of heels
*:*:* Can be due to trauma
*:*:* Can be due to inflammatory disease (RA, psoriatic arthritis, ankylosing spondylitis, Reiter’s)
*:*:* May improve with treatment of underlying disease process
*:* Calcaneal spurs
*:*:* Bony outgrowths that develop on plantar tuberosity
*:*:* Usually asymptomatic
*:*:* Pain can occur if large (>1 cm) with apex angled downward--pain with weight-bearing
*:* Heel pad syndrome
*:*:* Irritation of fat pad due to trauma
*:*:* Pain localized to heel pad; plantar fascia not tender
*:*:* Most commonly in marathon runners
*:*:* Self-limited, resolves within 2-3 weeks
*:* Tarsal tunnel syndrome
*:*:* Posterior tibial nerve compressed in tarsal tunnel
*:*:*:* (Beneath flexor retinaculum inferoposterior to medial malleolus)
*:*:* Can occur via local trauma (sprain, fracture), repetitive hyperpronation
*:*:* Also via inflammatory disease (RA), bony prominences, pregnancy, hypoT4
*:*:* Paresthesias, plantar pain (medial/lateral plantar nerve distribution)
*:*:* Symptoms often nocturnal or after standing, relieved by foot/ankle movement
*:* Referred pain (subtalar arthritis, lumbosacral (LS) radiculopathy)
*:*:* Treat the underlying condition
*:*:* For example, see [RSD], [CRPS], [Low back pain]
[[image:Ankle med & lat view.jpg|thumb|left|Ankle med & lat view]]
*:* Ligament Strain
*:*:* Pain anywhere that ligament connects bone to bone
*:*:* May be associated with swelling and skin color changes
*:*:* Often due to an inciting event (such as a turned or twisted ankle)
*:*:* May also be due to normal wear and tear or other forgotten injury
* '''Hindfoot – Posterior Region'''
*:* Achilles tendinitis
*:*:* Inflammation and microtears near Achilles tendon insertion
*:*:* Often associated with repetitive irritation (athletes)
*:*:* Bilateral involvement (in absence of quinolone) suggests Reiter’s or spondylitis
*:*:* Pain behind ankle with walking, standing, weight-bearing athletic activities
*:*:* Pain worse with activity--later stiffness and swelling
*:*:* Untreated cases--acute '''rupture''' (up to 10%) or chronic tendinitis
*:* Achilles tendon rupture
*:*:* Occurs after abrupt calf muscle contraction
*:*:* Typically occurs in patients > 30 years old with sporadic athletic activity
*:*:* Also associated with fluoroquinolone use
*:*:* Audible snap followed by severe pain in calf
*:*:* Partial rupture can occur without precipitating event
*:* Posterior tibial tenosynovitis
*:*:* Inflammation of tendon as it passes around the medial malleolus
*:*:* Exacerbants = ankle pronation, pes planus, obesity
*:*:* Can be associated w/tarsal tunnel syndrome, especially if significant pronation
*:*:* Pain and swelling at inner aspect of ankle, worse wtih walking
*:* Retrocalcaneal bursitis
*:*:* Inflammation of bursa between Achilles tendon and calcaneus
*:*:* Uncommon
*:*:* Pain behind ankle, increased with walking (plantar flexion)
*:* Pre-Achilles bursitis
*:*:* Inflammation of bursa between Achilles tendon (calcaneal insertion) and skin
*:*:* May resemble Achilles tendinitis, but less disabling; no significant risk tendon rupture
*:*:* Pain and localized swelling behind the heel
*:*:* Aggravated/caused by inappropriate shoes
*:* Ligament Strain
*:*:* Pain anywhere that ligament connects bone to bone
*:*:* May be associated with swelling and skin color changes
*:*:* Often due to an inciting event (such as a turned or twisted ankle)
*:*:* May also be due to normal wear and tear or other forgotten injury

== Presentation and Physical Exam ==
=== 1st MTP Joint Conditions ===
* '''Hallux Valgus'''
*:* Valgus deformity of MTP joint
*:*:* Prominent metatarsal head, toe points laterally
*:*:* First and second toe may overlap if advanced
*:* Tenderness along medial joint line (or over whole joint if acute flare)
*:* Joint enlargement due to subluxation, osteophytes, edema
*:* Crepitation with passive movement of MTP joint
*:* +/- Pain at extremes of passive plantar/dorsiflexion of toe
*:* +/- Limited range of motion (ROM) (hallux rigidus)
* '''Adventitial Bursitis of 1st MTP'''
*:* Erythema, swelling over medial aspect of MTP joint (focal area vs. full joint involvement with gout)
*:* Maximal tenderness over medial joint line
*:* Associated with hallux valgus deformity (increased friction with shoes) +/- resultant loss of ROM
*:* Mild pain with MTP flexion/extension (vs. gout with severe pain)
*:* Isometric toe flexion/extension against resistance painless (tendons spared)
* '''Gout'''
*:* Significant erythema, swelling and exquisite tenderness involving entire joint
*:* Severe pain with MTP flexion/extension
* '''Sesamoiditis or Fracture'''
*:* Localized tenderness/swelling on plantar palpation of MTP

=== Lesser MTP Forefoot Conditions ===
* '''Metatarsalgia'''
*:* Maximal tenderness at the MTP heads
*:* Plantar protrusion of metatarsal head(s) may be visible with patient lying prone
*:* Callus often present beneath involved metatarsal(s)
*:* Adjacent metatarsals may be hypermobile (shifting weight to involved metatarsal)
* '''Morton’s Neuroma'''
*:* Tenderness greatest in web space between MTP heads (vs. at MTP heads in metatarsalgia)
*:* Pain reproduced by squeezing MTP heads from sides (electric pain to ends of adjacent 2 toes)
*:* Click may be felt with squeeze + deep palpation in distal intermetatarsal space (Mulder’s sign)
*:* Passive ROM of MTP joints painless
*:* +/- Loss of sensation along inner aspects of 2 adjacent toes (advanced cases)
* '''Metatarsal Stress Fracture'''
*:* Localized tenderness over metatarsal shaft
*:* Dramatic dorsal foot swelling
*:* Pain when metatarsals squeezed from the sides

=== Hindfoot (Plantar) Conditions ===
[[image:Plantar fascitis.jpg|thumb|left|Plantar fascitis]]
* '''Plantar Fasciitis'''
*:* Focal point tenderness at the calcaneal origin of the plantar fascia – pain can be increased by toe dorsiflexion (stretch fascia) during palpation of medial plantar surface ~1.5” distal to posterior heel
*:* Medial-to-lateral compression of calcaneus usually less painful than local fascial tenderness (if compression more painful, must rule out calcaneal stress fracture)
*:* +/- Limited foot dorsiflexion (nl = 25-30°) due to shortening of Achilles tendon
*:* +/- Associated pes planus/cavus
* '''Infracalcaneal Bursitis'''
*:* Point tenderness directly under center of calcaneus (plantar surface)
*:* +/- Localized warmth/swelling
* '''Calcaneal Periostitis'''
*:* Diffuse tenderness along plantar aspect of heel and midfoot bilateral and along lateral edges of heels
*:* Evaluation for signs underlying rheumatologic disease indicated
* '''Calcaneal Spurs'''
*:* Usually no specific findings; prominent spur palpable through skin may require intervention
* '''Heel Pad Syndrome'''
*:* Pain localized to heel pad, aggravated by squeezing pad from side to side
*:* Plantar fascia not tender; pain not exacerbated by toe dorsiflexion
* '''Tarsal Tunnel Syndrome'''
*:* Reproduction of symptoms with percussion or pressure over flexor retinaculum (Tinel’s sign)
* '''Ligament Strain'''
*:* Pain anywhere that ligament connects bone to bone
*:* Swelling and skin color changes may be present
*:* Weather sensitivity can exist
=== Hindfoot (Posterior) Conditions ===
* '''Achilles Tendinitis'''
*:* Tender, fusiform thickening of Achilles tendon with “cobblestone” texture
*:* Pain exacerbated with resisted plantar flexion and passive stretching in dorsiflexion
*:* Ankle ROM normal, though may be limited by pain in dorsiflexion
*:* Preserved calf muscle strength with no palpable defects in tendon
* '''Achilles Tendon Rupture'''
*:* Weakness--patient may be unable to stand up on toes (with full rupture)
*:* Thompson Test
*:*:* Patient kneels on chair with feet hanging over edge
*:*:* Squeeze of normal calf muscle foot plantar flexion
*:*:* Squeeze on side with tendon rupture--no foot response
*:* Crescent Sign
*:*:* Blood tracking in soft tissues can be seen beneath malleolus or in foot/toes
* '''Posterior Tibial Tenosynovitis'''
*:* Local tenderness/swelling inferior and posterior to medial malleolus
*:* Swelling may obliterate normal depression inferior to malleolus
*:* Pain exacerbated by resisted ankle inversion and plantar flexion
*:* Passive forced eversion may worsen pain (tendon stretch)
*:* Normal ankle ROM
*:* +/- Pes planus, pes cavus, or ankle pronation
* '''Retrocalcaneal Bursitis'''
*:* Local tenderness and swelling in soft-tissue space between Achilles tendon and calcaneus/talus
*:* Pain increased with forced extreme plantar flexion (compression of bursa)
*:* Resisted ankle plantar/dorsiflexion, inversion/eversion painless (no tendon involvement)
*:* Normal ankle ROM
*:* +/- Significant swelling
* '''Pre-Achilles Bursitis'''
*:* Local midline tenderness and swelling ~1” superior to heel pad, small area of involvement
*:* Passive stretch of Achilles tendon (dorsiflexion) painless or minimally painful
*:* Resisted plantar flexion painless or minimally painful (unlike Achilles tendinitis)
*:* Normal ankle ROM
* '''Ligament Strain'''
*:* Pain anywhere that ligament connects bone to bone
*:* Swelling and skin color changes may be present
*:* Weather sensitivity can exist
== Management ==
=== Acute Traumatic Injury ===
* '''Fracture of Proximal Phalanx of Great Toe – nondisplaced'''
*:* Buddy tape the toe to adjacent toe
*:* Stiff shoes or a short-leg walking cast for 2 weeks
* '''Fracture of Lesser Toes – nondisplaced'''
*:* Buddy tape the toe to adjacent larger toe with cotton placed in toe web
*:* Wide toe-box shoes until healed
* '''Fracture of Metatarsals 1-4 – nondisplaced'''
*:* Ice, elevation, analgesia
*:* Short-leg walking cast for fractures of metatarsals 2-4
*:* First metatarsal fractures requires non-weightbearing casting for 2-3 weeks, then short-leg walking cast for 2-3 weeks more (total immobilization ~5 weeks)
* '''Fracture of 5th Metatarsal'''
*:* Dancer’s Fracture
*:*:* Short-leg walking cast
*:*:* Immobilization for 3-4 weeks to allow tendon reattachment
*:* Jones’ Fracture
*:*:* Bulky Jones dressing for 24-36 hours; no weightbearing
*:*:* Then short-leg walking cast for 3-4 weeks
*:* Transverse Fracture of Shaft
*:*:* Short-leg walking cast; at risk for nonunion despite immobilization
* '''Calcaneal Fracture – extra-articular'''
*:* Strict bedrest for 5-6 days with leg elevation (reduce swelling)
*:* Jones compression dressing for 2-3 days
*:* Short-leg walking cast
*:* Non-weightbearing ambulation only (crutches) until union seen on follw-up X-rays – usually takes weeks
*:* Gradual resumption of weightbearing thereafter
* '''Ligament Strain'''
*:* For the first 72 hours "ICE": ice, compression and elevation
*:* Range of Motion
*:* Depending upon the severity of the strain, reduced activity to non weight bearing for 4-6 weeks
*:* Use of a splint prn
*:* Ankle and foot intrinsic strengthening and balance exercises
[[Image: Walking feet.jpg|thumb|left|walking feet]]
=== Nontraumatic Injury ===
* '''Great Toe'''
*:* Hallux Valgus (bunion)
*:*:* Cotton or rubber spacer between 1st and 2nd toes
*:*:* Wide-toe-box shoes
*:*:* Felt ring or bunion shield to protect medial joint from shoe irritation
*:*:* Ice to side/top of toe for pain relief
*:*:* +/- nonsteriodal anti-inflammatory drugs (NSAIDs), elevation during flare
*:*:* Steroid injection (periarticular) at 4-6 weeks if above measures fail
*:*:* Podiatry/ortho referral for chronic cases (palliative bunionectomy)
*:* Adventitial Bursitis
*:*:* Wide-toe-box shoes
*:*:* Felt ring or bunion shield over medial aspect of joint
*:*:* Consider steroid injection for pain relief after rule out infection (caution in diabetic (DM) patients)
*:*:* NSAIDs often ineffective
*:* Gout (podagra)
*:*:* Ice, elevation, NSAIDs, +/- colchicine or prednisone taper
*:*:* Joint aspiration prone to confirm diagnosis and rule out infection
*:*:* Steroid injection (periarticular) if other treatment contraindicated
*:* Sesamoid Disorders
*:*:* Stiff-soled, low-heeled shoe with soft innersole – reduce stress on sesamoids
*:*:* Orthotics if above measures inadequate
*:*:* If sesamoid fracture, short-leg walking cast for 3-4 weeks, then stiff shoes
* '''Forefoot'''
*:* Metatarsalgia
*:*:* Soft innersoles, molded shoes, or metatarsal bars to disperse weight from MT
*:*:* Surgery needed in some cases, e.g. metatarsal head resection in rheumatoid arthritis (RA)
*:* Morton’s Neuroma
*:*:* Wide-toe-box shoes
*:*:* Soft, padded insoles with cotton or rubber spacer between involved toes
*:*:* Nerve block
*:*:* NSAIDs often ineffective
*:*:* Steroid injection may be beneficial if no relief with above measures
*:*:* Surgical neurectomy if above fails – may cause permanent toe numbness
*:* Metatarsal Stress Fracture
*:*:* Wide-toe-box shoes (decrease medial/lateral pressure)
*:*:* Padded insoles, walking with shortened stride to reduce impact
*:*:* Restricted weightbearing (standing/walking) till pain much improved
*:*:* Short-leg walking cast if persistent symptoms
* '''Hindfoot – plantar region'''
*:* Plantar Fasciitis
*:*:* Padded arch supports, weight loss if obese
*:*:* Soft heel pads or heel cups may relieve pain
*:*:* Ice to heel, massage of heel with tennis ball or frozen water bottle
*:*:* Achilles tendon stretching exercises
*:*:* NSAIDs may have limited benefit (2-3 week course)
*:*:* Steroid injection along plantar fascia can provide short-term relief
*:*:* Judicious use of injections given risk heel pad atrophy and fascial rupture
*:*:* Short-leg walking cast for 4-8 weeks may be beneficial
*:*:* Percutaneous Tenotomy for recalcitrant cases{{Diagnostic musculoskeletal ultrasound]]
*:*:* Open surgery rarely indicated
*:* Infracalcaneal Bursitis
*:*:* Ice, massage, NSAIDs
*:*:* Soft heel pad or heel cup to reduce impact
*:* Calcaneal Periostitis
*:*:* NSAIDs, heel lifts, treat any underlying inflammatory conditions
*:* Calcaneal Spurs
*:*:* Rarely requires treatment; consider heel pad or custom orthotic
*:*:* Surgery if painful spur palpable beneath heel pad
*:* Heel Pad Syndrome
*:*:* Ice during acute phase
*:*:* Rubber heel cups or padded arch supports worn for 1-2 weeks
*:*:* Limited weight bearing during first few days (crutches if needed)
*:*:* Avoidance of hard surfaces
*:*:* Ankle ROM and Achilles tendon stretching exercises during recovery
*:* Tarsal Tunnel Syndrome
*:*:* Cushioned soles, arch supports; orthoses if significant pronation
*:*:* NSAIDs
*:*:* Steroid injection with variable response
*:*:* Nerve blocks can be helpful
*:*:* Surgery may be beneficial, especially if anatomic deformity, e.g. ganglion
*:* Ligament Strain
*:*:* Ankle and foot intrinsic strengthening exercises
*:*:* Balance exercises
*:*:* Therapeutic modalities
*:*:* Orthotics
*:*:* [[Prolotherapy]]
* '''Hindfoot – posterior region'''
*:* Achilles Tendinitis
*:*:* Crutches/non-weightbearing for 7-10 days if severe, acute symptoms
*:*:* +/- Short-leg walking cast or air cast for moderate/severe cases
*:*:* Ice +/- NSAIDs (3-4 week course)
*:*:* Daily gentle stretching in dorsiflexion after acute symptoms to improve
*:*:* Padded heel cups or heel lift; double socks to decrease friction over tendon
*:*:* Vigorous stretches (goal 30° painless dorsiflexion) 3-4 weeks after symptoms resolve
*:*:* Local injection with either steriod, [[Prolotherapy]]
*:*:* Persistent tendinitis requires ortho referral (may need surgery)
*:* Achilles Tendon Rupture
*:*:* Orthopedics referral
*:* Posterior Tibial Tenosynovitis
*:*:* Correct ankle pronation with arch supports or high top shoes
*:*:* Correct pes planus with arch supports
*:*:* Limit standing and walking; use Velcro pull-on ankle brace
*:*:* Ice +/- NSAID (4 week course)
*:*:* Persistent symptoms may require injection, rigid immobilization
*:*:* Ankle stretching exercises during recovery phase
*:*:* Local injection with either steriod or [Prolotherapy]
*:* Retrocalcaneal Bursitis
*:*:* Restriction of repetitive ankle motion (jogging, stair-climbing)
*:*:* Ice, NSAIDs, elevation
*:*:* Avoidance of high heels
*:*:* Padded heel cups, shortened walking stride
*:*:* +/- High top shoes or velcro ankle brace to control heel motion
*:*:* Steroid injection can be very effective
*:*:* Achilles tendon stretching exercises during recovery phase
*:* Pre-Achilles Bursitis
*:*:* Padded heel cups, double socks or felt ring to decrease heel friction
*:*:* Avoidance of rigid-backed shoes; shortened walking/running stride
*:*:* Ice for analgesia
*:*:* Injection + immobilization (air or walking cast) for severe/recurrent cases
*:*:* Achilles tendon stretching exercises
*:* Ligament Strain
*:*:* Ankle and foot intrinsic strengthening exercises
*:*:* Balance exercises
*:*:* Therapeutic modalities
*:*:* Orthotics
*:*:* [[Prolotherapy]]
== References ==

== Acknowledgements ==
The content on this page was first contributed by: Rebecca Cunningham, M.D.
----
== Suggested Reading and Key General References ==
*[http://www.merck.com/mmpe/sec04/ch043/ch043a.html Merck Manual]
*[http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm Referred Back Pain at NINDS]
== Suggested Links and Web Resources ==
*[http://www.piedmontpmr.com Piedmontpmr.com]
== For Patients ==

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

[[Category:Disease]]
[[Category:Musculoskeletal Disease]]

Musculoskeletal problems of the foot

2014-10-04T19:11:39Z

Bobby Schwartz: /* Overview */

{{SI}}

'''Editors-In-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.]; [[User:Michael Tollison|Michael Tollison, M.D.]] [mailto:Tollison864@charter.net], Piedmont Orthopaedic Associates, Greenville, SC

==Overview==
[[Image:Foot & ankle kinesiology.jpg‎|thumb|left|Foot & ankle kinesiology]]
Foot and ankle pain is a very common condition. Anomalies range from [[osteoarthritis]], ligamentous strain [http://www.piedmontpmr.com/ligament-pain-stretched-torn-or-strained], nerve entrapment and [[neuropathy]] [http://www.piedmontpmr.com/peripheral-neuropathy-treatment-options-for-diabetic-and-small-fiber-types], peripheral neuropathy, to mechanical and postural induced abnormalities. Most cases respond to conservative care including physical therapy, orthotics, local injection and percutaneous tenotomy [http://www.piedmontpmr.com/ultrasound-guided-percutaneous-tenotomy-3]. In more recalcitrant cases surgical intervention is required.

==Associated Conditions==
It is not at all uncommon for someone to present with foot or ankle pain even when the primary problem is coming from nerve root irritation in the back [http://www.piedmontpmr.com/low-back-pain-getting-to-the-root-cause], venous reflux [http://www.piedmontpmr.com/treatment-for-burning-itching-swollen-painful-legs-2] or peripheral arterial disease [http://www.piedmontpmr.com/peripheral-arterial-disease-2]. It is therefor important to keep in mind that not all foot and ankle problems arise from the foot or ankle itself. If pain persists beyond a few weeks, it is wise to get a doctors opinion.

== History and Symptoms ==
The history of present illness (the facts that surround the onset of pain) and the symptoms associated with the chief complaint, can provide valuable clues as to its source. Examples of several conditions are listed below.

=== Acute Traumatic Injury ===
* '''Fracture of Proximal Phalanx of Great Toe'''
*:* Usually via direct trauma or toe-stubbing injury
*:* Usually minimal displacement; can by treated conservatively
* '''Fracture of Metatarsals 1-4'''
*:* Usually via direct blow to top of foot
*:* Midfoot pain, inability to bear weight, direct tenderness
*:* Nondisplaced
*:*:* Can be treated conservatively
*:* Displaced
*:*:* Require surgical reduction
* '''Fracture of 5<sup>th</sup> Metatarsal (MT)'''
*:* Dancer’s Fracture
*:*:* Severe inversion injury--avulsion of bone from proximal metatarsal
*:*:* Occurs at site of peroneus brevis insertion
*:*:* Can be treated conservatively (immobilization)
*:* Jones’ Fracture
*:*:* Fracture of proximal tuberosity of base of metatarsal
*:* Transverse fracture of shaft
*:*:* Can be managed conservatively, but high rate nonunion
* '''Calcaneal Fracture'''
*:* Most commonly fractured tarsal bone
*:* Usually via vertical falls or twisting injuries
*:* Intra-articular Fractures
*:*:* All require orthopedics referral; unpredictable healing
*:*:* May be complicated by chronic joint pain, arthritis, nerve entrapment
*:* Extra-articular Fractures
*:*:* Most can be treated without surgery
*:*:* Ortho referral for displaced posterior process fractures (Achilles disruption)
*:*:* Ortho referral for nonunion of anterior process fracture
[[Image:Xray osteoporotic heel2.jpg|thumb|left|Xray osteoporotic heel]]
=== Nontraumatic ===
* '''Great toe'''
*:* Hallux valgus (bunion)
*:*:* Metatarso-phalangeal osteoarthritis (MTP OA)--painful swelling of dorsomedial aspect of 1st metatarsal head
*:*:* Hallux valgus deformity associated (toe angulates laterally)
*:*:* Hyperpronation (flat feet) and poor footwear contribute
*:*:* Arthritic flares or bursitis can occur with ongoing pressure at medial joint line
*:* Adventitial bursitis
*:*:* Inflammation of bursal sac over medial 1st MTP joint due to friction/pressure
*:*:* Dramatic erythema, edema and tenderness
*:* Gout (podagra):
*:*:* Dramatic inflammatory response to monosodium urate (MSU) crystal deposition
*:*:* Can also affect tenosynovial sheaths (enthesitis) and other small joints of foot
*:* Sesamoid disorders
*:*:* Two sesamoids (medial and lateral) articulate on plantar aspect of 1st metatarsal (MT)
*:*:* Inflammation or fracture can occur with chronic stress (runners, dancers)
*:*:* Localized pain and swelling at plantar aspect of 1st
* '''Forefoot'''
*:* Metatarsalgia
*:*:* Pain at any of the 2nd-5th metatarsal heads with weight-bearing
*:*:* Can be related to inflammatory deformity with subluxation of MT head (right anterior)
*:* Morton’s neuroma
*:*:* Chronic irritation of digital nerve running between metatarsal heads
*:*:* Most commonly occurs between 3rd and 4th toes
*:*:* Burning pain btwn toes; cramping; numbness along sides of 2 adjacent toes
*:*:* Typically associated with poorly padded shoes, improves with forefoot massage
*:* Metatarsal stress fracture
*:*:* Microfracture of metatarsal after prolonged walking/standing (“march fracture”)
*:*:* Usually 2nd or 3rd metatarsal
*:*:* Sudden onset of pain, often without history of trauma
*:*:* Military recruits, athletes, osteoporotic patients at risk
* '''Hindfoot – Plantar Region'''
*:* Plantar fasciitis
*:*:* One of most common causes adult foot pain
*:*:* Heel pain worse with initiation of walking/standing after inactivity
*:*:* Results from strain of plantar fascia after jumping, prolonged standing
*:*:* Predisposing factors
*:*:*:* Obesity
*:*:*:* Flat feet (pes planus) or high arches (pes cavus)
*:*:*:* Excessive pronation
*:*:*:* Short Achilles tendons
*:*:* Can be an inflammatory process associated with systemic disease (rheumatoid arthritis (RA), Reiter’s)
*:*:* Calcaneal spurs may coexist or develop due to inflammation (but usually asymptomatic)
*:* Infracalcaneal bursitis
*:*:* Inflammation of bursa beneath calcaneus
*:*:* Pain/ache in mid-plantar aspect of calcaneus
*:*:* Symptoms increase with duration of weight-bearing
*:* Calcaneal periostitis
*:*:* Bilateral pain along plantar and lateral aspects of heels
*:*:* Can be due to trauma
*:*:* Can be due to inflammatory disease (RA, psoriatic arthritis, ankylosing spondylitis, Reiter’s)
*:*:* May improve with treatment of underlying disease process
*:* Calcaneal spurs
*:*:* Bony outgrowths that develop on plantar tuberosity
*:*:* Usually asymptomatic
*:*:* Pain can occur if large (>1 cm) with apex angled downward--pain with weight-bearing
*:* Heel pad syndrome
*:*:* Irritation of fat pad due to trauma
*:*:* Pain localized to heel pad; plantar fascia not tender
*:*:* Most commonly in marathon runners
*:*:* Self-limited, resolves within 2-3 weeks
*:* Tarsal tunnel syndrome
*:*:* Posterior tibial nerve compressed in tarsal tunnel
*:*:*:* (Beneath flexor retinaculum inferoposterior to medial malleolus)
*:*:* Can occur via local trauma (sprain, fracture), repetitive hyperpronation
*:*:* Also via inflammatory disease (RA), bony prominences, pregnancy, hypoT4
*:*:* Paresthesias, plantar pain (medial/lateral plantar nerve distribution)
*:*:* Symptoms often nocturnal or after standing, relieved by foot/ankle movement
*:* Referred pain (subtalar arthritis, lumbosacral (LS) radiculopathy)
*:*:* Treat the underlying condition
*:*:* For example, see [RSD], [CRPS], [Low back pain]
[[image:Ankle med & lat view.jpg|thumb|left|Ankle med & lat view]]
*:* Ligament Strain
*:*:* Pain anywhere that ligament connects bone to bone
*:*:* May be associated with swelling and skin color changes
*:*:* Often due to an inciting event (such as a turned or twisted ankle)
*:*:* May also be due to normal wear and tear or other forgotten injury
* '''Hindfoot – Posterior Region'''
*:* Achilles tendinitis
*:*:* Inflammation and microtears near Achilles tendon insertion
*:*:* Often associated with repetitive irritation (athletes)
*:*:* Bilateral involvement (in absence of quinolone) suggests Reiter’s or spondylitis
*:*:* Pain behind ankle with walking, standing, weight-bearing athletic activities
*:*:* Pain worse with activity--later stiffness and swelling
*:*:* Untreated cases--acute '''rupture''' (up to 10%) or chronic tendinitis
*:* Achilles tendon rupture
*:*:* Occurs after abrupt calf muscle contraction
*:*:* Typically occurs in patients > 30 years old with sporadic athletic activity
*:*:* Also associated with fluoroquinolone use
*:*:* Audible snap followed by severe pain in calf
*:*:* Partial rupture can occur without precipitating event
*:* Posterior tibial tenosynovitis
*:*:* Inflammation of tendon as it passes around the medial malleolus
*:*:* Exacerbants = ankle pronation, pes planus, obesity
*:*:* Can be associated w/tarsal tunnel syndrome, especially if significant pronation
*:*:* Pain and swelling at inner aspect of ankle, worse wtih walking
*:* Retrocalcaneal bursitis
*:*:* Inflammation of bursa between Achilles tendon and calcaneus
*:*:* Uncommon
*:*:* Pain behind ankle, increased with walking (plantar flexion)
*:* Pre-Achilles bursitis
*:*:* Inflammation of bursa between Achilles tendon (calcaneal insertion) and skin
*:*:* May resemble Achilles tendinitis, but less disabling; no significant risk tendon rupture
*:*:* Pain and localized swelling behind the heel
*:*:* Aggravated/caused by inappropriate shoes
*:* Ligament Strain
*:*:* Pain anywhere that ligament connects bone to bone
*:*:* May be associated with swelling and skin color changes
*:*:* Often due to an inciting event (such as a turned or twisted ankle)
*:*:* May also be due to normal wear and tear or other forgotten injury

== Presentation and Physical Exam ==
=== 1st MTP Joint Conditions ===
* '''Hallux Valgus'''
*:* Valgus deformity of MTP joint
*:*:* Prominent metatarsal head, toe points laterally
*:*:* First and second toe may overlap if advanced
*:* Tenderness along medial joint line (or over whole joint if acute flare)
*:* Joint enlargement due to subluxation, osteophytes, edema
*:* Crepitation with passive movement of MTP joint
*:* +/- Pain at extremes of passive plantar/dorsiflexion of toe
*:* +/- Limited range of motion (ROM) (hallux rigidus)
* '''Adventitial Bursitis of 1st MTP'''
*:* Erythema, swelling over medial aspect of MTP joint (focal area vs. full joint involvement with gout)
*:* Maximal tenderness over medial joint line
*:* Associated with hallux valgus deformity (increased friction with shoes) +/- resultant loss of ROM
*:* Mild pain with MTP flexion/extension (vs. gout with severe pain)
*:* Isometric toe flexion/extension against resistance painless (tendons spared)
* '''Gout'''
*:* Significant erythema, swelling and exquisite tenderness involving entire joint
*:* Severe pain with MTP flexion/extension
* '''Sesamoiditis or Fracture'''
*:* Localized tenderness/swelling on plantar palpation of MTP

=== Lesser MTP Forefoot Conditions ===
* '''Metatarsalgia'''
*:* Maximal tenderness at the MTP heads
*:* Plantar protrusion of metatarsal head(s) may be visible with patient lying prone
*:* Callus often present beneath involved metatarsal(s)
*:* Adjacent metatarsals may be hypermobile (shifting weight to involved metatarsal)
* '''Morton’s Neuroma'''
*:* Tenderness greatest in web space between MTP heads (vs. at MTP heads in metatarsalgia)
*:* Pain reproduced by squeezing MTP heads from sides (electric pain to ends of adjacent 2 toes)
*:* Click may be felt with squeeze + deep palpation in distal intermetatarsal space (Mulder’s sign)
*:* Passive ROM of MTP joints painless
*:* +/- Loss of sensation along inner aspects of 2 adjacent toes (advanced cases)
* '''Metatarsal Stress Fracture'''
*:* Localized tenderness over metatarsal shaft
*:* Dramatic dorsal foot swelling
*:* Pain when metatarsals squeezed from the sides

=== Hindfoot (Plantar) Conditions ===
[[image:Plantar fascitis.jpg|thumb|left|Plantar fascitis]]
* '''Plantar Fasciitis'''
*:* Focal point tenderness at the calcaneal origin of the plantar fascia – pain can be increased by toe dorsiflexion (stretch fascia) during palpation of medial plantar surface ~1.5” distal to posterior heel
*:* Medial-to-lateral compression of calcaneus usually less painful than local fascial tenderness (if compression more painful, must rule out calcaneal stress fracture)
*:* +/- Limited foot dorsiflexion (nl = 25-30°) due to shortening of Achilles tendon
*:* +/- Associated pes planus/cavus
* '''Infracalcaneal Bursitis'''
*:* Point tenderness directly under center of calcaneus (plantar surface)
*:* +/- Localized warmth/swelling
* '''Calcaneal Periostitis'''
*:* Diffuse tenderness along plantar aspect of heel and midfoot bilateral and along lateral edges of heels
*:* Evaluation for signs underlying rheumatologic disease indicated
* '''Calcaneal Spurs'''
*:* Usually no specific findings; prominent spur palpable through skin may require intervention
* '''Heel Pad Syndrome'''
*:* Pain localized to heel pad, aggravated by squeezing pad from side to side
*:* Plantar fascia not tender; pain not exacerbated by toe dorsiflexion
* '''Tarsal Tunnel Syndrome'''
*:* Reproduction of symptoms with percussion or pressure over flexor retinaculum (Tinel’s sign)
* '''Ligament Strain'''
*:* Pain anywhere that ligament connects bone to bone
*:* Swelling and skin color changes may be present
*:* Weather sensitivity can exist
=== Hindfoot (Posterior) Conditions ===
* '''Achilles Tendinitis'''
*:* Tender, fusiform thickening of Achilles tendon with “cobblestone” texture
*:* Pain exacerbated with resisted plantar flexion and passive stretching in dorsiflexion
*:* Ankle ROM normal, though may be limited by pain in dorsiflexion
*:* Preserved calf muscle strength with no palpable defects in tendon
* '''Achilles Tendon Rupture'''
*:* Weakness--patient may be unable to stand up on toes (with full rupture)
*:* Thompson Test
*:*:* Patient kneels on chair with feet hanging over edge
*:*:* Squeeze of normal calf muscle foot plantar flexion
*:*:* Squeeze on side with tendon rupture--no foot response
*:* Crescent Sign
*:*:* Blood tracking in soft tissues can be seen beneath malleolus or in foot/toes
* '''Posterior Tibial Tenosynovitis'''
*:* Local tenderness/swelling inferior and posterior to medial malleolus
*:* Swelling may obliterate normal depression inferior to malleolus
*:* Pain exacerbated by resisted ankle inversion and plantar flexion
*:* Passive forced eversion may worsen pain (tendon stretch)
*:* Normal ankle ROM
*:* +/- Pes planus, pes cavus, or ankle pronation
* '''Retrocalcaneal Bursitis'''
*:* Local tenderness and swelling in soft-tissue space between Achilles tendon and calcaneus/talus
*:* Pain increased with forced extreme plantar flexion (compression of bursa)
*:* Resisted ankle plantar/dorsiflexion, inversion/eversion painless (no tendon involvement)
*:* Normal ankle ROM
*:* +/- Significant swelling
* '''Pre-Achilles Bursitis'''
*:* Local midline tenderness and swelling ~1” superior to heel pad, small area of involvement
*:* Passive stretch of Achilles tendon (dorsiflexion) painless or minimally painful
*:* Resisted plantar flexion painless or minimally painful (unlike Achilles tendinitis)
*:* Normal ankle ROM
* '''Ligament Strain'''
*:* Pain anywhere that ligament connects bone to bone
*:* Swelling and skin color changes may be present
*:* Weather sensitivity can exist
== Management ==
=== Acute Traumatic Injury ===
* '''Fracture of Proximal Phalanx of Great Toe – nondisplaced'''
*:* Buddy tape the toe to adjacent toe
*:* Stiff shoes or a short-leg walking cast for 2 weeks
* '''Fracture of Lesser Toes – nondisplaced'''
*:* Buddy tape the toe to adjacent larger toe with cotton placed in toe web
*:* Wide toe-box shoes until healed
* '''Fracture of Metatarsals 1-4 – nondisplaced'''
*:* Ice, elevation, analgesia
*:* Short-leg walking cast for fractures of metatarsals 2-4
*:* First metatarsal fractures requires non-weightbearing casting for 2-3 weeks, then short-leg walking cast for 2-3 weeks more (total immobilization ~5 weeks)
* '''Fracture of 5th Metatarsal'''
*:* Dancer’s Fracture
*:*:* Short-leg walking cast
*:*:* Immobilization for 3-4 weeks to allow tendon reattachment
*:* Jones’ Fracture
*:*:* Bulky Jones dressing for 24-36 hours; no weightbearing
*:*:* Then short-leg walking cast for 3-4 weeks
*:* Transverse Fracture of Shaft
*:*:* Short-leg walking cast; at risk for nonunion despite immobilization
* '''Calcaneal Fracture – extra-articular'''
*:* Strict bedrest for 5-6 days with leg elevation (reduce swelling)
*:* Jones compression dressing for 2-3 days
*:* Short-leg walking cast
*:* Non-weightbearing ambulation only (crutches) until union seen on follw-up X-rays – usually takes weeks
*:* Gradual resumption of weightbearing thereafter
* '''Ligament Strain'''
*:* For the first 72 hours "ICE": ice, compression and elevation
*:* Range of Motion
*:* Depending upon the severity of the strain, reduced activity to non weight bearing for 4-6 weeks
*:* Use of a splint prn
*:* Ankle and foot intrinsic strengthening and balance exercises
[[Image: Walking feet.jpg|thumb|left|walking feet]]
=== Nontraumatic Injury ===
* '''Great Toe'''
*:* Hallux Valgus (bunion)
*:*:* Cotton or rubber spacer between 1st and 2nd toes
*:*:* Wide-toe-box shoes
*:*:* Felt ring or bunion shield to protect medial joint from shoe irritation
*:*:* Ice to side/top of toe for pain relief
*:*:* +/- nonsteriodal anti-inflammatory drugs (NSAIDs), elevation during flare
*:*:* Steroid injection (periarticular) at 4-6 weeks if above measures fail
*:*:* Podiatry/ortho referral for chronic cases (palliative bunionectomy)
*:* Adventitial Bursitis
*:*:* Wide-toe-box shoes
*:*:* Felt ring or bunion shield over medial aspect of joint
*:*:* Consider steroid injection for pain relief after rule out infection (caution in diabetic (DM) patients)
*:*:* NSAIDs often ineffective
*:* Gout (podagra)
*:*:* Ice, elevation, NSAIDs, +/- colchicine or prednisone taper
*:*:* Joint aspiration prone to confirm diagnosis and rule out infection
*:*:* Steroid injection (periarticular) if other treatment contraindicated
*:* Sesamoid Disorders
*:*:* Stiff-soled, low-heeled shoe with soft innersole – reduce stress on sesamoids
*:*:* Orthotics if above measures inadequate
*:*:* If sesamoid fracture, short-leg walking cast for 3-4 weeks, then stiff shoes
* '''Forefoot'''
*:* Metatarsalgia
*:*:* Soft innersoles, molded shoes, or metatarsal bars to disperse weight from MT
*:*:* Surgery needed in some cases, e.g. metatarsal head resection in rheumatoid arthritis (RA)
*:* Morton’s Neuroma
*:*:* Wide-toe-box shoes
*:*:* Soft, padded insoles with cotton or rubber spacer between involved toes
*:*:* Nerve block
*:*:* NSAIDs often ineffective
*:*:* Steroid injection may be beneficial if no relief with above measures
*:*:* Surgical neurectomy if above fails – may cause permanent toe numbness
*:* Metatarsal Stress Fracture
*:*:* Wide-toe-box shoes (decrease medial/lateral pressure)
*:*:* Padded insoles, walking with shortened stride to reduce impact
*:*:* Restricted weightbearing (standing/walking) till pain much improved
*:*:* Short-leg walking cast if persistent symptoms
* '''Hindfoot – plantar region'''
*:* Plantar Fasciitis
*:*:* Padded arch supports, weight loss if obese
*:*:* Soft heel pads or heel cups may relieve pain
*:*:* Ice to heel, massage of heel with tennis ball or frozen water bottle
*:*:* Achilles tendon stretching exercises
*:*:* NSAIDs may have limited benefit (2-3 week course)
*:*:* Steroid injection along plantar fascia can provide short-term relief
*:*:* Judicious use of injections given risk heel pad atrophy and fascial rupture
*:*:* Short-leg walking cast for 4-8 weeks may be beneficial
*:*:* Percutaneous Tenotomy for recalcitrant cases{{Diagnostic musculoskeletal ultrasound]]
*:*:* Open surgery rarely indicated
*:* Infracalcaneal Bursitis
*:*:* Ice, massage, NSAIDs
*:*:* Soft heel pad or heel cup to reduce impact
*:* Calcaneal Periostitis
*:*:* NSAIDs, heel lifts, treat any underlying inflammatory conditions
*:* Calcaneal Spurs
*:*:* Rarely requires treatment; consider heel pad or custom orthotic
*:*:* Surgery if painful spur palpable beneath heel pad
*:* Heel Pad Syndrome
*:*:* Ice during acute phase
*:*:* Rubber heel cups or padded arch supports worn for 1-2 weeks
*:*:* Limited weight bearing during first few days (crutches if needed)
*:*:* Avoidance of hard surfaces
*:*:* Ankle ROM and Achilles tendon stretching exercises during recovery
*:* Tarsal Tunnel Syndrome
*:*:* Cushioned soles, arch supports; orthoses if significant pronation
*:*:* NSAIDs
*:*:* Steroid injection with variable response
*:*:* Nerve blocks can be helpful
*:*:* Surgery may be beneficial, especially if anatomic deformity, e.g. ganglion
*:* Ligament Strain
*:*:* Ankle and foot intrinsic strengthening exercises
*:*:* Balance exercises
*:*:* Therapeutic modalities
*:*:* Orthotics
*:*:* [[Prolotherapy]]
* '''Hindfoot – posterior region'''
*:* Achilles Tendinitis
*:*:* Crutches/non-weightbearing for 7-10 days if severe, acute symptoms
*:*:* +/- Short-leg walking cast or air cast for moderate/severe cases
*:*:* Ice +/- NSAIDs (3-4 week course)
*:*:* Daily gentle stretching in dorsiflexion after acute symptoms to improve
*:*:* Padded heel cups or heel lift; double socks to decrease friction over tendon
*:*:* Vigorous stretches (goal 30° painless dorsiflexion) 3-4 weeks after symptoms resolve
*:*:* Local injection with either steriod, [[Prolotherapy]]
*:*:* Persistent tendinitis requires ortho referral (may need surgery)
*:* Achilles Tendon Rupture
*:*:* Orthopedics referral
*:* Posterior Tibial Tenosynovitis
*:*:* Correct ankle pronation with arch supports or high top shoes
*:*:* Correct pes planus with arch supports
*:*:* Limit standing and walking; use Velcro pull-on ankle brace
*:*:* Ice +/- NSAID (4 week course)
*:*:* Persistent symptoms may require injection, rigid immobilization
*:*:* Ankle stretching exercises during recovery phase
*:*:* Local injection with either steriod or [Prolotherapy]
*:* Retrocalcaneal Bursitis
*:*:* Restriction of repetitive ankle motion (jogging, stair-climbing)
*:*:* Ice, NSAIDs, elevation
*:*:* Avoidance of high heels
*:*:* Padded heel cups, shortened walking stride
*:*:* +/- High top shoes or velcro ankle brace to control heel motion
*:*:* Steroid injection can be very effective
*:*:* Achilles tendon stretching exercises during recovery phase
*:* Pre-Achilles Bursitis
*:*:* Padded heel cups, double socks or felt ring to decrease heel friction
*:*:* Avoidance of rigid-backed shoes; shortened walking/running stride
*:*:* Ice for analgesia
*:*:* Injection + immobilization (air or walking cast) for severe/recurrent cases
*:*:* Achilles tendon stretching exercises
*:* Ligament Strain
*:*:* Ankle and foot intrinsic strengthening exercises
*:*:* Balance exercises
*:*:* Therapeutic modalities
*:*:* Orthotics
*:*:* [[Prolotherapy]]
== References ==

== Acknowledgements ==
The content on this page was first contributed by: Rebecca Cunningham, M.D.
----
== Suggested Reading and Key General References ==
*[http://www.merck.com/mmpe/sec04/ch043/ch043a.html Merck Manual]
*[http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm Referred Back Pain at NINDS]
== Suggested Links and Web Resources ==
*[http://www.piedmontpmr.com Piedmontpmr.com]
== For Patients ==

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[[Category:Disease]]
[[Category:Musculoskeletal Disease]]

Medical tourism

2014-10-04T19:10:31Z

Bobby Schwartz: /* Description */

'''Editor-in-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.];

'''Associate Editor-In-Chief:''' [[Jeffrey Lefko,]] MHA, Lefko and Associates, Taylors, South Carolina

'''Medical tourism''' (also called '''medical travel''' or '''health tourism''') is a term initially coined by [[Travel agency|travel agencies]] and the [[mass media]] to describe to the rapidly-growing practice of [[travel]]ing to another country to obtain [[health care]].

Such services typically include elective procedures as well as complex specialized [[surgery|surgeries]] such as [[joint replacement]] ([[Knee replacement|knee]]/[[Hip replacement|hip]]), [[cardiac surgery]], [[dental surgery]], and [[Cosmetic surgery|cosmetic surgeries]]. The provider and customer use informal channels of communication-connection-contract, with less regulatory or legal oversight to assure quality and less formal recourse to reimbursement or redress, if needed.

Leisure aspects typically associated with travel and tourism may be included on such medical travel trips.

==History==
The concept of medical tourism is not a new one. The first recorded instance of medical tourism dates back thousands of years to when [[Greek]] pilgrims traveled from all over the [[Mediterranean]] to the small territory in the [[Saronic Gulf]] called [[Epidauria]]. This territory was the sanctuary of the healing god [[Asklepios]]. Epidauria became the original travel destination for medical tourism.

[[Spa town]]s may be considered an early form of medical tourism.

==Description==
Factors that have led to the recent increase in popularity of medical travel include the high cost of health care or wait times for procedures in industrialized nations, the ease and affordability of international travel, and improvements in technology and standards of care in many countries of the world.

Medical tourists can come from anywhere in the world, including Europe, the UK, Middle East, Japan, U.S. and Canada. This is because of their large populations, comparatively high wealth, the high expense of health care or lack of health care options locally, and increasingly high expectations of their populations with respect to health care.

A large draw to medical travel is cost, convenience and speed. Countries that operate public health-care systems are often so taxed that it can take considerable time to get non-urgent medical care. The time spent waiting for a procedure such as a hip replacement can be a year or more in Britain and Canada; however, in Singapore, Hong Kong, Thailand, Cuba, Colombia, Philippines or India, a patient could feasibly have an operation the day after their arrival. In Canada, the number of procedures in 2005 for which people were waiting was 782,936.<ref>{{cite web|url=http://www.medtrotter.com/publications/WHTC_2007.pdf|title=Health Tourism 2.0|publisher=World Health Tourism Congress|accessdate=2007-04-13}}</ref>

Additionally, patients are finding that insurance either does not cover various surgeries or imposes unreasonable restrictions on the choice of the facility, surgeon, or prosthetics to be used. Medical tourism for knee/hip replacements and stem cell therapy have emerged as some of the more widely accepted procedures in medical tourism because of the lower cost, ease of access, and minimal difficulties associated with the traveling to/from the procedure.

Medical tourists may seek essential health care services such as cancer treatment and brain and transplant surgery as well as complementary or 'elective' services such as aesthetic treatments (cosmetic surgery).

According to research found in an article by the University of Delaware publication, UDaily:

{{cquote|the cost of surgery in El Salvador, Panama, Argentina, Cuba, India, Thailand, Colombia, Philippines or South Africa can be one-tenth of what it is in the United States or Western Europe, and sometimes even less. A heart-valve replacement that would cost [[United States dollar|US]]$200,000 or more in the U.S., for example, goes for $10,000 in the Philippines and India—and that includes round-trip airfare and a brief vacation package. Similarly, a metal-free dental bridge worth $5,500 in the U.S. costs $500 in India or Bolivia and only $200 in the Philippines, a knee replacement in Thailand with six days of physical therapy costs about one-fifth of what it would in the States, and Lasik eye surgery worth $3,700 in the U.S. is available in many other countries for only $730. Cosmetic surgery savings are even greater: A full facelift that would cost $20,000 in the U.S. runs about $3,000 in Cuba, $2,700 in the Philippines or $2,500 in South Africa or $ 2,300 in Bolivia."<ref name="MedTourismWorldwide"/>}}

Popular '''medical travel''' worldwide destinations include:
[[Brunei]], [[Cuba]], [[Colombia]],[[Hong Kong]], [[Hungary]], [[India]], [[Israel]], [[Jordan]], [[Lithuania]], [[Malaysia]], [[The Philippines]], [[Singapore]], [[South Africa]], [[Thailand]], and recently, [[United Arab Emirates|UAE]] and [[New Zealand]].

Popular '''cosmetic surgery travel''' destinations include:[[Argentina]], [[Bolivia]], [[Brazil]], [[Colombia]], [[Costa Rica]], [[Cuba]], [[Mexico]] and [[Turkey]].

In Europe [[Belgium]], [[Poland]] and [[Slovakia]] are also breaking into the business.
[[South Africa]] is taking the term "medical tourism" very literally by promoting their "medical safaris": Come to see African wildlife and get a facelift in the same trip.<ref>[http://www.cbc.ca/news/background/healthcare/medicaltourism.html "Medical tourism: Need surgery, will travel"] ''CBC News Online'', [[June 18]], [[2004]], retrieved [[September 5]], [[2006]]</ref>

However, perceptions of medical tourism are not always positive. In places like the U.S.medical tourism is viewed as risky. In some parts of the world, wider political issues can influence where medical tourists will choose to seek out health care; for example, in late 2006, some patients from the Middle East were choosing to travel to Singapore or Hong Kong for health care rather than to the U.S. because of international tensions.

While the tourism component might be a big draw for some Southeast Asia countries that focus on simple procedures, they are not alone in this market. For example Panama,Costa Rica and India are positioning themselves to become primary medical destinations. India's commitment to this is demonstrated with a growing number of hospitals that are attaining the U.S. Joint Commission International accreditation to help to capture the US medical tourism market, while others looking beyond just the US market to potential clients from the United Kingdom, Europe and Australia may also look towards other [[international healthcare accreditation]] schemes for brand advantage.

Singapore also positions itself as a medical hub for health care services, medicine, biomedical research and pharmaceutical manufacturing converge. Singapore has made international news for many complex surgeries in specialties such as neurology, oncology, and organ transplants procedures. Currently Singapore boasts the largest number of U.S. Joint Commission accredited hospitals in the region.

In South America, countries such as Argentina, Bolivia, Brazil and Colombia lead on plastic surgery medical skills relying on the vast experience their surgeons have in treating the style-obsessed. It is estimated that 1 in 30 Argentineans have had plastic surgery procedures, making this population the most operated in the world after the U.S. and Mexico. In Bolivia and Colombia, plastic surgery has become quite common.

Companies are beginning to offer global health care options that will enable North American and European patients to access world health care at a fraction of the cost of domestic care. Medical tourism companies typically provide experienced nurse case managers to assist patients with pre- and post-travel medical issues. They also help provide resources for follow-up care upon the patient's return. While these services will initially be of interest to the self-insured patient, several studies indicate that the rapid growth of Health Savings Accounts in the U.S. will also drive interest to health care in other countries.

==[[International healthcare accreditation]]==
Because standards are everything when it comes to health care, there are parallel issues around medical tourism, [[international healthcare accreditation]], [[evidence-based medicine]] and [[quality assurance]].

Those people considering becoming medical tourists may be assisted in making rational choices by whether hospitals providing such services have been assessed and accredited by reputable and independent [[international healthcare accreditation|external accreditation bodies]]. In the [[USA]], JCI (Joint Commission International) fulfills such a role, while in the [[UK]] and [[Hong Kong]], the [[Trent Accreditation Scheme|Trent International Accreditation Scheme]] is a key player. The different [[international healthcare accreditation]] schemes vary in quality, size, intent and the skill of their marketing. They also vary in terms of cost to hospitals and healthcare institutions using them. They all have web sites.

Increasingly, some hospitals are looking towards "dual international accreditation", perhaps having both JCI to cover potential US clientele and [[Trent Accreditation Scheme|Trent]] for potential British and European clientele.

* [http://sofiha.ibusinessdot.com/ The Society for International Healthcare Accreditation], or SOFIHA, is a free-to-join group providing a forum for discussion and for the sharing of ideas and good practice by providers of international healthcare accreditation and users of the same - the primary role of this organisation is to promote a safe hospital environment for patients, wherever they travel to in the world for health care.

*

== Destinations ==

===Cuba===

For more than 40 years, Cuba has been a popular medical tourism destination. In 2006, Cuba attracted nearly 20000<ref>[http://www.caribbeannetnews.com/news-3085--6-6--.html Commentary: A Novel Tourism Concept] Caribbean Net News [[Aug 18]], [[2007]], retrieved [[Aug 18]], [[2007]]</ref> [[health tourists]].

In 2001, the BBC News reported that thousands of patients come to Cuba from as far away as Latin America and Europe, attracted by the "fine reputation of Cuban doctors, the low prices and nearby beaches on which to recuperate." <ref name="CubasMedicalSuccess">[http://news.bbc.co.uk/2/hi/americas/1535358.stm
BBC News [[Sept. 10]], [[2001]], retrieved [[July 20]], [[2007]]</ref>

A wide range of medical treatments are provided including joint replacement, cancer treatment, eye surgery, cosmetic surgery and addictions rehabilitation. Costs are about 60 to 80 percent less than U.S. costs.

Cuba has hospitals for Cuban residents, and others that focus on serving foreigners and diplomats. Cubans receive free healthcare for life.

In the 2007 American documentary film, "Sicko," which criticizes the U.S. healthcare system, producer [[Michael Moore]] leads a group of uninsured American patients to Cuba to obtain more affordable medical treatment. "Sicko" has greatly increased foreigners' interest in Cuban healthcare, especially Havana Hospital, which was featured in the film.

Statistically healthcare in Cuba compare very good to many countries worldwide. The chance of a Cuban child dying at five years of age or younger is 7 per 1000 live births in Cuba, while it's 8 per 1000 in the US, says the World Health Organization (WHO). Cuba has nearly twice as many physicians per person as the U.S. -- 5.91 doctors per thousand people compared to 2.56 doctors per thousand, according to WHO. Life expectancy in the two countries is almost equal. WHO reports that Cuban life expectancy at birth is 75 years for males, and 79 years for females. In comparison, the US life expectancy at birth is 75 and 80 years for males and females, respectively. Cuba's infant mortality rate is equal to that of the US at 6 percent. <ref name="WorldHealthOrganizationStatistics">[http://www.who.int/countries/cub/en WHO [[2005]], retrieved [[July 20]], [[2007]]</ref> <ref name="WorldHealthOrganizationStatistics">[http://www.who.int/whosis/whostat2007 WHO [[2007]], retrieved [[Aug 1]], [[2007]]</ref>

The Cuban government has developed Cuban medical tourism to generate income for the country. There is an ongoing program that sends thousands of Cuban doctors to Venezuela to help its poor residents, and this helps Cuba pay Venezuela for oil.

Residents of Canada, the UK and most other countries can travel to Cuba without any difficulty, and a tourist visa is generally required. For Americans, however, because of the US trade policy towards Cuba, travelers must either obtain U.S. government approval, or, more frequently, travel to Cuba from Canada, Mexico, the Bahamas, Jamaica or the Dominican Republic. North Americans can reach Cuba easily via daily flights from Toronto, Montreal, Cancun, Mexico City, Nassau (Bahamas), Kingston (Jamaica), and Santo Domingo (Dominican Republic). Cuban immigration authorities do not stamp the passports of US visitors so that Americans can keep their travels a private matter.

===Mexico===

One Washington Post article [http://www.washingtonpost.com/wp-dyn/content/article/2007/06/17/AR2007061701297.html Discount Dentistry, South of The Border] says "Mexican dentists often charge one-fifth to one-fourth of U.S. prices". This trend has alarmed some American healthcare providers and legislators. "In Texas, legislators explored the possibility of allowing health maintenance organizations to operate on both sides of the border. However, physicians in south Texas lobbied against the changes, arguing that local doctors could not compete with the lower costs in Mexico" [http://www.boston.com/news/nation/articles/2005/11/13/california_health_costs_send_patients_to_mexico_facilities/].

Indeed one does need to exercise caution as "the Mexican legal system makes it almost impossible to sue them" [http://www.washingtonpost.com/wp-dyn/content/article/2007/06/17/AR2007061701297.html]. However many who take the chance report that they are satisfied with the care received, "They have everything I need," says Luis Gonzales of San Diego, "They're clean. You don't see a difference between a doctor over here and over there". According to a report commissioned by Families U.S.A., a Washington advocacy group for health-care issues, "About 90 percent [feel] the care they had received in Mexico had been good or excellent. About 80 percent rated the care they had received in the United States as good or excellent" [http://query.nytimes.com/gst/fullpage.html?res=9E0CE5DA113CF930A15752C1A964958260].

Indeed more and more American insurers are providing coverage for travelers as the out of pocket costs to them are much lower. "With healthcare costs in the United States continuing to rise, many employers in Southern California are turning to insurance plans that send their workers to Mexico for routine care, plans that are growing by nearly 3,000 people a year".

===Panama===

In Panama, health and medical tourism is growing rapidly. Many factors are bringing health tourists to Panama. The combination of climate, scenic beauty, cultural diversity, strategic geographical position, one of the world’s key offshore trading centers, the hub of the Americas for international travel, the dollar as the official currency….but most important of all, the medical professionals are well trained from institutions around the world, use the latest technologies and medications, and have earned a reputation of quality professionals. Most of Panama’s doctors are bilingual, board certified, and accustomed to working with the same state of the art medical equipment and technology used in the United States and Europe. Medical tourists coming to Panama can stay at a 5-star hotel during convalescence for prices far below those in the United States and Europe. For example, dental implants costs an average of $2,500 per implant if placed in the US or Canada. On most procedures, Panama offers savings of more than 50% compared to the US and Europe.

Getting world-class medical service and vacation time in a luxury setting is affordable in Panama. You can find in this country a wide range of health services and experienced specialist physicians in all areas such as in dental implants, plastic surgery, assisted reproduction, cardiology, cosmetic dentistry, orthopedics, etc. You can even have an “extreme makeover” done and go back to your country not just feeling great but looking like a new person. People are traveling from around the world looking for high-quality health care at accessible prices as well as discovering Panama´s crystalline Caribbean waters, fascinating indigenous cultures, and deluxe resorts on the beach, in the rain forest, and in the mountains.

Many of these patients that have already come to Panama as health tourists, feel at ease immediately because both staff and doctors speak perfect English. They also report that they have been treated with utmost respect and feel doctors are genuinely interested in the person as an individual instead of feeling like a number. All leave Panama very surprised of the country’s professional doctors, hospitals, and advanced technology. These patients feel very pleased with the treatment or procedure received, especially because of the affordable prices and the wonderful vacation they spent in Panama.

Panama's main Hospitals have affiliations to renowned international Organizations such as: Baptist Health International of Miami, Cleveland Clinic, Tulane Health Science Center, Johns Hopkins International, Miami Children's Hospital, University of Nebraska Medical Center, The Kendall Medical Center in Florida, and Harvard Medical Faculty and Physicians at Beth Israel Deaconess Medical Center in USA.

For more information visit [http//:www.pana-health.com]

===Jordan===
Jordan is a popular destination for health tourism in the Middle East. Palestinians, Iraqis, Syrians, and Southeast Asians are frequent visitors, rumoredly including Iraq's President Jalal Talabani.

===Colombia===

Colombia has been treating patients from all over the world for years, especially for cosmetic and eye surgery. Colombia has also become a recognized provider of advanced cardiovascular and transplant surgery. What often compels persons to seek transplant surgery offshore is not only cost considerations, but waiting lists (such as in the U.S.) or the lack of an organized organ inventory and donor system in the home country. Colombia has such an organ donor and banking system which makes organs available to foreigners with certain legal restrictions. Orthopedic surgeries, such as knee and hip replacements, are done in Colombia with U.S.-made ([[FDA]]-approved) prosthetics at a fraction of the cost.

Colombia has many surgeons that have either trained and/or practiced in other countries such as the U.S. and Europe. Salaries for doctors, nurses, and supporting personnel in Colombia are about 20% of U.S. salaries for similar occupations even though they are required to have the same level of education and job skills. Real estate costs related to medical care facilities are also only a fraction of what they are in the U.S.

One advantage of Colombia for those from the U.S. and Canada is ease of travel and close proximity. Colombia offers cheaper airfares from the U.S. and Canada (and some European countries) than other destinations, such as those in Asia, and does not have the visa restrictions of other countries currently in the medical tourism marketplace.

===Philippines===

The Philippines has been growing as a destination for medical tourism. Cost savings are significant since foreign patients can benefit from the lower overhead costs and professional fees. Doctor's fees and facility costs are much lower. Thus, procedures can be performed at a fraction of the amount that a patient would spend on the same procedure in the US or Europe.

Philippine medical and nursing curricula are more difficult than many in Southeast Asia and many Filipino doctors have acquired their postgraduate or fellowship training from well-known institutions in the U.S. and other developed countries

===New Zealand===

New Zealand is a relatively new player to the medical travel market, focusing on non-acute surgical procedures and fertility treatment.

New Zealand is a destination for those international health travellers seeking high quality, affordable treatment in a first world country in world class private hospitals.

English is the main language spoken in New Zealand with its medical system based ,like other Commonwealth countries, on the British health system. Most of its specialist physicians have received training in New Zealand and the USA, or the UK.

The costs of private healthcare are significantly cheaper than the USA or the UK, with packages (airfare, accommodation, medical service etc) for procedures like hip replacement, or Coronary Artery bypass costing in total approximately half of the procedure cost alone in the US.

Direct flights between the west coast of North America and New Zealand are available, taking on average 12-13 hours.

===India===

India is known in particular for heart surgery, [[hip resurfacing]] and other areas of advanced medicine. The government and private hospital groups are committed to the goal of making India a world leader in the industry. The industry's main appeal is low-cost treatment. Most estimates claim treatment costs in India start at around a tenth of the price of comparable treatment in America or Britain.<ref>''Indian medical care goes global'', Aljazeera.Net, June 18, 2006 accessed at [http://english.aljazeera.net/NR/exeres/004054B8-F475-4C40-872D-5E0D91D25B12.htm] Nov 11, 2006 </ref>

Estimates of the value of medical tourism to India go as high as $2 billion a year by 2012.<ref>[http://www.indianexpress.com/story/12890.html "Just what the hospital ordered: Global accreditations"] by Zeenat Nazir, Indian Express, Sept 18, 2006 retrieved September 29, 2006]</ref>. The Indian government is taking steps to address other infrastructure issues that can serve as a deterrant to the country's growth in medical tourism.

The south Indian city of [[Chennai]] has been declared India's Health Capital, as it nets in 45% of health tourists from abroad and 30-40% of domestic health tourists.<ref>{{cite web
| url = http://www.indiainbusiness.nic.in/know-india/states/tamilnadu.htm
| title = India - The Emerging Global Health Destination
| author = Macguire, Suzanne
| publisher = EzineArticles
| date = 2007
| accessdate = 2007-09-12}}</ref>

===Singapore===

Singapore claims to be Asia's leading medical hub, with advanced research capabilities as well as nine hospitals and two medical centers that have obtained Joint Commission International (JCI) accreditation. This could be part of the reason why JCI chose to set up its Asia Pacific office in Singapore in 2006.<ref>[http://www.jointcommissioninternational.com/23070/?view=ViewArticle&articleId=23199 "http://www.jointcommissioninternational.com/23070/?view=ViewArticle&articleId=23199"]</ref> In time, Singapore hospitals may look towards other European or Asian-based hospital accreditation systems in an attempt to broaden their market, as JCI's principal appeal is to the U.S. market, only a portion of the potential global clientele.

[[SingaporeMedicine]] is a multi-agency government initiative that aims to develop Singapore into a leading destination for health care services. In 2005, some 374,000 visitors came to Singapore purely to seek healthcare.
<ref>[http://www.singaporemedicine.com "www.SingaporeMedicine.com"]</ref> Many patients come from neighboring countries, such as Indonesia and Malaysia. Patient numbers from Indochina, South Asia, the Middle East and Greater China to Singapore are also seeing fast growth. Patients from developed countries such as the U.S. are beginning to choose Singapore as their medical travel destination for relatively affordable health care services in a clean cosmopolitan city.

Singapore has made news for many complex and innovative procedures, such as the separation of conjoined twins and tooth-in-eye surgery. The successful separation of 10-month-old Nepalese conjoined twins in 2001 put Singapore's medical expertise into headlines around the world. Singapore has since accomplished many more milestones both in Asia and in the world arena.
<ref>[http://www.google.com]</ref>

===Thailand===

Medical tourism is a growing segment of [[Thailand]]'s tourism and health-care sectors. Lower labor costs translate into significant cost savings on procedures compared to hospitals in the [[United States]], and a higher, more personalized level of nursing care than [[Western world|westerners]] are accustomed to receiving in hospitals back home. Over one million people per year travel there for everything from cosmetic surgery to cutting edge cardiac treatment.{{Fact|date=June 2007}} In 2005, one Bangkok hospital took in 150,000 treatment seekers from abroad. In 2006, medical tourism was projected to earn the country 36.4 billion [[baht]].<ref>[http://www.expresshospitality.com/20060630/market08.shtml "Medical Tourism: Hidden dimensions"] by Rabindra Seth, ''Express Hospitality'', [[June]], [[2006]], retrieved [[September 12]], [[2006]]</ref>

Hospitals in Thailand are a popular destination for other Asians. Another hospital that caters to medical tourists, [[Bangkok Hospital]], has a [[Japan]]ese wing and [[Phyathai Hospitals Group]] has interpreters for over 22 languages, besides the English-speaking medical staff. When [[Nepal]] Prime Minister [[Girija Prasad Koirala]] needed medical care in 2006, he went to Bangkok.<ref>[http://www.kantipuronline.com/kolnews.php?&nid=78877 "Ailing PM speaks out: Urges all not to spread rumours about his health"] ''Kantipur Report'', [[July 7]], [[2006]], retrieved [[September 12]], [[2006]]</ref>

Bumrungrad International Hospital makes much of the fact that many of its staff are accredited in the UK, Europe and the U.S. The origins of the U.S. medical system are British, with the American Medical Association acknowledging that Manchester Physician Dr [[Thomas Percival]] is responsible for modern medical ethics, and even the founder of [[Harvard University]], [[John Harvard]], was born in [[Southwark]], [[London]]. The modern Thai medical system shares in this Anglo-U.S. inheritance, as [[Mahidol Adulyadej|Prince Mahidol of Songla]], the King's father, earned his MD degree from Harvard Medical School in the early 20th century. Prince Mahidol and another member of the Thai Royal Family paid for an American medical education for a group of Thai men and women[source??]. Prince Mahidol also convinced the Rockefeller Foundation to provide scholarships for Thai citizens to study medicine and nursing[source? Dubious given that Rockefeller was in Thailand from the early 1920's and Mahidol was a low-ranked royal, not in Thailand most of the time]. Funds from the Rockefeller Foundation were also used to help build modern medical training facilities in Thailand. The men and women who studied medicine and nursing as a result of Prince Mahidol's efforts [source?] became the first educators for the modern Thai medical system.

Today many Thai physicians hold U.S. or UK professional certification. Several Thai hospitals have relationships with educational facilities in the U.S. and UK (for example, [[Sheffield Hallam University]] has links with [[Bangkok]]}. The U.S. consular information sheet gives the Thai health care system high marks for quality, particularly facilities in Bangkok. The UK's Foreign and Commonwealth Office web site states "There are excellent international hospitals in Bangkok but they can be expensive".

Thailand offers everything from cardiac surgery to organ transplants at a price much lower than the U.S. or Europe, in a safe, clean environment.

However, there is indisputably a major HIV/AIDS problem in Thailand, as acknowledged by the World Health Organisation <ref>[http://www.wpro.who.int/NR/rdonlyres/B7C19BC9-1450-4233-98D6-7181270CECF5/0/HIV_AIDS_Asia_Pacific_Region2001.pdf "HIV/AIDS in Asia Pacific Region"], ''World health Organization''</ref> and dengue is becoming increasingly common. Thai hospitals are also notorious for practicing "racist pricing" whereby costs to an American patient are different from a Russian patient or a Middle Eastern patient and some hospitals blatantly advertise 15% discount for Thais (written in Thai script).

Thailand has a growing number of hospitals with JCAHO accreditation. Again, international hospital accreditation may be one way for hospitals to demonstrate their worth, and increasingly Thai hospitals competing for business in this sector may need to expand their international accreditation.

===Hong Kong===

[[Hong Kong]] possesses a superb medical infrastructure. A former [[British colony]] and now a Special Administrative Region (SAR) within [[China]], it has 12 private hospitals and more than 50 public hospitals. Among the widest range of health care services throughout the globe are on offer, and some Hong Kong private hospitals are considered among the best of their type in the world.

With respect to [[hospital accreditation]], [[Hong Kong]]'s 12 private hospitals have looked towards a partnership with the UK rather than the U.S. or Australia for [[international healthcare accreditation]] needs. All 12 are "Trent Hospitals", having been surveyed and accredited by the [[United Kingdom]]'s [[Trent Accreditation Scheme]] [http://www.trentaccreditationscheme.org] since the mid-1990s. This has been a major factor in the ascent of standards in Hong Kong private hospitals over recent years. The Trent scheme works closely with the hospitals it assesses to generate standards appropriate to the locality (with respect to culture, geography, public health, primary care interfaces etc.), and always uses combinations of UK-sourced and [[Hong Kong]]-sourced surveyors. This has led to a uniquely co-operative approach toward improvement of hospital standards. Some Trent Hospitals have now gone on to obtain dual international accreditation, with both Trent and JCI (and have therefore attained a standard surpassing even that of some of the best hospitals in Thailand and Singapore). Others are looking towards dual international accreditation with Trent and the Australian group.

Unlike [[Singapore]], the [[Hong Kong]] public hospitals are yet to commit to external accreditation.

Roundtrip airfares from North America, South America and Europe can vary from about US$600 to more than US$2000, so calculate that into your medical costs.

===Malaysia===
Malaysia has considerable ambitions to develop itself as a medical tourism hub. It is well-placed, as the country has excellent hospitals, English is widely spoken, and many staff have been trained to a high level in the United Kingdom or in the USA.

While Malaysia has a national accreditation scheme (MSQH), few of Malayia's hospitals currently boast [[international healthcare accreditation]]. Depending upon if they are planning to attract UK/European- or USA-sourced clientele, they may look towards either the UK's [[Trent Accreditation Scheme]] or the USA's [[Joint Commission International]] (or possibly both).

===United States===

In the past people from all over the world came to the United States in search of the best health care. Despite political pressures that have impacted the US health care system the United States remains a health care destination. More people travel within the United States as well. This phenomenon is referred to Domestic Medical Tourism. Several hospital systems such as the Cleveland Clinic, Johns Hopkins and the Mayo Clinic are known for their attraction of patients who travel for health care. More recently less well known, highly specialized private practices have contracted with companies like Bridge Health that facilitate domestic medical travel. These practices tend to offer unique services such as stem cell for regenerative medicine that offer distinction [http://www.piedmontpmr.com].

==Risks and rewards==

Medical tourism carries some risks that local medical procedures do not. Should complications arise, patients might not be covered by insurance or able to seek compensation via [[malpractice]] lawsuits. Some countries currently sought after as medical tourism destinations provide some form of legal remedies for medical malpractice. However, this legal avenue is unappealing to the medical tourist. Advocates of medical tourism advise prospective tourists to evaluate the unlikely legal challenges against the benefits of such a trip before undergoing any surgery abroad.

Some countries, such as India, Malaysia, Costa Rica, or Thailand have different infectious diseases than Europe and North America, and different prevalences of the same diseases compared to nations such as the U.S., Canada, and the UK. Exposure to disease without having built up natural immunity can be a hazard for weakened individuals, specifically for gastrointestinal diseases (e.g Hepatitis A, amoebic dysentery, paratyphoid) which could weaken progress, mosquito-transmitted diseases, influenza, and tuberculosis (e.g., 75% of South Africans have latent TB). International hospital accreditation with Trent or JCI, mentioned earlier, may be of value here when people are trying to choose a destination for their procedure.

Also, travel soon after surgery can increase the risk of complications, as can vacation activities. For example, scars will be darker and more noticeable if they sunburn while healing.<ref>[http://familydoctor.org/095.xml "Incision Care"], ''American Academy of Family Physicians'', [[July]], [[2005]], retrieved [[September 18]], [[2006]]</ref> Long flights can be bad for those with heart (thrombosis) or breathing-related problems.

However, because in poor tropical nations diseases run the gamut, doctors seem to be more open to the possibility of any infectious disease, including HIV, TB, and typhoid, there are cases in the West where patients were consistently misdiagnosed for years because such diseases are perceived to be "rare" in the West.<ref>{{cite web|url=http://www.lungil.org/il/copd/TBMisdiagnosed.asp|title=TB Often Misdiagnosed|publisher=American Lung Association of Illinois|accessdate=2007-03-10}}</ref>

For hospitals and doctors seeking to provide medical tourism services, there is the risk of being sued by a disgruntled patient, so medical indemnity services such as those provided by the [[Medical Protection Society]] are essential [http://www.medicalprotection.org/uk]. There is also, unfortunately, great potential for adverse publicity for an organisation if things go wrong, or are perceived to have gone wrong.

==See also==
[[International healthcare accreditation]]

[[Trent Accreditation Scheme]] (TAS)

[[Joint Commission International]] (JCI)

[[Tourism]]

==References==
<div class="references-small">
<references/>
</div>

==External links==











*[http://www.guardian.co.uk/argentina/story/0,,1930436,00.html The Guardian Unlimited: Buenos Aires or bust.]
*[http://www.travelandleisure.com/articles/the-medical-vacation/ The Medical Vacation] a [[Travel + Leisure Magazine]] article about medical tourism.
*[http://www.time.com/time/magazine/article/0,9171,1196429,00.html Time.com on "Outsourcing Your Heart"]
*[http://www.cbc.ca/news/background/healthcare/medicaltourism.html CBC News on "Medical tourism: Need surgery, will travel"]
*[http://yaleglobal.yale.edu/display.article?id=2016 India Fosters Growing 'Medical Tourism' Sector by Ray Marcelo (The Financial Times)]
*[http://seattlepi.nwsource.com/health/1500ap_outsourcing_health.html Businesses May Move Health Care Overseas (AP)]
*[http://abcnews.go.com/Business/IndustryInfo/story?id=2320839&page=1 A Cut Below: Americans Look Abroad for Health Care (ABC News)]
*[http://video.fox59.com/global/video/popup/pop_playerLaunch.asp?clipid1=1441095&at1=News&vt1=v&h1=Health+Works%3A+Americans+Seeking+Medical+Treatment+Overseas+5%2F15%2F07&d1=284300&redirUrl=http://www.fox59.com&activePane=info&LaunchPageAdTag=homepage
*[http://search.dmoz.org/cgi-bin/search?search=medical+tourism Listings of medical tourism websites] - [[Open Directory Project]]
*[http://www.guardian.co.uk/cuba/story/0,,2167200,00.html Cuban Healthcare: First World Results on a Third World Budget (The Guardian, London)]

[[Category:Dental tourism]]
[[Category:Health economics]]
[[Category:Healthcare]]
[[Category:Types of tourism]]
[[Category:International Healthcare Accreditation]]

[[da:Medicinsk turisme]]
[[es:Turismo Médico]]
[[ka:გამაჯანსაღებელი ტურიზმი]]
[[nl:Medisch toerisme]]
[[pl:Turystyka medyczna]]
[[simple:Medical Tourism]]
[[vi:Du lịch chăm sóc sức khoẻ]]
{{WikiDoc Sources}}

Medical tourism

2014-10-04T19:08:58Z

Bobby Schwartz: /* Description */

'''Editor-in-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.];

'''Associate Editor-In-Chief:''' [[Jeffrey Lefko,]] MHA, Lefko and Associates, Taylors, South Carolina

'''Medical tourism''' (also called '''medical travel''' or '''health tourism''') is a term initially coined by [[Travel agency|travel agencies]] and the [[mass media]] to describe to the rapidly-growing practice of [[travel]]ing to another country to obtain [[health care]].

Such services typically include elective procedures as well as complex specialized [[surgery|surgeries]] such as [[joint replacement]] ([[Knee replacement|knee]]/[[Hip replacement|hip]]), [[cardiac surgery]], [[dental surgery]], and [[Cosmetic surgery|cosmetic surgeries]]. The provider and customer use informal channels of communication-connection-contract, with less regulatory or legal oversight to assure quality and less formal recourse to reimbursement or redress, if needed.

Leisure aspects typically associated with travel and tourism may be included on such medical travel trips.

==History==
The concept of medical tourism is not a new one. The first recorded instance of medical tourism dates back thousands of years to when [[Greek]] pilgrims traveled from all over the [[Mediterranean]] to the small territory in the [[Saronic Gulf]] called [[Epidauria]]. This territory was the sanctuary of the healing god [[Asklepios]]. Epidauria became the original travel destination for medical tourism.

[[Spa town]]s may be considered an early form of medical tourism.

==Description==
Factors that have led to the recent increase in popularity of medical travel include the high cost of health care or wait times for procedures in industrialized nations, the ease and affordability of international travel, and improvements in technology and standards of care in many countries of the world.

Medical tourists can come from anywhere in the world, including Europe, the UK, Middle East, Japan, U.S. and Canada. This is because of their large populations, comparatively high wealth, the high expense of health care or lack of health care options locally, and increasingly high expectations of their populations with respect to health care.

A large draw to medical travel is cost, convenience and speed. Countries that operate public health-care systems are often so taxed that it can take considerable time to get non-urgent medical care. The time spent waiting for a procedure such as a hip replacement can be a year or more in Britain and Canada; however, in Singapore, Hong Kong, Thailand, Cuba, Colombia, Philippines or India, a patient could feasibly have an operation the day after their arrival. In Canada, the number of procedures in 2005 for which people were waiting was 782,936.<ref>{{cite web|url=http://www.medtrotter.com/publications/WHTC_2007.pdf|title=Health Tourism 2.0|publisher=World Health Tourism Congress|accessdate=2007-04-13}}</ref>

Additionally, patients are finding that insurance either does not cover various surgeries or imposes unreasonable restrictions on the choice of the facility, surgeon, or prosthetics to be used. Medical tourism for knee/hip replacements or stem cell therapy has emerged as some of the more widely accepted procedures in medical tourism because of the lower cost, ease of access, and minimal difficulties associated with the traveling to/from the procedure.

Medical tourists may seek essential health care services such as cancer treatment and brain and transplant surgery as well as complementary or 'elective' services such as aesthetic treatments (cosmetic surgery).

According to research found in an article by the University of Delaware publication, UDaily:

{{cquote|the cost of surgery in El Salvador, Panama, Argentina, Cuba, India, Thailand, Colombia, Philippines or South Africa can be one-tenth of what it is in the United States or Western Europe, and sometimes even less. A heart-valve replacement that would cost [[United States dollar|US]]$200,000 or more in the U.S., for example, goes for $10,000 in the Philippines and India—and that includes round-trip airfare and a brief vacation package. Similarly, a metal-free dental bridge worth $5,500 in the U.S. costs $500 in India or Bolivia and only $200 in the Philippines, a knee replacement in Thailand with six days of physical therapy costs about one-fifth of what it would in the States, and Lasik eye surgery worth $3,700 in the U.S. is available in many other countries for only $730. Cosmetic surgery savings are even greater: A full facelift that would cost $20,000 in the U.S. runs about $3,000 in Cuba, $2,700 in the Philippines or $2,500 in South Africa or $ 2,300 in Bolivia."<ref name="MedTourismWorldwide"/>}}

Popular '''medical travel''' worldwide destinations include:
[[Brunei]], [[Cuba]], [[Colombia]],[[Hong Kong]], [[Hungary]], [[India]], [[Israel]], [[Jordan]], [[Lithuania]], [[Malaysia]], [[The Philippines]], [[Singapore]], [[South Africa]], [[Thailand]], and recently, [[United Arab Emirates|UAE]] and [[New Zealand]].

Popular '''cosmetic surgery travel''' destinations include:[[Argentina]], [[Bolivia]], [[Brazil]], [[Colombia]], [[Costa Rica]], [[Cuba]], [[Mexico]] and [[Turkey]].

In Europe [[Belgium]], [[Poland]] and [[Slovakia]] are also breaking into the business.
[[South Africa]] is taking the term "medical tourism" very literally by promoting their "medical safaris": Come to see African wildlife and get a facelift in the same trip.<ref>[http://www.cbc.ca/news/background/healthcare/medicaltourism.html "Medical tourism: Need surgery, will travel"] ''CBC News Online'', [[June 18]], [[2004]], retrieved [[September 5]], [[2006]]</ref>

However, perceptions of medical tourism are not always positive. In places like the U.S.medical tourism is viewed as risky. In some parts of the world, wider political issues can influence where medical tourists will choose to seek out health care; for example, in late 2006, some patients from the Middle East were choosing to travel to Singapore or Hong Kong for health care rather than to the U.S. because of international tensions.

While the tourism component might be a big draw for some Southeast Asia countries that focus on simple procedures, they are not alone in this market. For example Panama,Costa Rica and India are positioning themselves to become primary medical destinations. India's commitment to this is demonstrated with a growing number of hospitals that are attaining the U.S. Joint Commission International accreditation to help to capture the US medical tourism market, while others looking beyond just the US market to potential clients from the United Kingdom, Europe and Australia may also look towards other [[international healthcare accreditation]] schemes for brand advantage.

Singapore also positions itself as a medical hub for health care services, medicine, biomedical research and pharmaceutical manufacturing converge. Singapore has made international news for many complex surgeries in specialties such as neurology, oncology, and organ transplants procedures. Currently Singapore boasts the largest number of U.S. Joint Commission accredited hospitals in the region.

In South America, countries such as Argentina, Bolivia, Brazil and Colombia lead on plastic surgery medical skills relying on the vast experience their surgeons have in treating the style-obsessed. It is estimated that 1 in 30 Argentineans have had plastic surgery procedures, making this population the most operated in the world after the U.S. and Mexico. In Bolivia and Colombia, plastic surgery has become quite common.

Companies are beginning to offer global health care options that will enable North American and European patients to access world health care at a fraction of the cost of domestic care. Medical tourism companies typically provide experienced nurse case managers to assist patients with pre- and post-travel medical issues. They also help provide resources for follow-up care upon the patient's return. While these services will initially be of interest to the self-insured patient, several studies indicate that the rapid growth of Health Savings Accounts in the U.S. will also drive interest to health care in other countries.

==[[International healthcare accreditation]]==
Because standards are everything when it comes to health care, there are parallel issues around medical tourism, [[international healthcare accreditation]], [[evidence-based medicine]] and [[quality assurance]].

Those people considering becoming medical tourists may be assisted in making rational choices by whether hospitals providing such services have been assessed and accredited by reputable and independent [[international healthcare accreditation|external accreditation bodies]]. In the [[USA]], JCI (Joint Commission International) fulfills such a role, while in the [[UK]] and [[Hong Kong]], the [[Trent Accreditation Scheme|Trent International Accreditation Scheme]] is a key player. The different [[international healthcare accreditation]] schemes vary in quality, size, intent and the skill of their marketing. They also vary in terms of cost to hospitals and healthcare institutions using them. They all have web sites.

Increasingly, some hospitals are looking towards "dual international accreditation", perhaps having both JCI to cover potential US clientele and [[Trent Accreditation Scheme|Trent]] for potential British and European clientele.

* [http://sofiha.ibusinessdot.com/ The Society for International Healthcare Accreditation], or SOFIHA, is a free-to-join group providing a forum for discussion and for the sharing of ideas and good practice by providers of international healthcare accreditation and users of the same - the primary role of this organisation is to promote a safe hospital environment for patients, wherever they travel to in the world for health care.

*

== Destinations ==

===Cuba===

For more than 40 years, Cuba has been a popular medical tourism destination. In 2006, Cuba attracted nearly 20000<ref>[http://www.caribbeannetnews.com/news-3085--6-6--.html Commentary: A Novel Tourism Concept] Caribbean Net News [[Aug 18]], [[2007]], retrieved [[Aug 18]], [[2007]]</ref> [[health tourists]].

In 2001, the BBC News reported that thousands of patients come to Cuba from as far away as Latin America and Europe, attracted by the "fine reputation of Cuban doctors, the low prices and nearby beaches on which to recuperate." <ref name="CubasMedicalSuccess">[http://news.bbc.co.uk/2/hi/americas/1535358.stm
BBC News [[Sept. 10]], [[2001]], retrieved [[July 20]], [[2007]]</ref>

A wide range of medical treatments are provided including joint replacement, cancer treatment, eye surgery, cosmetic surgery and addictions rehabilitation. Costs are about 60 to 80 percent less than U.S. costs.

Cuba has hospitals for Cuban residents, and others that focus on serving foreigners and diplomats. Cubans receive free healthcare for life.

In the 2007 American documentary film, "Sicko," which criticizes the U.S. healthcare system, producer [[Michael Moore]] leads a group of uninsured American patients to Cuba to obtain more affordable medical treatment. "Sicko" has greatly increased foreigners' interest in Cuban healthcare, especially Havana Hospital, which was featured in the film.

Statistically healthcare in Cuba compare very good to many countries worldwide. The chance of a Cuban child dying at five years of age or younger is 7 per 1000 live births in Cuba, while it's 8 per 1000 in the US, says the World Health Organization (WHO). Cuba has nearly twice as many physicians per person as the U.S. -- 5.91 doctors per thousand people compared to 2.56 doctors per thousand, according to WHO. Life expectancy in the two countries is almost equal. WHO reports that Cuban life expectancy at birth is 75 years for males, and 79 years for females. In comparison, the US life expectancy at birth is 75 and 80 years for males and females, respectively. Cuba's infant mortality rate is equal to that of the US at 6 percent. <ref name="WorldHealthOrganizationStatistics">[http://www.who.int/countries/cub/en WHO [[2005]], retrieved [[July 20]], [[2007]]</ref> <ref name="WorldHealthOrganizationStatistics">[http://www.who.int/whosis/whostat2007 WHO [[2007]], retrieved [[Aug 1]], [[2007]]</ref>

The Cuban government has developed Cuban medical tourism to generate income for the country. There is an ongoing program that sends thousands of Cuban doctors to Venezuela to help its poor residents, and this helps Cuba pay Venezuela for oil.

Residents of Canada, the UK and most other countries can travel to Cuba without any difficulty, and a tourist visa is generally required. For Americans, however, because of the US trade policy towards Cuba, travelers must either obtain U.S. government approval, or, more frequently, travel to Cuba from Canada, Mexico, the Bahamas, Jamaica or the Dominican Republic. North Americans can reach Cuba easily via daily flights from Toronto, Montreal, Cancun, Mexico City, Nassau (Bahamas), Kingston (Jamaica), and Santo Domingo (Dominican Republic). Cuban immigration authorities do not stamp the passports of US visitors so that Americans can keep their travels a private matter.

===Mexico===

One Washington Post article [http://www.washingtonpost.com/wp-dyn/content/article/2007/06/17/AR2007061701297.html Discount Dentistry, South of The Border] says "Mexican dentists often charge one-fifth to one-fourth of U.S. prices". This trend has alarmed some American healthcare providers and legislators. "In Texas, legislators explored the possibility of allowing health maintenance organizations to operate on both sides of the border. However, physicians in south Texas lobbied against the changes, arguing that local doctors could not compete with the lower costs in Mexico" [http://www.boston.com/news/nation/articles/2005/11/13/california_health_costs_send_patients_to_mexico_facilities/].

Indeed one does need to exercise caution as "the Mexican legal system makes it almost impossible to sue them" [http://www.washingtonpost.com/wp-dyn/content/article/2007/06/17/AR2007061701297.html]. However many who take the chance report that they are satisfied with the care received, "They have everything I need," says Luis Gonzales of San Diego, "They're clean. You don't see a difference between a doctor over here and over there". According to a report commissioned by Families U.S.A., a Washington advocacy group for health-care issues, "About 90 percent [feel] the care they had received in Mexico had been good or excellent. About 80 percent rated the care they had received in the United States as good or excellent" [http://query.nytimes.com/gst/fullpage.html?res=9E0CE5DA113CF930A15752C1A964958260].

Indeed more and more American insurers are providing coverage for travelers as the out of pocket costs to them are much lower. "With healthcare costs in the United States continuing to rise, many employers in Southern California are turning to insurance plans that send their workers to Mexico for routine care, plans that are growing by nearly 3,000 people a year".

===Panama===

In Panama, health and medical tourism is growing rapidly. Many factors are bringing health tourists to Panama. The combination of climate, scenic beauty, cultural diversity, strategic geographical position, one of the world’s key offshore trading centers, the hub of the Americas for international travel, the dollar as the official currency….but most important of all, the medical professionals are well trained from institutions around the world, use the latest technologies and medications, and have earned a reputation of quality professionals. Most of Panama’s doctors are bilingual, board certified, and accustomed to working with the same state of the art medical equipment and technology used in the United States and Europe. Medical tourists coming to Panama can stay at a 5-star hotel during convalescence for prices far below those in the United States and Europe. For example, dental implants costs an average of $2,500 per implant if placed in the US or Canada. On most procedures, Panama offers savings of more than 50% compared to the US and Europe.

Getting world-class medical service and vacation time in a luxury setting is affordable in Panama. You can find in this country a wide range of health services and experienced specialist physicians in all areas such as in dental implants, plastic surgery, assisted reproduction, cardiology, cosmetic dentistry, orthopedics, etc. You can even have an “extreme makeover” done and go back to your country not just feeling great but looking like a new person. People are traveling from around the world looking for high-quality health care at accessible prices as well as discovering Panama´s crystalline Caribbean waters, fascinating indigenous cultures, and deluxe resorts on the beach, in the rain forest, and in the mountains.

Many of these patients that have already come to Panama as health tourists, feel at ease immediately because both staff and doctors speak perfect English. They also report that they have been treated with utmost respect and feel doctors are genuinely interested in the person as an individual instead of feeling like a number. All leave Panama very surprised of the country’s professional doctors, hospitals, and advanced technology. These patients feel very pleased with the treatment or procedure received, especially because of the affordable prices and the wonderful vacation they spent in Panama.

Panama's main Hospitals have affiliations to renowned international Organizations such as: Baptist Health International of Miami, Cleveland Clinic, Tulane Health Science Center, Johns Hopkins International, Miami Children's Hospital, University of Nebraska Medical Center, The Kendall Medical Center in Florida, and Harvard Medical Faculty and Physicians at Beth Israel Deaconess Medical Center in USA.

For more information visit [http//:www.pana-health.com]

===Jordan===
Jordan is a popular destination for health tourism in the Middle East. Palestinians, Iraqis, Syrians, and Southeast Asians are frequent visitors, rumoredly including Iraq's President Jalal Talabani.

===Colombia===

Colombia has been treating patients from all over the world for years, especially for cosmetic and eye surgery. Colombia has also become a recognized provider of advanced cardiovascular and transplant surgery. What often compels persons to seek transplant surgery offshore is not only cost considerations, but waiting lists (such as in the U.S.) or the lack of an organized organ inventory and donor system in the home country. Colombia has such an organ donor and banking system which makes organs available to foreigners with certain legal restrictions. Orthopedic surgeries, such as knee and hip replacements, are done in Colombia with U.S.-made ([[FDA]]-approved) prosthetics at a fraction of the cost.

Colombia has many surgeons that have either trained and/or practiced in other countries such as the U.S. and Europe. Salaries for doctors, nurses, and supporting personnel in Colombia are about 20% of U.S. salaries for similar occupations even though they are required to have the same level of education and job skills. Real estate costs related to medical care facilities are also only a fraction of what they are in the U.S.

One advantage of Colombia for those from the U.S. and Canada is ease of travel and close proximity. Colombia offers cheaper airfares from the U.S. and Canada (and some European countries) than other destinations, such as those in Asia, and does not have the visa restrictions of other countries currently in the medical tourism marketplace.

===Philippines===

The Philippines has been growing as a destination for medical tourism. Cost savings are significant since foreign patients can benefit from the lower overhead costs and professional fees. Doctor's fees and facility costs are much lower. Thus, procedures can be performed at a fraction of the amount that a patient would spend on the same procedure in the US or Europe.

Philippine medical and nursing curricula are more difficult than many in Southeast Asia and many Filipino doctors have acquired their postgraduate or fellowship training from well-known institutions in the U.S. and other developed countries

===New Zealand===

New Zealand is a relatively new player to the medical travel market, focusing on non-acute surgical procedures and fertility treatment.

New Zealand is a destination for those international health travellers seeking high quality, affordable treatment in a first world country in world class private hospitals.

English is the main language spoken in New Zealand with its medical system based ,like other Commonwealth countries, on the British health system. Most of its specialist physicians have received training in New Zealand and the USA, or the UK.

The costs of private healthcare are significantly cheaper than the USA or the UK, with packages (airfare, accommodation, medical service etc) for procedures like hip replacement, or Coronary Artery bypass costing in total approximately half of the procedure cost alone in the US.

Direct flights between the west coast of North America and New Zealand are available, taking on average 12-13 hours.

===India===

India is known in particular for heart surgery, [[hip resurfacing]] and other areas of advanced medicine. The government and private hospital groups are committed to the goal of making India a world leader in the industry. The industry's main appeal is low-cost treatment. Most estimates claim treatment costs in India start at around a tenth of the price of comparable treatment in America or Britain.<ref>''Indian medical care goes global'', Aljazeera.Net, June 18, 2006 accessed at [http://english.aljazeera.net/NR/exeres/004054B8-F475-4C40-872D-5E0D91D25B12.htm] Nov 11, 2006 </ref>

Estimates of the value of medical tourism to India go as high as $2 billion a year by 2012.<ref>[http://www.indianexpress.com/story/12890.html "Just what the hospital ordered: Global accreditations"] by Zeenat Nazir, Indian Express, Sept 18, 2006 retrieved September 29, 2006]</ref>. The Indian government is taking steps to address other infrastructure issues that can serve as a deterrant to the country's growth in medical tourism.

The south Indian city of [[Chennai]] has been declared India's Health Capital, as it nets in 45% of health tourists from abroad and 30-40% of domestic health tourists.<ref>{{cite web
| url = http://www.indiainbusiness.nic.in/know-india/states/tamilnadu.htm
| title = India - The Emerging Global Health Destination
| author = Macguire, Suzanne
| publisher = EzineArticles
| date = 2007
| accessdate = 2007-09-12}}</ref>

===Singapore===

Singapore claims to be Asia's leading medical hub, with advanced research capabilities as well as nine hospitals and two medical centers that have obtained Joint Commission International (JCI) accreditation. This could be part of the reason why JCI chose to set up its Asia Pacific office in Singapore in 2006.<ref>[http://www.jointcommissioninternational.com/23070/?view=ViewArticle&articleId=23199 "http://www.jointcommissioninternational.com/23070/?view=ViewArticle&articleId=23199"]</ref> In time, Singapore hospitals may look towards other European or Asian-based hospital accreditation systems in an attempt to broaden their market, as JCI's principal appeal is to the U.S. market, only a portion of the potential global clientele.

[[SingaporeMedicine]] is a multi-agency government initiative that aims to develop Singapore into a leading destination for health care services. In 2005, some 374,000 visitors came to Singapore purely to seek healthcare.
<ref>[http://www.singaporemedicine.com "www.SingaporeMedicine.com"]</ref> Many patients come from neighboring countries, such as Indonesia and Malaysia. Patient numbers from Indochina, South Asia, the Middle East and Greater China to Singapore are also seeing fast growth. Patients from developed countries such as the U.S. are beginning to choose Singapore as their medical travel destination for relatively affordable health care services in a clean cosmopolitan city.

Singapore has made news for many complex and innovative procedures, such as the separation of conjoined twins and tooth-in-eye surgery. The successful separation of 10-month-old Nepalese conjoined twins in 2001 put Singapore's medical expertise into headlines around the world. Singapore has since accomplished many more milestones both in Asia and in the world arena.
<ref>[http://www.google.com]</ref>

===Thailand===

Medical tourism is a growing segment of [[Thailand]]'s tourism and health-care sectors. Lower labor costs translate into significant cost savings on procedures compared to hospitals in the [[United States]], and a higher, more personalized level of nursing care than [[Western world|westerners]] are accustomed to receiving in hospitals back home. Over one million people per year travel there for everything from cosmetic surgery to cutting edge cardiac treatment.{{Fact|date=June 2007}} In 2005, one Bangkok hospital took in 150,000 treatment seekers from abroad. In 2006, medical tourism was projected to earn the country 36.4 billion [[baht]].<ref>[http://www.expresshospitality.com/20060630/market08.shtml "Medical Tourism: Hidden dimensions"] by Rabindra Seth, ''Express Hospitality'', [[June]], [[2006]], retrieved [[September 12]], [[2006]]</ref>

Hospitals in Thailand are a popular destination for other Asians. Another hospital that caters to medical tourists, [[Bangkok Hospital]], has a [[Japan]]ese wing and [[Phyathai Hospitals Group]] has interpreters for over 22 languages, besides the English-speaking medical staff. When [[Nepal]] Prime Minister [[Girija Prasad Koirala]] needed medical care in 2006, he went to Bangkok.<ref>[http://www.kantipuronline.com/kolnews.php?&nid=78877 "Ailing PM speaks out: Urges all not to spread rumours about his health"] ''Kantipur Report'', [[July 7]], [[2006]], retrieved [[September 12]], [[2006]]</ref>

Bumrungrad International Hospital makes much of the fact that many of its staff are accredited in the UK, Europe and the U.S. The origins of the U.S. medical system are British, with the American Medical Association acknowledging that Manchester Physician Dr [[Thomas Percival]] is responsible for modern medical ethics, and even the founder of [[Harvard University]], [[John Harvard]], was born in [[Southwark]], [[London]]. The modern Thai medical system shares in this Anglo-U.S. inheritance, as [[Mahidol Adulyadej|Prince Mahidol of Songla]], the King's father, earned his MD degree from Harvard Medical School in the early 20th century. Prince Mahidol and another member of the Thai Royal Family paid for an American medical education for a group of Thai men and women[source??]. Prince Mahidol also convinced the Rockefeller Foundation to provide scholarships for Thai citizens to study medicine and nursing[source? Dubious given that Rockefeller was in Thailand from the early 1920's and Mahidol was a low-ranked royal, not in Thailand most of the time]. Funds from the Rockefeller Foundation were also used to help build modern medical training facilities in Thailand. The men and women who studied medicine and nursing as a result of Prince Mahidol's efforts [source?] became the first educators for the modern Thai medical system.

Today many Thai physicians hold U.S. or UK professional certification. Several Thai hospitals have relationships with educational facilities in the U.S. and UK (for example, [[Sheffield Hallam University]] has links with [[Bangkok]]}. The U.S. consular information sheet gives the Thai health care system high marks for quality, particularly facilities in Bangkok. The UK's Foreign and Commonwealth Office web site states "There are excellent international hospitals in Bangkok but they can be expensive".

Thailand offers everything from cardiac surgery to organ transplants at a price much lower than the U.S. or Europe, in a safe, clean environment.

However, there is indisputably a major HIV/AIDS problem in Thailand, as acknowledged by the World Health Organisation <ref>[http://www.wpro.who.int/NR/rdonlyres/B7C19BC9-1450-4233-98D6-7181270CECF5/0/HIV_AIDS_Asia_Pacific_Region2001.pdf "HIV/AIDS in Asia Pacific Region"], ''World health Organization''</ref> and dengue is becoming increasingly common. Thai hospitals are also notorious for practicing "racist pricing" whereby costs to an American patient are different from a Russian patient or a Middle Eastern patient and some hospitals blatantly advertise 15% discount for Thais (written in Thai script).

Thailand has a growing number of hospitals with JCAHO accreditation. Again, international hospital accreditation may be one way for hospitals to demonstrate their worth, and increasingly Thai hospitals competing for business in this sector may need to expand their international accreditation.

===Hong Kong===

[[Hong Kong]] possesses a superb medical infrastructure. A former [[British colony]] and now a Special Administrative Region (SAR) within [[China]], it has 12 private hospitals and more than 50 public hospitals. Among the widest range of health care services throughout the globe are on offer, and some Hong Kong private hospitals are considered among the best of their type in the world.

With respect to [[hospital accreditation]], [[Hong Kong]]'s 12 private hospitals have looked towards a partnership with the UK rather than the U.S. or Australia for [[international healthcare accreditation]] needs. All 12 are "Trent Hospitals", having been surveyed and accredited by the [[United Kingdom]]'s [[Trent Accreditation Scheme]] [http://www.trentaccreditationscheme.org] since the mid-1990s. This has been a major factor in the ascent of standards in Hong Kong private hospitals over recent years. The Trent scheme works closely with the hospitals it assesses to generate standards appropriate to the locality (with respect to culture, geography, public health, primary care interfaces etc.), and always uses combinations of UK-sourced and [[Hong Kong]]-sourced surveyors. This has led to a uniquely co-operative approach toward improvement of hospital standards. Some Trent Hospitals have now gone on to obtain dual international accreditation, with both Trent and JCI (and have therefore attained a standard surpassing even that of some of the best hospitals in Thailand and Singapore). Others are looking towards dual international accreditation with Trent and the Australian group.

Unlike [[Singapore]], the [[Hong Kong]] public hospitals are yet to commit to external accreditation.

Roundtrip airfares from North America, South America and Europe can vary from about US$600 to more than US$2000, so calculate that into your medical costs.

===Malaysia===
Malaysia has considerable ambitions to develop itself as a medical tourism hub. It is well-placed, as the country has excellent hospitals, English is widely spoken, and many staff have been trained to a high level in the United Kingdom or in the USA.

While Malaysia has a national accreditation scheme (MSQH), few of Malayia's hospitals currently boast [[international healthcare accreditation]]. Depending upon if they are planning to attract UK/European- or USA-sourced clientele, they may look towards either the UK's [[Trent Accreditation Scheme]] or the USA's [[Joint Commission International]] (or possibly both).

===United States===

In the past people from all over the world came to the United States in search of the best health care. Despite political pressures that have impacted the US health care system the United States remains a health care destination. More people travel within the United States as well. This phenomenon is referred to Domestic Medical Tourism. Several hospital systems such as the Cleveland Clinic, Johns Hopkins and the Mayo Clinic are known for their attraction of patients who travel for health care. More recently less well known, highly specialized private practices have contracted with companies like Bridge Health that facilitate domestic medical travel. These practices tend to offer unique services such as stem cell for regenerative medicine that offer distinction [http://www.piedmontpmr.com].

==Risks and rewards==

Medical tourism carries some risks that local medical procedures do not. Should complications arise, patients might not be covered by insurance or able to seek compensation via [[malpractice]] lawsuits. Some countries currently sought after as medical tourism destinations provide some form of legal remedies for medical malpractice. However, this legal avenue is unappealing to the medical tourist. Advocates of medical tourism advise prospective tourists to evaluate the unlikely legal challenges against the benefits of such a trip before undergoing any surgery abroad.

Some countries, such as India, Malaysia, Costa Rica, or Thailand have different infectious diseases than Europe and North America, and different prevalences of the same diseases compared to nations such as the U.S., Canada, and the UK. Exposure to disease without having built up natural immunity can be a hazard for weakened individuals, specifically for gastrointestinal diseases (e.g Hepatitis A, amoebic dysentery, paratyphoid) which could weaken progress, mosquito-transmitted diseases, influenza, and tuberculosis (e.g., 75% of South Africans have latent TB). International hospital accreditation with Trent or JCI, mentioned earlier, may be of value here when people are trying to choose a destination for their procedure.

Also, travel soon after surgery can increase the risk of complications, as can vacation activities. For example, scars will be darker and more noticeable if they sunburn while healing.<ref>[http://familydoctor.org/095.xml "Incision Care"], ''American Academy of Family Physicians'', [[July]], [[2005]], retrieved [[September 18]], [[2006]]</ref> Long flights can be bad for those with heart (thrombosis) or breathing-related problems.

However, because in poor tropical nations diseases run the gamut, doctors seem to be more open to the possibility of any infectious disease, including HIV, TB, and typhoid, there are cases in the West where patients were consistently misdiagnosed for years because such diseases are perceived to be "rare" in the West.<ref>{{cite web|url=http://www.lungil.org/il/copd/TBMisdiagnosed.asp|title=TB Often Misdiagnosed|publisher=American Lung Association of Illinois|accessdate=2007-03-10}}</ref>

For hospitals and doctors seeking to provide medical tourism services, there is the risk of being sued by a disgruntled patient, so medical indemnity services such as those provided by the [[Medical Protection Society]] are essential [http://www.medicalprotection.org/uk]. There is also, unfortunately, great potential for adverse publicity for an organisation if things go wrong, or are perceived to have gone wrong.

==See also==
[[International healthcare accreditation]]

[[Trent Accreditation Scheme]] (TAS)

[[Joint Commission International]] (JCI)

[[Tourism]]

==References==
<div class="references-small">
<references/>
</div>

==External links==











*[http://www.guardian.co.uk/argentina/story/0,,1930436,00.html The Guardian Unlimited: Buenos Aires or bust.]
*[http://www.travelandleisure.com/articles/the-medical-vacation/ The Medical Vacation] a [[Travel + Leisure Magazine]] article about medical tourism.
*[http://www.time.com/time/magazine/article/0,9171,1196429,00.html Time.com on "Outsourcing Your Heart"]
*[http://www.cbc.ca/news/background/healthcare/medicaltourism.html CBC News on "Medical tourism: Need surgery, will travel"]
*[http://yaleglobal.yale.edu/display.article?id=2016 India Fosters Growing 'Medical Tourism' Sector by Ray Marcelo (The Financial Times)]
*[http://seattlepi.nwsource.com/health/1500ap_outsourcing_health.html Businesses May Move Health Care Overseas (AP)]
*[http://abcnews.go.com/Business/IndustryInfo/story?id=2320839&page=1 A Cut Below: Americans Look Abroad for Health Care (ABC News)]
*[http://video.fox59.com/global/video/popup/pop_playerLaunch.asp?clipid1=1441095&at1=News&vt1=v&h1=Health+Works%3A+Americans+Seeking+Medical+Treatment+Overseas+5%2F15%2F07&d1=284300&redirUrl=http://www.fox59.com&activePane=info&LaunchPageAdTag=homepage
*[http://search.dmoz.org/cgi-bin/search?search=medical+tourism Listings of medical tourism websites] - [[Open Directory Project]]
*[http://www.guardian.co.uk/cuba/story/0,,2167200,00.html Cuban Healthcare: First World Results on a Third World Budget (The Guardian, London)]

[[Category:Dental tourism]]
[[Category:Health economics]]
[[Category:Healthcare]]
[[Category:Types of tourism]]
[[Category:International Healthcare Accreditation]]

[[da:Medicinsk turisme]]
[[es:Turismo Médico]]
[[ka:გამაჯანსაღებელი ტურიზმი]]
[[nl:Medisch toerisme]]
[[pl:Turystyka medyczna]]
[[simple:Medical Tourism]]
[[vi:Du lịch chăm sóc sức khoẻ]]
{{WikiDoc Sources}}

Holistic health

2014-10-04T19:05:56Z

Bobby Schwartz: /* Philosophy */

'''Editor-in-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.];

'''Holistic health''' refers to a [[philosophy]] of medical care that views physical and [[mind|mental]] aspects of life as closely interconnected and equally important approaches to treatment. While frequently associated with [[alternative medicine]], it is also increasingly used in mainstream medical practice as part of a broad view of [[patient]] care. Many primary care providers and integrative medicine specialists today utilize a holistic approach to patient care.

==History==

[[Holism]] as a health concept has existed for ages outside of [[academia|academic]] circles, but only relatively recently has the modern medical establishment begun to integrate it into the mainstream [[health care]] system. In the United States, the first National Conference on Holistic Health was conducted by the Health Optimizing Institute with the [[University of California, San Diego]] School of Medicine in June [[1975]].

==Philosophy==

[[Holism]] refers to the idea that an entity is greater than the sum of its parts. In the case of health, the entity in question is the [[human body]]. Holistic concepts of [[health]] and [[physical fitness|fitness]] view achieving and maintaining good health as involving more than just taking care of all the various components that make up the physical body—attention must be paid to aspects such as [[emotion]]al and [[spirituality|spiritual]] well-being as well. The goal is a wellness that encompasses the entire person, rather than just the lack of physical [[pain and nociception|pain]] or [[disease]]. Some practices refer to this as "reducing total load", the total number of things that do not allow you to get well.

Holistic health is not itself a method of treatment, but instead an approach to how treatment should be applied. Traditional medical philosophy treats physical [[symptom]]s, using standardized methods such as the [[medical prescription|prescription of drugs]] or the undertaking of [[surgery]], while the patient is only passively involved. Practices emphasizing holistic health, on the other hand believe that they are treating the whole person. Practitioners of holistic medicine believe that attitudes affect the present condition, and the patient may play an active role in the healing process.

Some medical practices have embraced a Holistic Model [http://www.piedmontpmr.com/disease-management-reducing-total-load] but have not always referred to it as such. For example Sherry Rogers,MD popularized a concept of Reducing Total Load, the total number of things that interfere with someone getting well. While reducing total load is a holistic concept since it is based inside of a medical model it is not as frequently associated with holism. .

==Criticism==

Some holistic health advocates subscribe to alternative medical practices which conventional medicine does not support. Some common practices such as [[acupuncture]] and [[chiropractic]] have not received total acceptance by supporters of [[evidence-based medicine]], who require rigorous [[scientific method|scientific testing]] before incorporating them in to a course of treatment. While health care is in evolution, as some of these alternative treatments lack experimental, double blinded evidence, they have not received widespread acceptance in the physician community.

==See also==

{{col-begin}}
{{col-3}}
*[[Alternative medicine]]
*[[Biopsychosocial model]]
*[[Evidence-based medicine]]
*[[Osteopathic medicine]]
*[[Exercise]]
{{col-3}}
*[[Fruitarianism]]
*[[Herbalism]]
*[[Holism]]
*[[Meditation]]
*[[Medical model]]
*[[Mucoid plaque]]
{{col-3}}
*[[Naturopathic medicine]]
*[[Natural Hygiene]]
* [[Pastoral care]]
*[[Prolotherapy]]
{{col-end}}

==References==

<references/>

==External links==
*[http://www.holisticwellness.com/ Holistic Wellness] (Free holistic directory of practitioners and schools)
*[http://www.holistica.fr/en/ HOLISTICA] Holistic Health
*[http://www.holisticlocal.com/ Holistic Local] - (Social networking & holistic business directory)
*[http://www.holistic-community.co.uk/ Holistic Community] - (Information and resources within the field of Holistic Therapy)
*[http://www.ahha.org/ American Holistic Health Association] (organization website)
*[http://www.ahha.org/ American Holistic Health Association] (organization website)
*[http://www.drugrehabcenter.com/ Holistic Drug Rehab]
*[http://healing.about.com/ About Holistic Healing] (About.com site focuses on holistic approach to living life.)
Culture)
*[http://www.shamanism.com Huichol Indian Shamanism - Holistic health based culture]
*[http://www.piedmontpmr.com Clinical medical practice model]
*[http://www.wholistichealingresearch.com] - (Research and practice information)

[[Category:Alternative medicine]]
[[Category:Health]]
[[Category:New Age]]

[[af:Holistiese genesing]]
[[de:Ganzheit]]
[[es:Medicina holística]]
[[he:רפואה הוליסטית]]
{{WikiDoc Sources}}

Fibromyalgia

2014-10-04T19:04:01Z

Bobby Schwartz: /* Treatment */

__NOTOC__
'''For patient information page click [[{{PAGENAME}} (patient information)|here]]'''
{{Infobox_Disease
| Name = Fibromyalgia
| Image =
| Caption =
| DiseasesDB = 
| ICD10 = {{ICD10|M|79|7|m|70}}
| ICD9 = {{ICD9|729.1}}
| ICDO =
| OMIM =
| MedlinePlus = 000427
| MeshID = D005356
}}
{{Fibromyalgia}}
'''Editor(s)-in-Chief:''' [[C. Michael Gibson]], M.S.,M.D. [mailto:charlesmichaelgibson@gmail.com] Phone:617-632-7753; [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.]

{{SK}} Fibromyositis; fibrositis; diffuse myofascial pain syndrome; fibromyalgia, primary; fibromyalgia, secondary; fibromyalgia-fibromyositis syndrome; fibromyositis-fibromyalgia syndrome; fibrositis; myofascial pain syndrome, diffuse; rheumatism, muscular
==[[Fibromyalgia overview|Overview]]==
==[[Fibromyalgia historical perspective|Historical Perspective]]==
==[[Fibromyalgia pathophysiology|Pathophysiology]]==

==[[Fibromyalgia causes|Causes]]==

==[[Fibromyalgia differential diagnosis|Differentiating Fibromyalgia from other Diseases]]==

==[[Fibromyalgia epidemiology and demographics|Epidemiology and Demographics]]==
==[[Fibromyalgia natural history, complications and prognosis|Natural History, Complications and Prognosis]]==

==Diagnosis==
[[Fibromyalgia diagnostic criteria|Diagnostic Criteria]] | [[Fibromyalgia history and symptoms|History and Symptoms]] | [[Fibromyalgia physical examination|Physical Examination]] | [[Fibromyalgia laboratory findings|Laboratory Findings]] | [[Fibromyalgia other diagnostic studies|Other Diagnostic Studies]]

==Treatment==
[[Fibromyalgia medical therapy|Medical Therapy]] | [[Fibromyalgia psychotherapy|Psychotherapy]] | [[Fibromyalgia future or investigational therapies|Future or Investigational Therapies]] | [http://piedmontpmr.com/disease-management-reducing-total-load/ Reducing Total Load]

==Case Studies==
:[[Fibromyalgia case study one|Case #1]]

==Related Chapters==
* [[Somatosensory Amplification]]

{{Diseases of the musculoskeletal system and connective tissue}}

[[Category:Rheumatology]]
[[Category:Diseases involving the fasciae]]
[[Category:Syndromes]]
[[Category:Ailments of unknown etiology]]
[[Category:Overview complete]]

[[ca:Fibromiàlgia]]
[[de:Fibromyalgie]]
[[es:Fibromialgia]]
[[eu:Fibromialgia erreumatiko]]
[[fr:Fibromyalgie]]
[[it:Fibromialgia]]
[[he:דאבת השרירים]]
[[nl:Fibromyalgie]]
[[ja:線維筋痛症]]
[[no:Fibromyalgi]]
[[pl:Fibromialgia]]
[[pt:Fibromialgia]]
[[fi:Fibromyalgia]]
[[sv:Fibromyalgi]]

{{WH}}
{{WS}}

Fibromyalgia

2014-10-04T19:02:15Z

Bobby Schwartz: /* Treatment */

__NOTOC__
'''For patient information page click [[{{PAGENAME}} (patient information)|here]]'''
{{Infobox_Disease
| Name = Fibromyalgia
| Image =
| Caption =
| DiseasesDB = 
| ICD10 = {{ICD10|M|79|7|m|70}}
| ICD9 = {{ICD9|729.1}}
| ICDO =
| OMIM =
| MedlinePlus = 000427
| MeshID = D005356
}}
{{Fibromyalgia}}
'''Editor(s)-in-Chief:''' [[C. Michael Gibson]], M.S.,M.D. [mailto:charlesmichaelgibson@gmail.com] Phone:617-632-7753; [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.]

{{SK}} Fibromyositis; fibrositis; diffuse myofascial pain syndrome; fibromyalgia, primary; fibromyalgia, secondary; fibromyalgia-fibromyositis syndrome; fibromyositis-fibromyalgia syndrome; fibrositis; myofascial pain syndrome, diffuse; rheumatism, muscular
==[[Fibromyalgia overview|Overview]]==
==[[Fibromyalgia historical perspective|Historical Perspective]]==
==[[Fibromyalgia pathophysiology|Pathophysiology]]==

==[[Fibromyalgia causes|Causes]]==

==[[Fibromyalgia differential diagnosis|Differentiating Fibromyalgia from other Diseases]]==

==[[Fibromyalgia epidemiology and demographics|Epidemiology and Demographics]]==
==[[Fibromyalgia natural history, complications and prognosis|Natural History, Complications and Prognosis]]==

==Diagnosis==
[[Fibromyalgia diagnostic criteria|Diagnostic Criteria]] | [[Fibromyalgia history and symptoms|History and Symptoms]] | [[Fibromyalgia physical examination|Physical Examination]] | [[Fibromyalgia laboratory findings|Laboratory Findings]] | [[Fibromyalgia other diagnostic studies|Other Diagnostic Studies]]

==Treatment==
[[Fibromyalgia medical therapy|Medical Therapy]] | [[Fibromyalgia psychotherapy|Psychotherapy]] | [[Fibromyalgia future or investigational therapies|Future or Investigational Therapies]] | Reducing Total Load [http://piedmontpmr.com/disease-management-reducing-total-load/Reducing Total Load]

==Case Studies==
:[[Fibromyalgia case study one|Case #1]]

==Related Chapters==
* [[Somatosensory Amplification]]

{{Diseases of the musculoskeletal system and connective tissue}}

[[Category:Rheumatology]]
[[Category:Diseases involving the fasciae]]
[[Category:Syndromes]]
[[Category:Ailments of unknown etiology]]
[[Category:Overview complete]]

[[ca:Fibromiàlgia]]
[[de:Fibromyalgie]]
[[es:Fibromialgia]]
[[eu:Fibromialgia erreumatiko]]
[[fr:Fibromyalgie]]
[[it:Fibromialgia]]
[[he:דאבת השרירים]]
[[nl:Fibromyalgie]]
[[ja:線維筋痛症]]
[[no:Fibromyalgi]]
[[pl:Fibromialgia]]
[[pt:Fibromialgia]]
[[fi:Fibromyalgia]]
[[sv:Fibromyalgi]]

{{WH}}
{{WS}}

Complex regional pain syndrome

2014-10-04T18:56:21Z

Bobby Schwartz: /* Diagnosis */

__NOTOC__
'''For patient information click [[{{PAGENAME}} (patient information)|here]]'''
{{Infobox_Disease |
Name = {{PAGENAME}} |
Image = severe CRPS.jpg|
Caption = Severe CRPS of right arm|
}}
{{Complex regional pain syndrome}}
'''Editor-In-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.]; {{AE}} [[User:zorkun|Cafer Zorkun]] M.D., PhD.

{{SK}} Sudek osteodystrophy; reflex sympathetic osteodystrophy; shoulder-hand syndrome; algodystrophic syndrome; algodystrophy; algoneurodystrophy; causalgia; complex regional pain syndrome type 1; complex regional pain syndrome type 2
==[[Complex regional pain syndrome overview|Overview]]==

==[[Complex regional pain syndrome historical perspective|Historical Perspective]]==

==[[Complex regional pain syndrome classification|Classification]]==

==[[Complex regional pain syndrome pathophysiology|Pathophysiology]]==

==[[Complex regional pain syndrome causes|Causes]]==

==[[Complex regional pain syndrome differential diagnosis|Differentiating Complex Regional Pain Syndrome from other Diseases]]==

==[[Complex regional pain syndrome epidemiology and demographics|Epidemiology and Demographics]]==

==[[Complex regional pain syndrome risk factors|Risk Factors]]==

==[[Complex regional pain syndrome natural history, complications and prognosis|Natural History, Complications and Prognosis]]==

==Diagnosis==

[[Complex regional pain syndrome diagnostic criteria|Diagnostic Criteria]] | [[Complex regional pain syndrome history and symptoms|History and Symptoms]] | [[Complex regional pain syndrome physical examination|Physical Examination]] | [[Complex regional pain syndrome laboratory findings|Laboratory Findings]] | [[Complex regional pain syndrome x ray|X Ray]] | [[Thermography|Neuromusculoskeletal Thermography]] | [[Complex regional pain syndrome other imaging findings|Other Imaging Findings]] | [[Complex regional pain syndrome other diagnostic studies|Other Diagnostic Studies]]

==Treatment==

[[Complex regional pain syndrome medical therapy|Medical Therapy]] | [[Complex regional pain syndrome surgery|Surgery]] | [[Complex regional pain syndrome primary prevention|Primary Prevention]] | [[Complex regional pain syndrome cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Complex regional pain syndrome future or investigational therapies|Future or Investigational Therapies]]

==Case Studies==

[[Complex regional pain syndrome case study one|Case #1]]

{{PNS diseases of the nervous system}}
{{Diseases of the musculoskeletal system and connective tissue}}

[[Category:Neurology]]
[[Category:Orthopedics]]
[[Category:Rheumatology]]
[[Category:Primary care]]
[[Category:Disease]]

[[de:Komplexes regionales Schmerzsyndrom]]
[[fr:Algoneurodystrophie]]
[[nl:Posttraumatische dystrofie]]
[[pl:Zespół algodystroficzny]]

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

Back pain

2014-10-04T18:54:15Z

Bobby Schwartz: /* Diagnosis */

__NOTOC__
{| class="infobox" style="float:right;"
|-
| [[File:Siren.gif|30px|link={{PAGENAME}} resident survival guide]]|| <br> || <br>
| [[{{PAGENAME}} resident survival guide|Resident<br>Survival<br>Guide]]
|}
'''For patient information click [[{{PAGENAME}} (patient information)|here]]'''
{{Back pain}}

{{CMG}}; [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.]; '''Associate Editor-In-Chief:''' {{CZ}}, {{MUT}}

{{SK}} Backache; back ache; notalgia; dorsalgia

==[[Back pain overview|Overview]]==

==[[Back pain historical perspective|Historical Perspective]]==

==[[Back pain pathophysiology|Pathophysiology]]==

==[[Back pain causes|Causes]]==

==[[Back pain differential diagnosis|Differentiating Back Pain from other Diseases]]==

==[[Back pain epidemiology and demographics|Epidemiology and Demographics]]==

==[[Back pain risk factors|Risk Factors]]==

==[[Back pain natural history, complications and prognosis|Natural History, Complications and Prognosis]]==

==Diagnosis==

[[Back pain history and symptoms|History and Symptoms]] | [[Back pain physical examination|Physical Examination]] | [[Back pain laboratory findings|Laboratory Findings]] | [[Back pain x ray|X Ray]] | [[Back pain CT|CT]] | [[Back pain MRI|MRI]] | [[Back pain ultrasound|Ultrasound]] | [[Back pain other imaging findings|Other Imaging Findings]] | [[Thermography|Neuromusculoskeletal Thermography]] | [[Back pain other diagnostic studies|Other Diagnostic Studies]]

==Treatment==

[[Back pain medical therapy|Medical Therapy]] | [[Back pain surgery|Surgery]] | [[Back pain conservative treatment|Conservative Treatment]] | [[Back pain primary prevention|Primary Prevention]] | [[Back pain secondary prevention|Secondary Prevention]] | [[Back pain cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Back pain future or investigational therapies|Future or Investigational Therapies]]

==Lecture==

[[Media:Back_Pain.ppt|Back Pain]]

==Case Studies==
[[Back pain case study one|Case #1]]

==Related Chapters==
* [[Failed back syndrome]]
* [[Low back pain]]
* [[Posterior Rami Syndrome]]
* [[Tension myositis syndrome]]
* [[Upper back pain]]
* [[Pelvic girdle pain | Pregnancy related pelvic girdle pain]]

{{Diseases of the musculoskeletal system and connective tissue}}

[[de:Rückenschmerzen]]
[[es:Espalda#Dolor de espalda]]
[[fr:mal de dos]]
[[it:Dorsopatia]]
[[nl:Rugpijn]]
[[pt:Dor nas costas]]
[[simple:back pain]]

[[Category:Pain]]
[[Category:Orthopedics]]
[[Category:Rheumatology]]
[[Category:Signs and symptoms]]
[[Category:Neurology]]
[[Category:Emergency medicine]]
[[Category:Primary care]]
[[Category:Neurosurgery]]
[[Category:Disease]]

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

Back pain

2014-10-04T18:53:17Z

Bobby Schwartz: /* Diagnosis */

__NOTOC__
{| class="infobox" style="float:right;"
|-
| [[File:Siren.gif|30px|link={{PAGENAME}} resident survival guide]]|| <br> || <br>
| [[{{PAGENAME}} resident survival guide|Resident<br>Survival<br>Guide]]
|}
'''For patient information click [[{{PAGENAME}} (patient information)|here]]'''
{{Back pain}}

{{CMG}}; [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.]; '''Associate Editor-In-Chief:''' {{CZ}}, {{MUT}}

{{SK}} Backache; back ache; notalgia; dorsalgia

==[[Back pain overview|Overview]]==

==[[Back pain historical perspective|Historical Perspective]]==

==[[Back pain pathophysiology|Pathophysiology]]==

==[[Back pain causes|Causes]]==

==[[Back pain differential diagnosis|Differentiating Back Pain from other Diseases]]==

==[[Back pain epidemiology and demographics|Epidemiology and Demographics]]==

==[[Back pain risk factors|Risk Factors]]==

==[[Back pain natural history, complications and prognosis|Natural History, Complications and Prognosis]]==

==Diagnosis==

[[Back pain history and symptoms|History and Symptoms]] | [[Back pain physical examination|Physical Examination]] | [[Back pain laboratory findings|Laboratory Findings]] | [[Back pain x ray|X Ray]] | [[Back pain CT|CT]] | [[Back pain MRI|MRI]] | [[Back pain ultrasound|Ultrasound]] | [[Back pain other imaging findings|Other Imaging Findings]] | [[Neuromusculoskeletal Thermography|Thermography]] | [[Back pain other diagnostic studies|Other Diagnostic Studies]]

==Treatment==

[[Back pain medical therapy|Medical Therapy]] | [[Back pain surgery|Surgery]] | [[Back pain conservative treatment|Conservative Treatment]] | [[Back pain primary prevention|Primary Prevention]] | [[Back pain secondary prevention|Secondary Prevention]] | [[Back pain cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Back pain future or investigational therapies|Future or Investigational Therapies]]

==Lecture==

[[Media:Back_Pain.ppt|Back Pain]]

==Case Studies==
[[Back pain case study one|Case #1]]

==Related Chapters==
* [[Failed back syndrome]]
* [[Low back pain]]
* [[Posterior Rami Syndrome]]
* [[Tension myositis syndrome]]
* [[Upper back pain]]
* [[Pelvic girdle pain | Pregnancy related pelvic girdle pain]]

{{Diseases of the musculoskeletal system and connective tissue}}

[[de:Rückenschmerzen]]
[[es:Espalda#Dolor de espalda]]
[[fr:mal de dos]]
[[it:Dorsopatia]]
[[nl:Rugpijn]]
[[pt:Dor nas costas]]
[[simple:back pain]]

[[Category:Pain]]
[[Category:Orthopedics]]
[[Category:Rheumatology]]
[[Category:Signs and symptoms]]
[[Category:Neurology]]
[[Category:Emergency medicine]]
[[Category:Primary care]]
[[Category:Neurosurgery]]
[[Category:Disease]]

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

Bioelectromagnetism

2014-10-04T18:49:34Z

Bobby Schwartz: /* Description */

'''Editor-in-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.];

'''Associate Editor-In-Chief:''' [mailto:aschwartz@neuro.fsu.edu][[Austin Schwartz,]] Department of Biophysics, Florida State University, Tallahassee, Florida

'''Bioelectromagnetism''' (sometimes equated with '''bioelectricity''') refers to the electrical, magnetic or [[electromagnetic field]]s produced by living [[cell (biology)|cell]]s, [[biological tissue|tissue]]s or [[organism]]s. Examples include the [[cell potential]] of cell membranes and the [[electric current]]s that flow in [[nerve]]s and [[muscle]]s, as a result of [[action potential]]s. It is not to be confused with [[bioelectromagnetics]], which deals with the effect on life from external electromagnetism.

==Description==

Biological cells use bioelectricity to store metabolic energy, to do work or [[signal transduction|trigger internal changes]], and to signal one another. Bioelectromagnetism is the electric current produced by action potentials along with the [[magnetic field]]s they generate through the phenomenon of [[electromagnetism]]. These action potentials are generated through activation of ion channels, which in turn cause a change in membrane potential of the cells in which they are located. Ion channels and the ions that flow through them are the most basic units that lead to bioelectromagnetism.

Bioelectromagnetism is studied primarily through the technique of [[electrophysiology]]. In the late eighteenth century, the Italian physician and physicist [[Luigi Galvani]] first recorded the phenomenon while dissecting a frog at a table where he had been conducting experiments with [[static electricity]]. Galvani coined the term animal electricity to describe the phenomenon, while contemporaries labeled it [[galvanism]]. Galvani and contemporaries regarded muscle activation as resulting from an electrical fluid or substance in the [[nerves]]. Electrophysiology can be used to measure currents and action potentials in single cells from cell culture containing ion channels of interest and tissue culture from central or peripheral nervous systems of interest. Measurements can be made in vivo and in vitro.

Bioelectromagnetism is an aspect of all [[organism|living things]], including all plants and animals. Several kinds of bioelectromagnetism exist. Photo-electromagnetism refers to the special relationship between photons and its biological responses (for example: photosynthesis and cytochrome oxidase dependent electron transport. [[Biological thermodynamics|Bioenergetics]] is the study of [[energy]] relationships of living organisms. [[Biodynamics]] deals with the energy utilization and the activities of organisms. Some animals have acute bioelectric sensors, and others, such as migratory [[bird]]s, are believed to navigate in part by orienting with respect to the [[Earth's magnetic field]]. Also, [[shark]]s are more sensitive to local interaction in electromagnetic fields than most [[human]]s. Other animals, such as the [[electric eel]], are able to generate large [[electric field]]s outside their bodies.

In the life sciences, [[biomedical engineering]] uses concepts of [[electrical network|circuit]] theory, molecular biology, pharmacology, and bioelectricity. Bioelectromagnetism is associated with [[biorhythm]]s and [[chronobiology]]. [[Biofeedback]] is used in [[physiology]] and [[psychology]] to monitor rhythmic cycles of physical, mental, and emotional characteristics and as a technique for teaching the control of bioelectric functions.

Bioelectromagnetism involves the interaction of [[ion]]s. Bioelectromagnetism is sometimes difficult to understand because of the differing types of bioelectricity, such as brainwaves, [[myoelectricity]] (e.g., heart-muscle phenomena), and other related subdivisions of the same general bioelectromagnetic phenomena. One such phenomenon is a [[Electroencephalography|brainwave]], which [[neurophysiology]] studies, where bioelectromagnetic fluctuations of [[voltage]] between parts of the [[cerebral cortex]] are detectable with an [[electroencephalograph]]. This is primarily studied in the [[brain]] by way of the electroencephalogram or "EEG."

==See also==
*[[Signals (biology)]]
*[[Electrophysiology]]
*[[Magnetobiology]]
*[[Electroencephalography]]
**[[Electroencephalography#Wave types|Brain waves]]
*[[Membrane potential]]
** [[Resting potential]]
** [[Action potential]]
*[[Biorhythm]]
*[[Electrochemical potential]]
*[[Electrochemistry]]
*[[Electric fish]]
*[[Electromyography]]

==External links, resources, and references==

''Information''
* A short history of Bioelectromagnetism [http://butler.cc.tut.fi/~malmivuo/bem/bembook/01/01.htm]
* Malmivuo, Jaakko, and Robert Plonsey, ''' "''[http://butler.cc.tut.fi/~malmivuo/bem/bembook/ Bioelectromagnetism],'' ''' ''Principles and Applications of Bioelectric and Biomagnetic Fields''". Oxford University Press, New York - Oxford. 1995.
* [http://www.ijbem.org/ International Journal of Bioelectromagnetism]
* [http://www.isbem.org/ International Society for Bioelectromagnetism]
* [http://csep1.phy.ornl.gov/CSEP/BF/BF.html Direct and Inverse Bioelectric Field Problems]
* [http://www.pote.hu/biofizika/eng/education/lecture2001/bioelec/index.html Bioelectricity]. Biophysics lectures.

''Groups''
* [http://elecmech.snu.ac.kr/project/biomagnetism.html Bioelectromagnetism Research Group]
* [http://www.vanderbilt.edu/lsp/ Living State Physics Group]
* [http://www.berlin.ptb.de/8/_indexe.html Physikalisch-Technische Bundesanstalt]. Laboratory for Bioelectricity/Biomagnetism, Berlin.
* [http://www.psi.edu.tc PSI - Bak] - Human Bio-magnetism.
* [http://www.rgi.tut.fi/ Ragnar Granit Institute].

[[Category:Physiology]]
[[Category:Biophysics]]

[[cs:Biomagnetismus]]
[[de:Bioelektromagnetismus]]
[[es:Biomagnetismo]]
[[fr:Bioélectromagnétisme]]
[[pt:Bioelectricidade]]
[[sr:Биоелектрицитет]]

Barre lieou

2014-10-04T18:43:11Z

Bobby Schwartz: /* Overview */

{{SI}}

'''Editor-In-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.], Ross Hauser, M.D. [mailto:HauserM@caringmedical.com], Physical Medicine and Rehabilitation Specialist, Oak Park, IL

==Overview==
The "Posterior Cervical Sympathetic Syndrome of Barre-Lieou consists of [[headache]], [[neck pain]], [[blurred vision]], [[tinnitus]], [[dysphagia]] and [[paresthesias]]. Common clinical presentations include mixed headaches, vasomotor headache and complicated flexion-extension (whiplash) injuries.

==Historical Perspective and Etymology==
In 1925 Jean Alexandre Barre, M.D., a French Neurologist described a syndrome consisting cervicogenic headache in association with ringing in the ears, blurred vision, trouble swallowing and vertigo. The majority of these symptoms were thought to be due to over activity in the posterior cervical sympathetic nervous system (a group of nerves located near the vertebrae in the neck).

The syndrome was again described in 1928 by Yong-Choen Lieou, a Chinese physician. In 1947 Louis Gayral published "Oto-neuro-opthalomologic Manifestations of Cervical Origin" in The Lancet. The article was subtitled the "Posterior Cervical Sympathetic Syndrome of Barre-Lieou" and the name Barre-lieou for the syndrome has been popularized ever since.

==Pathophysiology==

It has been hypothesized to be due to a traction injury of the [[posterior cervical sympathetic chain]] in association with musculoskeletal injury of the head or neck.

==Causes==

===Common Causes===

*Traumatic flexion-extension movement

===Complete List of Causes in Alphabetical Order===

*Autoimmune disorders

*Gunshot wounds

*[[Head trauma]]

*Infection

*Traumatic flexion-extension movement

==Epidemiology and Demographics==

Barre Lieou syndrome is listed as a "rare disease" by the Office of Rare Diseases (ORD) of the National Institutes of Health (NIH). This means that Barre Lieou syndrome, or a subtype of Barre Lieou syndrome, affects less than 200,000 people in the US population.

==Diagnosis==
==Symptoms==
[[Image:Autonomic Nerves In The neck.jpg|thimb|left|Autonomic Nerves In The Neck]]The identifying factors that distinguish Barre-Lieou from other injuries of the head and neck include involvement of the autonomic nervous system. The most commonly described symptoms include tinnitus, vertigo (dizziness, nausea, vomiting, blurred vision, tearing of the eyes and sinus congestion however other symptoms may also include swelling on one side of the face, localized cyanosis (bluish color) of the face, facial numbness, hoarseness, shoulder pain, dysesthesias (pins and needles sensations) of the hands & forearms, muscle weakness and fatigue.

===Laboratory Findings===
[[Image:Left Maxillary Barre Lieou.jpg|thumb|left|Left Maxillary Barre-Lieou]]Sympathetic Skin Response studies ([[Thermography]]) are an excellent diagnostic tool for Barre- Lieou [http://www.piedmontpmr.com/diagnose-treat-barre-lieou-neck-pain-blurred-vision-nausea-vertigo-tinnitus-2]. Sympathetic Skin Response studies are a fractal measurement of galvonic impedance. Since both vasomotor and sudomotor physiology is controlled by the autonomic nervous system, assymetry patterns (reduced galvonic impedance or cold regions) in facial structures, especially when seen in association with localized hot spots in the ipsilateral omohyoid or nuchal ligament.

Other diagnostic techniques are dependent upon clinical response to treatment of the underling disorder. Sphenopalatine ganglion or Superior Cervical Sympathetic ganglion blocks can provide dramatic relief. If a C23 interspinous ligament strain is the underlying generator then local injection at that local can be curative.

==Treatment==
[[Image:SPG.JPG|thumb|left|Sphenopalantine Ganglion]]Many of the same injections (Sphenopalatine ganglion or Superior Cervical Sympathetic ganglion blocks) used for diagnosis are also used for treatment. Using a hit or miss approach to treatment by selecting a particular block based upon symptoms alone is far less effective then block selection based upon objective findings with Sympathetic Skin Response studies ([[Thermography]]) however. In addition to employing sympathetic block, treating the underlying source, or generator of sympathetic response, can be curative [http://www.piedmontpmr.com/sympathetic-pain-versus-rsd].

[[Prolotherapy]] can be very effective in treating the underlying source, especially if the sympathetic response is due to underlying ligament strain (such as the nuchal ligament, C23 interspinous ligament) or tendinosis (especially at the nuchal ligament). As with all sympathetic pain syndromes, it is best to block above the sympathetic response and to do so before trying to treat the underlying source.

Medications by mouth, including muscle relaxers, NSAID's, analgesics and hypnotics are often helpful, however due to the autonomic manifestations seen with Barre- Lieou vasoactive agents such as clonidine, oral magnesium supplements or Epsom salts baths can often be even more effective.

Restorative therapy, including the use of physical agents such as electrical stimulation, TENS and ultrasound, are helpful adjunct treatments. Stretching what is tight and reeducating what is weak are often more helpful then exercise directed toward strengthening.

==Prognosis==
For most cases the prognosis is good, however recalcitrant cases of Barre-lieou are common place. There is a tendency for symptoms to improve over time, but it can take years. More severe cases are disabling and less severe cases just a detractor to quality of life. With proper care and treatment symptoms do frequently respond more quickly then without treatment, so like other sympathetic pain syndromes aggressive care is recommended.

==Similar disorders==
[[CRPS]], [[RSD]], Vasomotor migraine, Cluster headaches, Atypcial facial pain and certain cases of TMJ can produce similar symptoms. When they do it is essentially a result of autonomic involvement.

==External links==

* [http://www.piedmontpmr.com Piedmontpmr.com]
* [http://www.piedmontpmr.com/diagnose-treat-barre-lieou-neck-pain-blurred-vision-nausea-vertigo-tinnitus-2]
* [http://www.caringmedical.com/conditions/Barre-Lieou_Syndrome.htm Barre-Lieou Syndrome]
* [http://rarediseases.info.nih.gov/SiteSearch.aspx?usterms=barre%20lieou NIH]

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Voltage-gated ion channel

2014-10-04T18:41:28Z

Bobby Schwartz:

'''Editor-in-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.];

'''Associate Editor-In-Chief:''' [[Austin B. Schwartz,]] PhD Candidate, Department of Biophysics, Florida State University

==Overview==
'''Voltage-gated ion channels''' are a class of [[Transmembrane protein|transmembrane]] [[ion channel]]s that are activated by changes in electrical [[potential difference]] near the channel; these types of ion channels are especially critical in [[neuron]]s, but are common in many types of [[cell (biology)|cells]]. All voltage gates contain repeating sequences of arginine that are responsible for the charged portion of the domain.

They have a crucial role in excitable neuronal and muscle tissues, allowing a rapid and coordinated depolarization in response to triggering [[Voltage drop|voltage change]]. Found along the [[axon]] and at the [[synapse]], voltage-gated ion channels directionally propagate electrical signals.

==Structure==
They generally are composed of several subunits arranged in such a way that there is a central pore through which ions can travel down their [[electrochemical gradient]]s. The channels tend to be quite ion-specific, although similarly sized and charged ions may also travel through them to some extent.

==Examples==
Examples include:
* the [[sodium channel|sodium]] and [[potassium channel|potassium]] voltage-gated channels of nerve and muscle.
* the [[voltage-gated calcium channel]]s that play a role in neurotransmitter release in pre-synaptic nerve endings.

==Mechanism==
From [[x-ray crystallography|crystallographic]] structural studies of a [[potassium channel]], assuming that this structure remains intact in the corresponding [[plasma membrane]], it is possible to surmise that when a [[potential difference]] is introduced over the membrane, the associated [[electromagnetic field]] induces a conformational change in the potassium channel. The conformational change distorts the shape of the channel proteins sufficiently such that the cavity, or channel, opens to admit ion influx or efflux to occur across the membrane, down its electrochemical gradient. This subsequently generates an electrical [[current (electricity)|current]] sufficient to depolarise the cell membrane.

[[Sodium ion channel#Voltage gated sodium channels|Voltage-gated sodium channels]] and [[Voltage-dependent calcium channel|calcium channels]] are made up of a single polypeptide with four homologous domains. Each domain contains 6 membrane spanning alpha helices. One of these helices, S4, is the voltage sensing helix. It has many positive charges such that a high positive charge outside the cell repels the helix - inducing a conformational change such that ions may flow through the channel. Potassium channels function in a similar way, with the exception that they are composed of four separate polypeptide chains, each comprising one domain.

The voltage-sensitive [[protein domain]] of these channels (the "voltage sensor") generally contains a region composed of S3b and S4 helices, known as the "paddle" due to its shape, which appears to be a [[conserved sequence]], interchangable across a wide variety of cells and species. [[Genetic engineering]] of the paddle region from a species of volcano-dwelling archaebacteria into rat brain potassium channels results in a fully functional ion channel, as long as the whole intact paddle is replaced.<ref>Alabi AA, Bahamonde MI, Jung HJ, Kim JI, Swartz KJ. "Portability of Paddle Motif Function and Pharmacology in Voltage Sensors." "Nature", November 15, 2007. </ref> This "modularity" allows use of simple and inexpensive model systems to study the function of this region, its role in disease, and pharmaceutical control of its behavior rather than being limited to poorly characterized, expensive, and/or difficult to study preparations. <ref>Long SB, Tao X, Campbell EB, MacKinnon R. "Atomic Structure of a Kv Channel in a Lipid Membrane-Like Environment." "Nature", November 15, 2007.</ref>

==External links==
*[http://www.iuphar-db.org/index_ic.jsp The IUPHAR Compendium of Voltage-gated Ion Channels 2005]
* {{MeshName|Voltage-Dependent+Anion+Channels}}

==References==
<references/>

==See also==

* [[Ion channel]]
* [[Voltage-dependent calcium channel]]
* [[Sodium ion channel]]
* [[Potassium channel]]
* [[Voltage-gated potassium channel]]

{{Ion channels}}

[[Category:Ion channels]]
[[Category:Integral membrane proteins]]

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{{WikiDoc Sources}}
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Traditional Chinese medicine

2014-10-04T18:34:36Z

Bobby Schwartz:

{{SI}}

'''Editor-in-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.];

{{Alternative medical systems}}
[[Image:ChineseMedicine-HK.JPG|thumb|right|300px|Traditional Chinese medicine shop in [[Tsim Sha Tsui]], [[Hong Kong]].]]

'''Traditional Chinese medicine''' (also known as '''TCM''', {{zh-stp|s=中医|t=中醫|p=zhōngyī }}) is a range of [[traditional medicine|traditional medical]] practices originating in [[China]] that developed over several thousand years. The English phrase "TCM" was created in the 1950s by the PRC in order to export Chinese medicine; there is no equivalent phrase in Chinese (zhōngyī xué translates literally as simply "Chinese medicine studies"). In fact, TCM is a modern compilation of traditional Chinese medicine. TCM practices include theories, diagnosis and treatments such as [[Chinese herbology|herbal medicine]], [[acupuncture]] and [[Tui na|massage]]; often [[Qigong]] is also strongly affiliated with TCM. TCM is a form of so-called ''Oriental medicine'', which includes other traditional [[East Asia]]n [[medical]] systems such as traditional [[Kampo|Japanese]], and [[Traditional Korean medicine|Korean]] medicine.

TCM theory asserts that processes of the human body are interrelated and in constant interaction with the environment. Signs of disharmony help the TCM practitioner to understand, treat and prevent illness and disease. TCM is therefore often considered to be holoistic in its approach.

In the West, traditional Chinese medicine is considered [[alternative medicine]]. In [[mainland China]] and [[Taiwan]], TCM is considered an integral part of the [[health care system]]. For example, TCM treatments may be prescribed to counter the side effects of [[chemotherapy]], cravings and withdrawal symptoms of [[drug addiction|drug addicts]], and a variety of [[chronic (medicine)|chronic]] conditions.

TCM theory is based on a number of philosophical frameworks including the theory of [[Yin-yang]], the [[five elements (Chinese philosophy)|Five Elements]], the human body [[Meridian (Chinese medicine)|Meridian]] system, [[Zang Fu]] organ theory, and others. Diagnosis and treatment are conducted with reference to these concepts. TCM does not operate within a scientific paradigm but some practitioners make efforts to bring practices into a biomedical and [[evidence-based medicine]] framework.

==History==
[[Image:ChineseMedecine.JPG|thumb|right|200px|An old Chinese medical chart]]
Much of the [[philosophy]] of traditional Chinese medicine derived from the same philosophical bases that contributed to the development of [[Taoist]] philosophy, and reflects the classical [[China|Chinese]] belief that individual human experiences express causative principles effective in the environment at all scales.

During the golden age of his reign from 2698 to 2596 B.C, as a result of a dialogue with his minister Ch'i Pai (岐伯), the [[Yellow Emperor]] is supposed by [[Chinese tradition]] to have composed his '''[[Neijing Suwen]] (內經素問)''' or ''Basic Questions of Internal Medicine'', also known as the ''[[Huangdi Neijing]]''. Modern scholarly opinion holds that the extant text of this title was compiled by an anonymous scholar no earlier than the Han dynasty just over two-thousand years ago.

During the Han Dynasty, [[Zhang Zhong Jing]] (張仲景), the [[Hippocrates]] of China, who was [[mayor]] of [[Chang-sha]] toward the end of the [[2nd century AD]], wrote a ''Treatise on Cold Damage'', which contains the earliest known reference to ''Neijing Suwen''. The [[Jin Dynasty (265-420)|Jin dynasty]] practitioner and advocate of [[acupuncture]] and [[moxibustion]], [[Huang-fu Mi]] ([[215]] - [[282]] AD), also quoted the [[Yellow Emperor]] in his ''[[Jia Yi Jing]]'' (甲乙經), ca. [[265]] AD. During the [[Tang dynasty]], Wang Ping claimed to have located a copy of the originals of the ''Neijing Suwen'', which he expanded and edited substantially. This work was revisited by an imperial commission during the [[11th century|11th century AD]].

[[Classical Chinese Medicine]] (CCM) is notably different from Traditional Chinese Medicine (TCM). The [[Kuomintang|Nationalist]] government elected to abandon and outlaw the practice of CCM as it did not want China to be left behind by scientific progress. For 30 years, CCM was forbidden in China and several people were prosecuted by the government for engaging in CCM. In the [[1960s|1960's]], [[Mao Zedong]] finally decided that the government could not continue to outlaw the use of CCM. He commissioned the top 10 doctors (M.D.'s) to take a survey of CCM and create a standardized format for its application. This standardized form is now known as TCM.

Today, TCM is what is taught in nearly all those medical schools in China, most of [[Asia]] and [[Northern America]], that teach traditional medical practices at all. To learn CCM typically one must be part of a family lineage of medicine. Recently, there has been a resurgence in interest in CCM in China, Europe and United States, as a specialty.

Contact with [[Western culture]] and medicine has not displaced TCM. While there may be traditional factors involved in the persistent practice, two reasons are most obvious in the westward spread of TCM in recent decades. Firstly, TCM practices are believed by many to be very effective, sometimes offering palliative efficacy where the best practices of Western medicine fail, especially for routine ailments such as [[flu]] and [[Allergy|allergies]], and managing to avoid the [[toxicity]] of some chemically composed medicines. Secondly, TCM provides the only care available to ill people, when they cannot afford to try the western option. On the other hand, there is, for example, no longer a distinct branch of Chinese [[physics]] or Chinese [[biology]].

TCM formed part of the [[Barefoot doctors|barefoot doctor]] program in the [[People's Republic of China]], which extended [[public health]] into rural areas. It is also cheaper to the PRC government, because the cost of training a TCM practitioner and staffing a TCM hospital is considerably less than that of a practitioner of Western medicine; hence TCM has been seen as an integral part of extending health services in China.

There is some notion that TCM requires supernatural forces or even cosmology to explain itself. However most historical accounts of the system will acknowledge it was invented by a culture of people that were already tired of listening to shamans trying to explain illnesses on evil spirits<ref>"It could be said that the theory of the 5 Elements, and its application to medicine, marks the beginning of what one might call 'scientific' medicine and a departure from Shamanism. No longer do healers look for a supernatural cause of disease: they now observe Nature and, with a combination of the inductive and deductive method, the set out to find patterns within it and, by extension, apply these in the interpretation of disease" - from an introductory textbook used by many acupuncture courses - {{cite book |last= Maciocia |first= Giovanni |title= [[The Foundations of Chinese Medicine]] |publisher= [[Churchill Livingstone]] |year=1989 |isbn= 0-443-03980-1 | pages=p.16 }}</ref>; any reference to supernatural forces is usually the result of romantic translations or poor understanding and will not be found in the Taoist-inspired classics of acupuncture such as the [[Huang Di Nei Jing|Nèi Jīng]] or [[Zhenjiu Dacheng|Zhēnjiǔ Dàchéng]]. The system's development has over its history been skeptically analysed extensively, and practice and development of it has waxed and waned over the centuries and cultures which it has travelled<ref>{{cite book |last= Needham |first= Joseph |coauthors=Lu Gwei-Djen |title= [[Celestial Lancets]] |publisher= [[Cambridge University Press]] |year=1980 |isbn= 0-521-21513-7 | pages=pp.69-170, 262-302 }}</ref> - yet the system has still survived this far. It is true that the focus from the beginning has been on pragmatism, not necessarily understanding of the mechanisms of the actions - and that this has hindered its modern acceptance in the West. This, despite that there were times such as the early 18th Century when "acupuncture and moxa were a matter of course in polite European society"<ref>Needham et al[1980], p. 296</ref>

=== Timeline ===
The history of TCM can be summarized by a list of important doctors and books.
nknown, [[Huang Di Nei Jing|''Huáng Dì Nèi Jīng'']] (黃帝內經)(Classic of Internal Medicine by [[Yellow Emperor|Emperor Huang]]) - Sù Wèn (素問) & Líng Shū (靈樞). The earliest classic of TCM passed on to the present.

* [[Warring States Period]] (5th century BC to 221 BC): Silk scrolls recording channels and collaterals, Zu Bi Shi Yi Mai Jiu Jing (Moxibustion Classic of the Eleven Channels of Legs and Arms), and Yin Yang Shi Yi Mai Jiu Jing (Moxibustion Classic on the Eleven Yin and Yang Channels)

* [[Eastern Han Dynasty]] (206 BC–AD 220) to Three Kingdoms Period (220 - 280 AD):
** Zhen Jiu Zhen Zhong Jing (Classic of Moxibustion and Acupuncture Preserved in a Pillow) by [[Hua Tuo|Huà Tuó (華佗)]]
** Shang Han Za Bing Lun, also known as Shāng Hán Lùn (Treatise on Febrile and Miscellaneous Diseases) by [[Zhang Zhong Jing|Zhāng Zhòng Jǐng (張仲景)]]

*[[Jìn Dynasty (265-420)]]: Zhēn Jiǔ Jiǎ Yǐ Jīng (Systematic Classic of Acupuncture and Moxibustion) by [[Huangfu Mi|Huángfǔ Mì (皇甫謐)]].

* [[Tang Dynasty]] ([[June 18]], 618–June 4, 907)
**[[Bei Ji Qian Jin Yao Fang]] (Emergency Formulas of a thousand gold worth) and Qian Jin Yi Fang (Supplement to the Formulas of a thousand gold worth) by [[Sun Simiao|Sūn Sīmiǎo (孫思邈)]]
** Wai Tai Mi Yao (Arcane Essentials from the Imperial Library) by Wang Tao

* [[Song Dynasty]] (960 – 1279):
** Tóngrén Shūxué Zhēn Jiǔ Tú Jīng (Illustrated Manual of the Practice of Acupuncture and Moxibustion at (the Transmission) (and other) Acu-points, for use with the Bronze Figure) by [[Wang Weiyi|Wáng Wéi Yī (王惟一)]].
**Emergence of Wenbing School{{Fact|date=February 2007}}

* [[Yuan Dynasty]] (1271 to 1368): Shísì Jīng Fā Huī (Exposition of the Fourteen Channels) by [[Hua Shou|Huá Shòu (滑壽)]].

* [[Ming Dynasty]] (1368 to 1644): Climax of acupuncture and Moxibustion. Many famous doctors and books. Only name a few:
** Zhēnjiǔ Da Quan (A Complete Collection of Acupuncture and Moxibustion) by [[Xu Feng]]
** Zhēnjiǔ Jù Yīng Fa Hui (鍼灸聚英??) (An Exemplary Collection of Acupuncture and Moxibustion and their Essentials) by [[Gao Wu|Gāo Wǔ (高武)]]
** Zhēnjiǔ Dàchéng (針灸大成)(Compendium of Acupuncture and Moxibustion) by [[Yang Jizhou]], a milestone book. 1601CE, Yáng Jì Zhōu (楊繼洲).
** Běncǎo Gāng Mù (本草綱目)([[Compendium of Materia Medica]]) by [[Li Shizhen|Lǐ Shízhēn (李時珍)]], the most complete and comprehensive pre-modern herb book
**Wen Yi Lun by Wu YouShing{{Fact|date=February 2007}}

* [[Qing Dynasty]](1644-1912):
**Yi Zong Jin Jian (Golden Reference of the Medical Tradition) by Wu Quan, sponsored by the imperial.
**Zhen Jiu Feng Yuan (The Source of Acupuncture and Moxibustion) by [[Li Xuechuan]]
**Wen Zhen Lun Dz by Ye TianShi{{Fact|date=February 2007}}
**Wen Bing Tiao Bian(Systematized Identification of Warm Disease) written by Wu Jutong, a Qing dynasty physician, in 1798 C.E.<ref>http://www.pacificcollege.edu/alumni/newsletters/winter2004/damp_warmth.html</ref>

== Theory ==
The foundation principles of Chinese medicine are not necessarily uniform, and are based on several schools of thought. Received TCM can be shown to be most influenced by [[Taoism]], [[Buddhism]], and [[Neo-Confucianism]].

Since 1200 BC, Chinese academics of various schools have focused on the observable natural laws of the universe and their implications for the practical characterisation of humanity's place in the universe. In the [[I Ching]] and other Chinese literary and philosophical classics, they have described some general principles and their applications to health and healing:

*There are observable principles of constant change by which the Universe is maintained. Humans are part of the universe and cannot be separated from the '''universal process of change'''.
*As a result of these apparently inescapable primordial principles, the Universe (and every process therein) tends to eventually '''balance''' itself. '''Optimum health results from living harmoniously''', allowing the spontaneous process of change to bring one closer to balance. If there is no change (stagnation), or too much change (catastrophism), balance is lost and illnesses can result.
*Everything is ultimately interconnected. Always use a '''[[holistic]]''' ("systemic" or "system-wide") approach when addressing imbalances.

One modern interpretation of Traditional Chinese medicine's "macro" or holistic view of disease is that well-balanced human bodies can resist most everyday [[bacteria]] and [[virus]]es, which are ubiquitous and quickly changing. Infection, while having a proximal cause of a microorganism, would have an underlying cause of an imbalance of some kind. TCM would target the theorized imbalance, not the infectious organism.{{Fact|date=February 2007}} A TCM practitioner might give very ''different'' herbal prescriptions to patients affected by the ''same'' type of affliction, because the different symptoms reported by the patients would indicate a different type of imbalance. There is a popular saying in China: ''Chinese medicine treats humans while western medicine treats diseases''.

== Model of the body ==
{{main|TCM model of the body}}
Traditional Chinese medicine is largely based on the [[philosophy|philosophical]] concept that the human body is a small universe with a set of complete and sophisticated interconnected systems, and that those systems usually work in balance to maintain the healthy function of the human body. The balance of [[yin and yang]] is considered with respect to [[qi]] ("breath", "life force", or "spiritual energy"), [[blood]], [[Jing (TCM)|jing]] ("kidney essence" or "semen"), other [[bodily fluids]], the [[Five elements (Chinese philosophy)|Five elements]], [[emotion]]s, and the [[soul]] or [[spirit]] ('''shen'''). TCM has a unique [[TCM model of the body|model of the body]], notably concerned with the [[Meridian (Chinese medicine)|meridian system]]. Unlike the Western anatomical model which divides the physical body into parts, the Chinese model is more concerned with function. Thus, the TCM Spleen is not a specific piece of flesh, but an aspect of function related to transformation and transportation within the body, and of the mental functions of thinking and studying.

There are significant regional and philosophical differences between practitioners and schools which in turn can lead to differences in practice and theory.

Models of the body include:

*[[Yin or Yang]]
*[[Five elements (Chinese philosophy)|Five elements]]
*[[Zang Fu theory]]
*[[Meridian (Chinese medicine)]]
*[[Three jiaos]] also known as the Triple Burner or the Triple Warmer

The Yin/Yang and five element theories may be applied to a variety of systems other than the human body, whereas Zang Fu theory, meridian theory and three-jiao (Triple warmer) theories are more specific.

There are also separate models that apply to specific pathological influences, such as the [[Four stages]] theory of the progression of warm diseases, the [[Six levels]] theory of the penetration of cold diseases, and the [[Eight principles]] system of disease classification.

== Diagnostics ==

Following a macro philosophy of disease, traditional Chinese diagnostics are based on overall observation of human symptoms rather than "micro" level laboratory tests. There are four types of TCM diagnostic methods: observe (望 wàng), hear and smell (聞 wén), ask about background (問 wèn) and touching (切 qiè).<ref name=Maciocia>{{cite book|first=Giovanni|last=Maciocia|title=The Foundations of Chinese Medicine|publisher=Churchill Livingstone|year=1989}}</ref> The pulse-reading component of the touching examination is so important that Chinese patients may refer to going to the doctor as "Going to have my pulse felt"<ref name=Kaptchuk>{{cite book|first=Ted|last=Kaptchuk|title=Chinese Medicine: The Web That Has No Weaver|edition=2nd|year=2000|Publisher=Random House}}</ref>

Traditional Chinese medicine is considered to require considerable diagnostic skill. A training period of years or decades is said to be necessary for TCM practitioners to understand the full complexity of symptoms and dynamic balances. According to one Chinese saying, ''A good (TCM) doctor is also qualified to be a good prime minister in a country''. Modern practitioners in China often use a traditional system in combination with Western methods.{{Fact|date=February 2007}}

=== Techniques ===
* Palpation of the patient's [[radial artery]] [[pulse]] ([[Pulse diagnosis]]) in six positions
* Observation of the appearance of the patient's [[tongue]]
* Observation of the patient's [[face]]
* Palpation of the patient's body (especially the [[abdomen]]) for tenderness
* Observation of the sound of the patient's [[human voice|voice]]
* Observation of the surface of the [[ear]]
* Observation of the [[vein]] on the [[index finger]] on small children
* Comparisons of the relative warmth or coolness of different parts of the body
* Observation of the patient's various odors
* Asking the patient about the effects of his problem
* Anything else that can be observed without instruments and without harming the patient

== Treatment ==
The below methods are considered as part of the Chinese medicine treatment:
# [[Chinese herbology|Chinese herbal medicine]](中藥)
# [[Acupuncture]] and [[Moxibustion]] (針灸)
# ''Die-da'' or ''Tieh Ta'' (跌打)
# [[Chinese food therapy]] (食療)
# [[Tui na]] (推拿) - massage therapy
# [[Qigong]] (氣功) and related breathing and meditation exercise
# Physical exercise such as [[T'ai Chi Ch'uan]] (太極拳) and other [[Chinese martial arts]]
# Mental health therapy such as [[Feng shui]] (風水) and [[Chinese astrology]]

Specific treatment methods are grouped into these branches. [[Cupping]] and [[Gua Sha]] (刮痧) are part of Tui Na. [[Auriculotherapy]] (耳燭療法) comes under the heading of Acupuncture and Moxibustion. ''Die-da'' or ''Tieh Ta'' (跌打) are practitioners who specialize in healing [[Physical trauma|trauma]] injury such as bone fractures, sprains, and bruises. Some of these specialists may also use or recommend other disciplines of Chinese medical therapies (or Western medicine in modern times) if serious injury is involved. Such practice of bone-setting is not common in the West.

== Branches ==
Traditional Chinese medicine has many branches, the most prominent of which are the Jingfang (经方学派) and Wenbing(温病学派) schools. The Jingfang school relies on the principles contained in the Chinese medicine classics of the [[Han Dynasty|Han]] and [[Tang dynasty]], such as [[Huangdi Neijing]] and [[Shenlong Bencaojing]]. The more recent Wenbing school's practise is largely based on more recent books including [[Compendium of Materia Medica]] from [[Ming Dynasty|Ming]] and [[Qing Dynasty]], although in theory the school follows the teachings of the earlier classics as well. Intense debates between these two schools lasted until the [[Cultural Revolution]] in mainland [[China]], when Wenbing school used political power to suppress the opposing school.{{Facts|date=February 2007}}

== Scientific view ==
=== The question of efficacy ===
Much of the [[scientific research]] on TCM has focused on [[acupuncture]]. Currently, there is no scientific consensus as to whether acupuncture is effective or only has value as a [[placebo]]. [[evidence-based medicine|Evidence-based]] reviews of existing clinical trials, conducted by the [[Cochrane Collaboration]] and [[Bandolier (journal)|Bandolier]], have suggested efficacy for idiopathic [[headache]][http://www.cochrane.org/reviews/en/ab001218.html] and post-operative [[nausea]][http://www.cochrane.org/reviews/en/ab003281.html][http://www.jr2.ox.ac.uk/bandolier/band71/b71-9.html], but for most conditions have concluded a lack of effectiveness or an insufficiency of well-conducted clinical trials.[http://www.jr2.ox.ac.uk/bandolier/booth/alternat/AT003.html] The [[World Health Organisation]] (WHO), the [[National Institutes of Health]] (NIH), and the [[American Medical Association]] (AMA) have also commented on acupuncture[http://www.aaom.org/default.asp?pagenumber=47494][http://www.ama-assn.org/ama/pub/category/13638.html]. Though these groups disagree on the standards and interpretation of the evidence for acupuncture, there is general agreement that it is relatively safe, and that further investigation is warranted. The 1997 NIH [http://consensus.nih.gov/1997/1997Acupuncture107html.htm Consensus Development Conference Statement] on acupuncture concluded:

<blockquote>
...promising results have emerged, for example, showing efficacy of acupuncture in adult postoperative and chemotherapy nausea and vomiting and in postoperative dental pain. There are other situations such as addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, osteoarthritis, low back pain, carpal tunnel syndrome, and asthma, in which acupuncture may be useful as an adjunct treatment or an acceptable alternative or be included in a comprehensive management program. Further research is likely to uncover additional areas where acupuncture interventions will be useful.
</blockquote>

Much less scientific research has been done on Chinese herbal medicines, which comprise much of TCM.
Some doubts about the efficacy of many TCM treatments are based on their apparent basis in [[inductive reasoning]] — for example, that plants with heart-shaped leaves will help the heart, or that ground bones of the [[tiger]] can function as a stimulant because tigers are energetic animals. While the [[doctrine of signatures]] does underlie the selection of many of the ingredients of herbal medicines, this does not necessarily mean that some substances may not (perhaps by coincidence) possess attributed medicinal properties. For example, it is possible that while herbs may have been originally selected on erroneous grounds, only those that were deemed effective have remained in use. Potential barriers to scientific research include the large amount of money and expertise required to conduct [[double-blind]] [[clinical trial]]s, and the lack of financial incentive from the ability to obtain [[patent]]s. Traditional practitioners usually have no philosophical objections to scientific studies on the effectiveness of treatments.{{Fact|date=February 2007}}

Pharmacological compounds have been isolated from some Chinese herbal medicines; [[Chinese wormwood]] (''qinghao'') was the source for the discovery of [[artemisinin]], which is now used worldwide to treat multi-drug resistant strains of falciparum [[malaria]], and is also under investigation as an anti-cancer agent. Many Chinese herbal medicines are marketed as [[dietary supplement]]s in the West, and there is considerable controversy over their effectiveness, safety, and regulatory status. For example, ''ma huang'', or [[ephedra]], which contains [[ephedrine]] and [[pseudoephedrine]], is restricted in the [[United States]], due to the risk of adverse impact on the [[cardiovascular system]] and some deaths due to consumption of extracts in high doses.

=== Safety ===
Acupressure and acupuncture are largely accepted to be safe from results gained through medical studies. Several cases of [[pneumothorax]], nerve damage and infection have been reported as resulting from acupuncture treatments. These adverse events are extremely rare especially when compared to other medical interventions, and were found to be due to practitioner negligence. Dizziness and bruising will sometimes result from acupuncture treatment.

Some governments have decided that Chinese acupuncture and herbal treatments should only be administered by persons who have been educated to apply them safely. "A key finding is that the risk of adverse events is linked to the length of education of the practitioner, with practitioners graduating from extended Traditional Chinese Medicine education programs experiencing about half the adverse event rate of those practitioners who have graduated from short training programs." [http://www.health.vic.gov.au/archive/archive2006/chinese/report/sumfind.htm]

Certain Chinese herbal medicines involve a risk of [[allergy|allergic]] reaction and in rare cases involve a risk of [[poison]]ing. Cases of acute and chronic poisoning due to treatment through ingested Chinese medicines are found in [[China]], [[Hong Kong]], and [[Taiwan]], with a few deaths occurring each year. Many of these deaths do occur however, when patients self prescribe herbs or take unprocessed versions of toxic herbs. The raw and unprocessed form of [[aconite]], or fuzi is the most common cause of poisoning. The use of aconite in Chinese herbal medicine is usually limited to processed aconite, in which the toxicity is denatured by heat treatment.

Furthermore, potentially toxic and [[carcinogenic]] compounds such as [[arsenic]] and [[cinnabar]] are sometimes prescribed as part of a medicinal mixture or used on the basis of "''using poison to cure poison''". Unprocessed herbals are sometimes adulterated with chemicals that may alter the intended effect of a herbal preparation or prescription. Much of these are being prevented with more empirical studies of Chinese herbals and tighter regulation regarding the growing, processing, and prescription of various herbals.

In the United States, the Chinese herb ''má huáng'' (麻黄; lit. "hemp yellow") — known commonly in the West by its Latin name [[Ephedra]] — was banned in 2004 by the [[Food and Drug Administration|FDA]], although, the FDA's final ruling exempted traditional Asian preparations of Ephedra from the ban. The Ephedra ban was meant to combat the use of this herb in Western weight loss products, a usage that directly conflicts with traditional Asian uses of the herb. There were no cases of Ephedra based fatalities with patients using traditional Asian preparations of the herb for its traditionally intended uses. This ban was ordered lifted in April 2005 by a Utah federal court judge. However, the ruling was appealed and on August 17, 2006, the Appeals Court upheld the FDA's ban of ephedra, finding that the 133,000-page administrative record compiled by the FDA supported the agency's finding that ephedra posed an unreasonable risk to consumers.

Many Chinese medicines have different names for the same ingredient depending on location and time, but worse yet, ingredients with vastly different medical properties have shared similar or even same names. For example, there was a report that [[mirabilite]]/[[sodium sulphate]] decahydrate (芒硝) was misrecognized as [[sodium nitrite]] (牙硝)[http://www.hkcccm.com/main.php?id1=164&id2=165], resulting in a poisoned victim[http://www3.news.gov.hk/ISD/ebulletin/tc/category/healthandcommunity/040503/html/040503tc05003.htm][http://www.info.gov.hk/gia/general/200405/03/0503212.htm]. In some Chinese medical texts, both names are interchangeable[http://www.100md.com/html/DirDu/2004/07/25/53/75/65.htm]. Chinese herbal medicine authorities are working towards improved standards in this area [http://www.cmrb.vic.gov.au/current-news/draft/CMRBDisPaperInternet.pdf].

== Relationship with Western medicine==
Within China, there has been a great deal of cooperation between TCM practitioners and Western medicine, especially in the field of [[ethnomedicine]]. Chinese herbal medicine includes many compounds which are unused by Western medicine, and there is great interest in those compounds as well as the theories which TCM practitioners use to determine which compound to prescribe. For their part, advanced TCM practitioners in China are interested in statistical and experimental techniques which can better distinguish medicines that work from those that do not. One result of this collaboration has been the creation of peer reviewed scientific journals and medical databases on traditional Chinese medicine.

Outside of China, the relationship between TCM and Western medicine is more contentious. While more and more medical schools are including classes on alternative medicine in their curricula, older Western doctors and scientists are far more likely than their Chinese counterparts to skeptically view TCM as archaic pseudoscience and superstition. This skepticism can come from a number of sources. For one, TCM in the West tends to be advocated either by Chinese immigrants or by those that have lost faith in [[conventional medicine]]. Many people in the West have a stereotype of the East as mystical and unscientific, which attracts those in the West who have lost hope in science and repels those who believe in scientific explanations. There have also been experiences in the West with unscrupulous or well-meaning but improperly-trained "TCM practitioners" who have done people more harm than good in many instances.

As an example of the different roles of TCM in China and the West, a person with a broken bone in the West (i.e. a routine, "straightforward" condition) would almost never see a Chinese medicine practitioner or visit a [[martial art]]s school to get the bone set, whereas this is routine in China. As another example, most TCM hospitals in China have [[electron microscope]]s and many TCM practitioners know how to use one.

Most Chinese in China do not see traditional Chinese medicine and Western medicine as being in conflict. In cases of emergency and crisis situations, there is generally no reluctance in using conventional Western medicine. At the same time, belief in Chinese medicine remains strong in the area of maintaining health. As a simple example, you see a Western doctor if you have acute [[appendicitis]], but you do exercises or take Chinese herbs to keep your body healthy enough to prevent appendicitis, or to recover more quickly from the surgery. Very few practitioners of Western medicine in China reject traditional Chinese medicine, and most doctors in China will use some elements of Chinese medicine in their own practice.

A degree of integration between Chinese and Western medicine also exists in China. For instance, at the Shanghai cancer hospital, a patient may be seen by a multidisciplinary team and be treated concurrently with radiation surgery, Western drugs and a traditional herbal formula. A report by the [[Victoria (Australia)|Victorian]] state government in [[Australia]] on TCM education in China noted:
:Graduates from TCM university courses are able to diagnose in Western medical terms, prescribe Western pharmaceuticals, and undertake minor surgical procedures. In effect, they practise TCM as a specialty within the broader organisation of Chinese health care. [http://www.health.vic.gov.au/archive/archive2006/chinese/report/8.htm]

In other countries it is not necessarily the case that traditional Chinese and Western medicine are practiced concurrently by the same practitioner. TCM education in Australia, for example, does not qualify a practitioner to provide diagnosis in Western medical terms, prescribe scheduled pharmaceuticals, nor perform surgical procedures. [http://www.health.vic.gov.au/archive/archive2006/chinese/report/4.htm] While that jurisdiction notes that TCM education does not qualify practitioners to prescribe Western drugs, a separate legislative framework is being constructed to allow registered practitioners to prescribe Chinese herbs that would otherwise be classified as poisons. [http://www.cmrb.vic.gov.au/current-news/draft/CMRBDisPaperInternet.pdf]

It is worth noting that the practice of Western medicine in China is somewhat different from that in the West. In contrast to the West, there are relatively few [[allied health professional]]s to perform routine [[medical procedure]]s or to undertake procedures such as [[massage]] or [[physical therapy]].

In addition, Chinese practitioners of Western medicine have been less impacted by trends in the West that encourage patient empowerment, to see the patient as an individual rather than a collection of parts, and to do nothing when medically appropriate. Chinese practitioners of Western medicine have been widely criticized for over-prescribing drugs such as [[corticosteroid]]s or [[antibiotic]]s for common [[virus|viral]] infections. It is likely that these medicines, which are generally known to be useless against viral infections, would provide less relief to the patient than traditional Chinese herbal remedies.

Traditional Chinese diagnostics and treatments are often much cheaper than Western methods which require high-tech equipment or extensive chemical manipulation.

TCM doctors often criticize Western doctors for paying too much attention to laboratory tests and showing insufficient concern for the overall feelings of patients. {{Fact|date=July 2007}}

Modern TCM practitioners will refer patients to Western medical facilities if a medical condition is deemed to have put the body too far out of "balance" for traditional methods to remedy.

== Animal products ==
[[Image:Seahorse Skeleton Macro 8 - edit.jpg|200px|thumb|Dried [[seahorse]]s like these are extensively used in traditional medicine in China and elsewhere]]
Animal products are used in certain Chinese formulae, which may present a problem for [[vegan]]s and [[vegetarians]]. If informed of such restrictions, practitioners can often use alternative substances.

The use of [[endangered species]] is controversial within TCM. In particular, is the belief that [[tiger]] penis and [[rhinoceros]] horn are [[aphrodisiac]]s (although the traditional use of rhinoceros horn is to reduce fever.)<ref name=Bensky_Clavey_Stoger>{{cite book|title=Chinese Herbal Medicine Material Medica (3rd Edition)|last=Bensky, Clavey and Stoger|publisher=Eastland Press|year=2004}}</ref> This depletes these species in the wild. Medicinal use is also having a major impact on the populations of [[seahorse]]s.[http://www.pbs.org/wgbh/nova/seahorse/vincent.html]

[[Shark fin soup]] is traditionally regarded as beneficial for health in East Asia. According to Compendium of Materia Medica, it's good at strengthening the waist, supplementing vital energy, nourishing blood, invigorating kidney and lung and improving digestion. However, such claims are not supported by scientific evidence.[http://www.sfgate.com/cgi-bin/article.cgi?file=/g/archive/2003/01/20/urbananimal.DTL]. Furthermore, they have been found to contain high levels of mercury, which is known for its ill effects.

The [[animal rights]] movement notes that a few traditional Chinese medicinal solutions use [[bile bear|bear bile]]. To extract maximum amounts of the bile, the bears are often fitted with a sort of permanent [[catheter]]. The treatment itself and especially the extraction of the bile is very painful, causes damage to the intestines of the bear, and often kills the bears. However, due to international attention on the issues surrounding its harvesting, bile is now rarely used by practitioners outside of China, gallbladders from butchered cattle are recommended as a substitute for this ingredient<ref name=Bensky_Clavey_Stoger>{{cite book|title=Chinese Herbal Medicine Material Medica (3rd Edition)|last=Bensky, Clavey and Stoger|publisher=Eastland Press|year=2004}}</ref> Bensky, Clavey and Stoger's comprehensive Chinese herbal text deals with substances derived from endangered species in an appendix, with an emphasis on recommending alternatives.

== Opposition ==
Starting from late 19th century, politicians and Chinese scholars with background in Western medicine have been trying to phase out TCM totally in [[China]]. Some of the prominent advocates of the elimination of TCM include:
* [[Lu Xun]], who argues that TCM doctors are intentionally or unintentionally deceiving their patients
* [[Wang Jingwei]], who asserts that TCM has no basis in human anatomy nor any scientific foundation
* [[Li Ao]], who argues that TCM is a kind of [[superstition]].
* [[Fang Shimin]], who argues that TCM is [[pseudo-science]] and may be unsafe due to a lack of [[Double blind]] tests.{{Facts|date=February 2007}}

The attempts to curtail TCM in China always provoke large scale debates but have never completely succeeded. Still, many researchers and practitioners of TCM in China and the United States argue the need to document TCM's efficacy with controlled, double blind experiments. These efforts remain hampered by the difficulty of creating effective placebos for acupuncture studies.{{Facts|date=February 2007}}

The attempt to phase out TCM in [[Japan]] partially succeeded after [[Meiji Restoration]]. However, in the 1920s a movement emerged that attempted to restore traditional medical practice, especially acupuncture. This movement, known as the [[Meridian Therapy]] movement ([[Keiraku Chiryo]] in Japanese) persists to this day. Furthermore, many Japanese physicians continue to practice Kampo, a form of traditional medicine based on the Shang Han Lun tradition of Chinese herbal medicine.{{Facts|date=February 2007}}

==Dose of Modernity==
On September 6, 2007, Abraham Chan, President of the Modernized Chinese Medicine International Association in [[Hong Kong]] announced that Traditional Chinese Medicine is getting a modern dose by transforming the plants and ingredients to [[soluble]] [[granules]] and [[tablets]]. He said that the [[pills]] and sachets used 675 [[plant]] and [[fungi]] ingredients and about 25 from non-plant sources such as [[snakes]], [[geckos]], [[toads]], [[bees]] and [[earthworms]].<ref>[http://www.reuters.com/article/lifestyleMolt/idUSSP9273620070906 Reuters, Chinese medicine gets a dose of modernity]</ref>

==See also==
* ''[[Compendium of Materia Medica]]''
* [[Chinese herbology]]
* [[Chinese patent medicine]]
* [[Hua Tuo]]
* [[Pharmacognosy]]
* [[Public health in the People's Republic of China]]
* [[Qigong]]
* [[Kampo]] (TCM practiced in Japan)
* [[Traditional Korean medicine]]
* [[Traditional Mongolian medicine]]
* [[Doctor of Acupuncture & Oriental Medicine]]
* [[Feng shui]]

==Footnotes==
{{reflist|2}}

==References==
* Chang, Stephen T. <cite>The Great Tao</cite>; Tao Longevity; ISBN 0-942196-01-5 [[Stephen T. Chang]]
* Kaptchuck, Ted J., <cite>The Web That Has No Weaver</cite>; Congdon & Weed; ISBN 0-8092-2933-1Z
* Jin, Guanyuan, Xiang, Jia-Jia and Jin, Lei: <cite>Clinical Reflexology of Acupuncture and Moxibustion</cite>; Beijing Science and Technology Press, Beijing, 2004. ISBN 7-5304-2862-4
* Maciocia, Giovanni, <cite>The Foundations of Chinese Medicine: A Comprehensive Text for Acupuncturists and Herbalists</cite>; Churchill Livingstone; ISBN 0-443-03980-1
* Ni, Mao-Shing, <cite>The Yellow Emperor's Classic of Medicine : A New Translation of the Neijing Suwen with Commentary</cite>; Shambhala, 1995; ISBN 1-57062-080-6
* Holland, Alex <cite>Voices of Qi: An Introductory Guide to Traditional Chinese Medicine</cite>; North Atlantic Books, 2000; ISBN 1-55643-326-3
* Unschuld, Paul U., <cite>Medicine in China: A History of Ideas</cite>; University of California Press, 1985; ISBN 0-520-05023-1
* Scheid, Volker, <cite>Chinese Medicine in Contemporary China: Plurality and Synthesis</cite>; Duke University Press, 2002; ISBN 0822328577
* Qu, Jiecheng, <cite>[http://www.cp1897.com.hk/html/profess/chime/essays/profess0403s02.htm When Chinese Medicine Meets Western Medicine - History and Ideas] (in Chinese)</cite>; Joint Publishing (H.K.), 2004; ISBN 962-04-2336-4
* Chan, T.Y. (2002). Incidence of herb-induced aconitine poisoning in Hong Kong: impact of publicity measures to promote awareness among the herbalists and the public. ''Drug Saf.'' 25:823–828.
* Benowitz, Neal L. (2000) Review of adverse reaction reports involving ephedrine-containing herbal products. ''Submitted to U.S. Food and Drug Administration.'' [[January 17]].
* Porkert, Manfred ''The Theoretical Foundations of Chinese Medicine'' MIT Press, 1974 ISBN 0-262-16058-7
* Hongyi, L., Hua, T., Jiming, H., Lianxin, C., Nai, L., Weiya, X., Wentao, M. (2003) Perivascular Space: Possible anatomical substrate for the meridian. Journal of Complimentary and Alternative Medicine. 9:6 (2003) pp851-859

==External links==
*[http://www.tcmworld.org/ Traditional Chinese Medicine World Foundation], not-for-profit organization dedicated to educating individuals and health-care practitioners about classical traditional Chinese medicine and natural healing.
*[http://ejournals.worldscientific.com.sg/ajcm/ajcm.shtml American Journal of Chinese Medicine], academic journal for TCM.
*[http://www.nlm.nih.gov/hmd/chinese/chinesehome.html Classics of Traditional Chinese Medicine], by the National Library of Medicine (NLM)
*[http://www.cmir.org.uk Chinese Medical Institute and Register]
*[http://consensus.nih.gov/1997/1997Acupuncture107html.htm Acupuncture. NIH Consensus Statement 1997 Nov 3-5; 15(5):1-34.]
*[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15510787 Effects of acupuncture on gastroparesis study]
*[http://www.commonweal.org/pubs/choices/19.html Traditional Chinese Medicine--A Favored Adjunctive Therapy for American Cancer Patients]
*[http://www.jyi.org/volumes/volume6/issue5/features/feng.html Merging Chinese Traditional Medicine into the American Health System]
*[http://www.chinesemedicinesampler.com/theorybasic.html The Chinese Medicine Sampler]- Historical Roots of Traditional Chinese Medicine
* [http://www.acupuncture.com.au Traditional Chinese Medicine news, information, education, research and discussion] - A regularly updated TCM website based in Australia
* [http://www.medicacompletehealth.com.au Monthly newsletters on Chinese Medicine and Health (AUS)]
* [http://www.nccaom.org National Certification Commission for Acupuncture and Oriental Medicine (USA)]
* [http://www.aaom.org American Association for Acupuncture and Oriental Medicine]
* [http://www.csomaonline.org California State Oriental Medical Association (CSOMA)]
* [http://www.jcm.co.uk The Journal of Chinese Medicine: academic level journal for TCM]
* [http://www.chinesemedicinetimes.com/wiki/CMTpedia Advanced Online Encyclopedia for Chinese Medicine and Acupuncture]

===Schools of Classical Chinese Medicine===
*[http://www.ncnm.edu/academics/classical_chinese_medicine_school.php Classical Chinese Medicine School at National College of Natural Medicine] - Masters of Science in Oriental Medicine (MSOM) degree that offers a four-year program that educates students in the practice of Oriental medicine as illustrated by Chinese medical classics in the topics of acupuncture, Chinese herbal medicine, qi gong, tui na and more. ([[Portland, OR]])

===Schools of Traditional Chinese Medicine===

* [http://www.aimc.edu Acupuncture & Integrative Medicine College, Berkeley | Acupuncture School] - masters degree in Oriental medicine/traditional Chinese medicine (TCM), and other programs in medical qigong (certification), and Japanese acupuncture (certification) ([[Berkeley, CA]])

*[http://www.aaaom.edu American Academy of Acupuncture and Oriental Medicine] - Masters Degree in Acupuncture and Oriental Medicine - specializing in Traditional Chinese Medicine including - acupuncture, herbology, dietary therapy, exercise therapy (Qi Gong, Tai Chi) and Tuina Massage. ([[Roseville, MN]])

* [http://www.actcm.edu American College of Traditional Chinese Medicine] - acupuncture school, traditional Chinese medicine (TCM), Chinese herbal medicine, tui na certification ([[San Francisco, CA]])

* [http://www.instituteoftraditionalmedicine.com/ Institute of Traditional Medicine] - offers [http://www.instituteoftraditionalmedicine.com/programs.html programs] in Oriental Medicine, and Acupuncture, as well as Herbal Medicine, Asian Body Work Therapy, and Traditional Arts. Distinguished by a holistic [http://www.instituteoftraditionalmedicine.com/vision.html vision and philosophy] which offers its students the opportunity to explore and study [http://www.instituteoftraditionalmedicine.com/tradmed.html Oriental Medicine and other forms of traditional healing] ([[Toronto, Ontario, Canada]])

* [http://www.acupuncture.edu/midwest/ Midwest College of Oriental Medicine] - offers a combined Bachelor of Science in Nutrition and Master's in traditional Chinese medicine (TCM), acupuncture certification, and a new doctoral program.

* [http://www.nesa.edu New England School of Acupuncture] - acupuncture school, traditional Chinese medicine (TCM), Chinese herbal medicine, Chinese medical qigong, integrative medicine, and Japanese acupuncture ([[Newton, MA]])

* [[Oregon College of Oriental Medicine]] - acupuncture school, traditional Chinese medicine, Chinese herbal medicine, [[Qigong]], [[Shiatsu]], [[Tui Na]], taiji quan, clinical [[doctor of acupuncture & Oriental medicine]] degree program ([[Portland, OR]])

* [http://www.pacificrimcollege.ca Pacific Rim College] - School of Acupuncture and Oriental Medicine - Diploma in Acupuncture, Diploma in Acupuncture and Oriental Medicine, Doctor of Traditional Chinese Medicine. ([[Victoria, British Columbia, Canada]])

* [http://www.acupuncturecollege.edu Southwest Acupuncture College, Boulder, CO] - an accredited post-graduate college that offers a Master's of Science in Oriental Medicine, which includes Chinese herbal medicine, acupuncture, [[qi gong]], [[shiatsu]], [[tui na]], tai ji, and clinical experience. The Master's degree is an extensive, four-year, 3000-plus-hour program ([[Boulder, CO]])

* [http://www.yosan.edu Yo San University of Traditional Chinese Medicine] - acupuncture, herbal medicine, chi development ([[Los Angeles, California]])

===Online databases===
* [http://www.tacocity.com.tw/-47005045b4f4cd4cc97a21bd7a480578%7C1190037829-/pbcm/cmed.htm 中醫檔案區]("Chinese medicine place") Classical texts in public domain.
* [http://www.tcmet.com.tw 電子中醫藥古籍文獻]("Electronic old Chinese Medicine books and texts") Classical texts for FTP
* [http://myweb.hinet.net/home1/lotusea/lotusea-books-giga.htm 蓮花海軟體工作坊]("Lotus Sea software working place") Free Classical text database searchable software with downloadable compress files of the texts

<br>

[[Category:Traditional Chinese medicine|*]]
[[Category:Alternative medical systems]]
[[Category:Pharmacy]]

[[de:Traditionelle Chinesische Medizin]]
[[es:Medicina china tradicional]]
[[eo:Ĉina tradicia medicino]]
[[fr:Médecine chinoise]]
[[ko:중의학]]
[[id:Pengobatan tradisional Tionghoa]]
[[it:Medicina tradizionale cinese]]
[[he:רפואה סינית]]
[[ja:伝統中国医学]]
[[pt:Medicina tradicional chinesa]]
[[fi:Perinteinen kiinalainen lääkintä]]
[[sv:Traditionell kinesisk medicin]]
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[[zh-yue:中醫]]
[[zh:中医学]]
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Thermography (Sympathetic galvonic skin studies)

2014-10-04T18:28:47Z

Bobby Schwartz: /* Advantages of Thermography */

{{SI}}

'''Editors-In-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.], Jeff Cohen, M.D., Department of Rehabilitation Medicine, New York University School of Medicine [mailto:Jeffrey.Cohen@nyumc.org]

==Overview==
[[Image:Infrared legs.jpg|thumb|left|332px|Infrared Image of the posterior aspect of the legs]]
[[Image:Infrared RLE RSD.jpg|thumb|left|Sympathetic Skin Response Thermogram: RLE RSD]]
[[Image:Infrared RUE RSD.jpg|thumb|left|Sympathetic Skin Response Thermogram: RUE RSD]]
[[Image:Infrered Right Facial Dystrophy.jpg|thumb|left|Sympathetic Skin Response Thermogram: Right Facial Dystrophy]]
[[Image:Infrared Left Trapezius Hot Spot.jpg|thumb|left|Sympathetic Skin Response Thermogram: Left Angry Back Firing "C" Syndrome of the Trapezius]]
[[Image:Infrared LUE TOS.jpg|thumb|left|Sympathetic Skin Response Thermogram: Left Upper Extremity TOS]]
'''Thermography''', '''thermal imaging''', or '''thermal video''', is a type of [[infrared]] imaging. Thermographic cameras detect [[electromagnetic radiation|radiation]] in the [[infrared]] range of the [[electromagnetic spectrum]] (roughly 900–14,000 [[nanometer]]s or 0.9–14 [[µm]]) and produce images of that radiation. Since infrared radiation is emitted by all objects based on their temperatures, according to the [[black body]] [[Planck's law of black-body radiation|radiation law]], thermography makes it possible to "see" one's environment with or without [[optical spectrum|visible]] illumination. The amount of radiation emitted by an object increases with temperature, therefore thermography allows one to see variations in temperature (hence the name). Thermographic images are direct measurements of sympathetic skin galvonic impedance. When viewed by thermographic camera, warm objects stand out well against cooler backgrounds; humans and other warm-blooded animals become easily visible against the environment, day or night. As a result, thermography's extensive use can historically be ascribed to the military and security services.

Thermal imaging photography finds many other uses. For example, [[firefighter]]s use it to see through [[smoke]], find persons, and localize the base of a fire. With thermal imaging, electric power line maintenance technicians locate overheating joints and parts, a telltale sign of their failure, to eliminate potential hazards. Where [[thermal insulation]] becomes faulty, building construction technicians can see heat leaks to improve the efficiencies of cooling or heating air-conditioning. Thermal imaging cameras are also installed in some luxury cars to aid the driver, the first being the 2000 Cadillac DeVille. Ever since the [[SARS]] outbreak of 2003 airports have also found utility in screening airport passangers for fever.

The largest medical application for infrared thermal imaging includes those musculoskelatal pain conditions that are weather sensitive ([[RSD]], [[CRPS]], [[Fibromyalgia]], [[Thoracic Outlet Syndrome]], etc)[http://www.piedmontpmr.com/robert-g-schwartz-md-rsd-crps-complex-chronic-pain-physical-vascular-medicine-2]. In this instance sympathetic skin response is mapped through cold exposure over time. Sympathetic skin responses, skin galvonic impedance and thermal asymmetry patterns all overlap with each other]<ref>Koor, I. The Collected Papers of Irvin Koor. The American Academy of Osteopathy; 1988,23-74</ref> [http://www.wikidoc.org/images/c/c8/AAT_Guidelines_1-25-06_as_published_in_thermology_intl.pdf Internationally peer reviewed guidelines]for neuromusculoskeletal thermography were adopted in 2006.

Breast thermal imaging has also been used to assess for cancer. Serial studies over time are used for comparative purposes in this application. Some physiological activities, particularly cold stress response in human beings and other warm-blooded animals can also be monitored with thermographic imaging<ref>Gulevich SJ, Conwell TD, Lane J, et al. Stress Infrared Telethermography is useful in the diagnosis of complex regional pain syndrome, type 1 (formerly reflex sympathetic dystrophy). Clinical Journal of Pain 1997;13:50-59</ref>

The appearance and operation of a modern [[infrared camera|thermographic camera]] is often similar to a camcorder. Enabling the user to see in the infrared spectrum is a function so useful that ability to record their output is often optional. A recording module is therefore not always built-in. Instead of CCD sensors, most thermal imaging cameras use CMOS Focal Plane Array (FPA). The most common types are [[InSb]], [[InGaAs]], [[QWIP]] FPA.

The newest technologies are using low cost and uncooled [[microbolometer]]s FPA sensors. Their resolution is considerably lower than of optical cameras, mostly 160x120 or 320x240 pixels, up to 640x512 for the most expensive models. Thermographic cameras are much more expensive than their visible-spectrum counterparts, and higher-end models are often export-restricted. Older [[bolometer]]s or more sensitive models as InSB require cryogenic cooling, usually by a miniature [[Stirling cycle]] refrigerator or [[liquid nitrogen]].

==Difference between IR film & Thermography==

IR film is sensitive to temperatures between 250 °[[Celsius|C]] and 500 °C while thermography is sensitive to approximately -50 °C to over 2,000 °C. So for a IR film to show something it must be over 250 °C or be reflecting infrared radiation from something that is at least that hot. Night vision goggles normally just amplify the small amount of [[light]] that is available outside like starlight or moon light and can't see heat or work in complete darkness.

==Advantages of Thermography==

* You get a visual picture so that you can compare temperatures over a large area
* With medical applications vasomotor mapping provides insight into generator identification
* It is real time capable of catching moving targets
* Able to find deteriorating components prior to failure
* Measurement in areas inaccessible or hazardous for other methods

==Limitations & disadvantages of thermography==

* Quality cameras are expensive and are easily damaged
* Interpretation of images requires training and experience
* Accurate temperature measurements in outside environments hard to make because of differing emissivities

==Applications==

* Condition monitoring
* Medical imaging
* Research
* Process control
* Non destructive testing
* [[Chemical imaging]]

Thermal infrared imagers convert the [[energy]] in the infrared wavelength into a visible light video display. All objects above 0 [[kelvin]]s emit thermal infrared energy so thermal imagers can passively see all objects regardless of ambient light. However, most thermal imagers only see objects warmer than -50 °C.

The [[Thermal radiation#Properties|spectrum and amount of thermal radiation]] depend strongly on an object's surface temperature. This makes it possible for a thermal camera to display an object's temperature. However, other factors also influence the radiation, which limits the accuracy of this technique. For example, the radiation depends not only on the temperature of the object, but is also a function of the [[emissivity]] of the object. Also, radiation also originates from the surroundings and is reflected in the object, and the radiation from the object and the reflected radiation will also be influenced by the [[absorption]] of the [[atmosphere]].

==See also==
* [[Infrared camera]]
* [[Infrared thermometer]]
* [[Infrared detector]]
* [[Chemical Imaging]]
* [[RSD]]
* [[CRPS]]

=References=
{{reflist|2}}
*Practice Guidelines Committee, American Academy of Thermology, "Guidelines for Neuromusculoskeletal Thermography", Thermology International: 2006,5-9.
*Uematsu S, Edwin DH, Jankel WR, et al: Quantification Of Thermal Assymetry: I. Normal Values And Reproducibility. J Neurosurg 69: 552,1988.
*Lee M, Cohen, J. Editors. Rehabilitation Medicine and Thermography. New York University Medical Center. Impress publications; Wilsonville, OR 2008
*Schwartz, R. Resolving Complex Pain. Piedmont Physical Medicine & Rehabilitation; Greenville, SC 2006
*Cousins M, Bridenbaugh P, Editors. Neural Blockade In Clinical Anesthesia and Management Of Pain. Philadelphia, Lippincott, 1998.
* Raj PP. Pain Medicine A Comprehensive Review. St. Louis, Mosby-Year Book Inc, 2003.
*Gonzalez, E. The Nonsurgical Management of Acute Low Back Pain. New York: Demos Vermande, 1997
*Palmer J, Uematsu S, Jankel W, Perry A. A Cellist With Arm Pain: Thermal Asymmetry In Scalene Anticus Syndrome, Achieves Of Physical Medicine & Rehabilitation 1991;72:237-42

==External links==
*[http://www.goinfrared.com/success/image_gallery.asp Good examples of FLIR thermographic images broken down by industry application]
*[http://www.irinfo.org/ IrInfo.org, online resource for infrared thermography]
*[http://www.infratec.de/en/infratec/submenu/theory/basics.html Physical basics]
*[http://www.piedmontpmr.com/medical-thermography-for-weather-sensitive-sympathetic-pain-sympathetic-galvonic-skin-studies-3/ Medical Thermograpy]
*[http://www.radio101.info/thermographie/pictures.htm various examples of thermographic images]
*[http://vzone.virgin.net/ljmayes.mal/pubs/uncooled.htm Uncooled Thermal Imaging]
[[Category:Thermodynamics]]
[[Category:Measurement]]

[[ca:Termografia]]
[[de:Thermografie]]
[[fr:Thermographie]]
[[it:Termografia]]
[[he:תרמוגרפיה]]
[[nl:Thermografie]]
[[ja:サーモグラフィー]]
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[[pt:Termografia]]
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Sports medicine

2014-10-04T18:26:29Z

Bobby Schwartz: /* The future of sports medicine */

{{SI}}

'''Editors-In-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.], Paul Tortland, D.O., Assistant clinical professor at the University of Conneticut Health Center, Dept of Internal Medicine

==Overview==
'''Sports medicine''' specializes in preventing, diagnosing and treating injuries related to participating in sports and/or exercise, specifically the rotation or deformation of joints or muscles caused by engaging in such physical activities. The sports medicine "team" includes specialty [[physician]]s and [[surgery|surgeon]]s, [[athletic trainer|athletic trainer]]s, [[physical therapist]]s, coaches, other personnel, as well as the athlete himself/herself. Because of the competitive nature of sports, a primary focus of sports medicine is the rapid recovery of patients, which drives many innovations in the field.

Sports medicine has always been difficult to define because it is not a single specialty, but an area that involves [[health care professional]]s, researchers and educators from a wide variety of disciplines. Its function is not only curative and rehabilitative, but especially preventive.

Despite this wide scope, there has been a tendency for many to assume that sport-related problems are by default [[musculoskeletal]] and that sports medicine is a [http://www.piedmontpmr.com/what-is-physiatry physiatry] or an [[orthopaedic]] specialty. There is much more to sports medicine than just musculoskeletal diagnosis and treatment. Illness or injury in sport can be caused by many factors; from [[natural environment|environment]]al to [[physiology|physiological]] and [[psychology|psychological]].

Consequently, sports medicine can encompass an array of specialties, including [[cardiology]], [[pulmonology]], [[dermatology]], [[ophthalmology]], [[rehabilitation medicine]], [[orthopaedic surgery]], [[arthroscopy]], [[exercise physiology]], [[biomechanics]], and [[traumatology]]. For example, heat, cold or altitude during training and competition can alter performance or may even be life threatening. The female triad of disordered eating, menstrual disturbances, and bone density problems, and the problems of [[pregnant]] or aging athletes demand knowledge from many diverse fields. In addition, the management of [[endocrinology|endocrinological]] diseases and other such problems in the athlete demands both medical expertise and sport-specific knowledge.

The use of supplements, pharmacological or otherwise, and the topics of doping control and [[gender verification]] present complex moral, legal and [[health]]-related difficulties. Further unique problems are associated with international sporting events, such as the effects of travel and acclimatization, and the attempt to balance an athlete's participation with his or her health. Much of this draws on new fields of study, in which extensive clinical and basic science research is burgeoning.

== Sports medicine in the United States ==
The Sports Medicine specialist, either an Orthopedist or a Primary-care Sports Medicine specialist, is usually the leader of the sports medicine team, which also includes physician and surgeon specialists, physiologists, athletic trainers, physical therapists, coaches, other personnel, and, of course, the athlete.

Doctors wishing to specialize start with a primary residency program in family practice, internal medicine, emergency medicine, pediatrics, or physical medicine and rehabilitation. Then, they generally obtain one to two years of additional training through accredited fellowship (subspecialty) programs in sports medicine. Physicians who are board certified in one of the preceding displines are then eligible to take a subspecialty qualification examination in sports medicine. Additional forums, which add to the expertise of a Sports Medicine Specialist, include continuing education in sports medicine, and membership and participation in sports medicine societies.

Sports medicine has been a recognized subspecialty of the American Board of Medical Specialties since 1989. Currently there are more than 70 sports medicine fellowships and approximately one thousand certified Sports Medicine Specialists in the United States.

==History==
The origins of sports medicine lie in ancient Greece and ancient Rome where [[physical education]] was a needed aspect of youth – training and athletic contests first became a part of everyday life during these times.
However, it was not until in 1928 at the Olympics in St. Moritz, when a committee came together to plan the First International Congress of Sports Medicine, that the term itself was coined.
In the 5th century, however, the care of athletes was primarily the responsibility of specialists. These were trainer-coaches and were considered to be experts on [[diet (nutrition)|diet]], [[physical therapy]], and [[hygiene]] as well as on sport-specific techniques.
The first use of therapeutic exercise is credited to [[Herodicus]], who is thought to have been one of [[Hippocrates]]' teachers.
Until the 2nd century AD, when the first "team doctor", [[Galen]], was appointed to the gladiators, the [[physician]] only became involved if there was an [[injury]].

Whether or not there was good communication or rapport between the trainer-coaches and the team physician back then is a matter of speculation. What is clear, however, is that from its beginnings, sports medicine has been multidisciplinary, and charged with the obligation not only to treat injuries but also to help prevent them, and to instruct and prepare athletes for competition. This link with physical education has remained in place throughout its evolution.

===First Olympic sports medicine team===
While watching his daughter Louise swim at the 1968 Summer Olympics in Mexico City, Dr. J. C. Kennedy, a doctor based in London, Ontario, Canada concluded for a variety of reasons that competing athletic teams from Canada should be accompanied by a qualified and well organized medical team. This belief led him to be a founding father of the Canadian Academy of Sport Medicine. One of the primary mandates of this society was to provide expert care to Canadian athletes, and in 1972 Dr. Kennedy was appointed chief medical officer of the first "true" medical team, at the 1972 Summer Olympics in Munich, Germany.
Other countries soon followed this example and assigned medical teams to their own Olympic athletes.

Dr. Kennedy's vision was not limited to traveling Canadian athletes. At a time when sport medicine clinics were unheard of in Canada, he convinced his university's administration to convert a former wrestling room into The Athletic Injuries Clinic that officially opened in 1972. The first Nautilus equipment in Canada was purchased from funds raised to outfit this clinic. Dr. Kennedy inspired and fostered an interest in research in sport medicine, for which the University of Western Ontario (UWO) and London, Ontario have become known.

==The future of sports medicine==

According to Dr. David Janda, orthopedic surgeon and director of The Institute for Preventative Medicine in Michigan, prevention is sports medicine's final frontier.
The risk of injury will never be entirely eliminated, but modifications in training techniques, equipment, sports venues and rules, based on outcomes of meaningful research have shown that it can be lowered.

One rapidly advancing field with great potential for applications in prevention is the study of the body's [[neuromuscular]] adaptations. A study of specific preseason neuromuscular training for soccer players demonstrated a significant decrease in the incidence of [[anterior cruciate ligament]] tears. In another investigation by Janda ''et al.'', serious injuries in recreational softball were reduced by 98% when breakaway bases were used. Stem cell and platelet rich plasma grafting have become popular interventions for sports injuries, especially when rapid treatment and response is needed.

Participation in all forms of physical activity at all levels is a huge part of everyday life, and its benefits to health and quality of life are clear. Sports medicine's continued growth and development may help the benefits of physical activity to be fully and safely realized.

== See also ==
* [[Arthroscopy]]
* [[Athletic trainer]]
* [[Physical exercise|Exercise]]
* [[Nutrition]]
* [[Overtraining]]
* [[Sports injuries]]
* [[Sports nutrition]]
* [[Sports training]]
* National Academy of Sports Medicine
* [[Prolotherapy]]
*[[Diagnostic musculoskeletal ultrasonography]]

==External links==
*[http://www.acsm.org American College of Sports Medicine] advances and integrates scientific research to provide educational and practical applications of exercise science and sports medicine.
*[http://www.amssm.org/ American Medical Society for Sports Medicine] to foster a collegial relationship among dedicated, competent sports medicine specialists, to provide a quality educational resource for AMSSM members, other sports medicine professionals, and the general public.
*[http://www.casm-acms.org/ Canadian Academy of Sport Medicine] advance the art and science of sport medicine, including health promotion and disease prevention, for the benefit of all Canadians through programs of education, research and service.
*[http://www.fims.org The Fédération Internationale de Médecine du Sport (FIMS)/International Federation of Sports Medicine] is an international organisation with a common involvement with sports medicine on all continents. FIMS aims primarily to promote the study and development of sports medicine throughout the world, and to assist athletes in achieving optimal performance by maximising their genetic potential, health, nutrition, and high-quality medical care and training.
*[http://www.nasm.org National Academy of Sports Medicine] Since 1987, the National Academy of Sports Medicine (NASM) has been the recognized global leader in certification, continuing education, solutions and tools for the health, fitness, sports performance and sports medicine professionals. Today, NASM serves more than 100,000 members in 80 countries. In addition to its evidence-based NCCA-accredited fitness certification program, Certified Personal Trainer (CPT), NASM also offers a progressive career track with Advanced Specializations, Continuing Education courses, and accredited Bachelor and Master Degree programs. The NASM educational continuum is designed to help today’s health and fitness professional enhance their career while empowering their clients to live healthier lives.
*[http://www.nata.org National Athletic Trainers' Association]
*[http://www.thebiomechanicslab.com The Biomechanics Lab - dedicated to spreading knowledge about biomechanics, kinesiology, sports medicine, strength and conditioning and much more!]This website provides a medium for connection between indiviudals in the biomechanics field. Started by a Northeastern University student.
*[http://www.rehabmatters.com RehabMatters] RehabMatters specialises in sports injury and orthopaedic rehabilitation and is dedicated to the prevention and management of sports injuries and musculoskeletal problems. No matter if you've recently had a knee replacement for joint arthritis or if you're an elite athlete coming back from injury - rehabilitation is challenging. The RehabMatters Website can help you through this challenge with practical information to get the best possible outcome from your rehabilitation. The RehabMatters Website is designed to support the relationship between patients and their physicians and therapists and provides a range of evidence based rehabilitation topics and reviews of current opinion.
*Several online resources are available from [http://wehelpwhathurts.homestead.com/sportsinjuries.html an overview of sports injuries] to [http://wehelpwhathurts.homestead.com/healthsportsandfitness.html kinesiology] and [http://rgsmedicalinsight.homestead.com/hometutorialp1.html mind-body issues].
*[http://www.sosmed.org Seacoast Orthopedics & Sports Medicine] Learn about sports medicine and the various different treatments that are currently available using the latest cutting edge technology.
*[http://slaptear.com slaptear.com] slaptear.com is a community driven sports medicine website. The shared experiences of the members build accurate profiles for recovery from a variety of injuries and surgical procedures. Pre op patients can learn all the little details that frequently are not discussed. Post op patients can compare their recovery patterns and determine if they are on the right track.

[[Category:Orthopedics]]
[[Category:Sports medicine| ]]

[[ar:طب رياضي]]
[[de:Sportmedizin]]
[[es:Medicina deportiva]]
[[fr:Médecine du sport]]
[[it:Medicina dello sport]]
[[nl:Sportgeneeskunde]]
[[ja:スポーツ医学]]
[[pt:Medicina esportiva]]
[[ru:Спортивная медицина]]

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Platelet rich plasma

2014-10-04T18:22:27Z

Bobby Schwartz: /* Treatment */

{{SI}}

'''Editor-in-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.]; Mayo Friedlis, M.D. [mailto:Mfriedlis@aol.com], Physical Medicine and Pain Management Speicialist, Capitol Spine and Pain Centers, Fairfax, VA

{{EJ}}

==Overview==
PRP is an autologous blood therapy that stimulates your body’s natural healing process through the injection of its own growth factors into injured areas. Research and clinical data show that PRP injections are extremely safe, with minimal risk for any adverse reaction or complication. Because PRP is produced from your own blood, there is no concern for rejection or disease transmission. There is a small risk of infection from any injection into the body, but this is rare. Some research suggests that PRP may have an anti-bacterial property which protects against possible infection.

Your body naturally recruits platelets and white blood cells from the blood to initiate a healing response. Under normal conditions, platelets store numerous growth factors which are released in response to signals from the injured tissue. Special PRP devices concentrate platelets from whole blood. When the PRP is injected into the damaged tissue growth factor release is enhanced so that natural healing is accelerated. Desired results include by enhancing the body's natural healing capacity, and a more rapid, more efficient, more thorough restoration of tissue to a healthy state [http://www.piedmontpmr.com/platelet-rich-plasma-prp-treatment-through-natural-healing-3].

==History==
PRP was initially developed in the 1970s. It enjoyed increasing use in hospital and outpatient surgical settings in the 1980's and began to be utilized in physician offices for musculoskeletal procedures in the 1990's. Technological advances have enabled the administration of PRP to become more popular among musculoskeletal physicians (physiatrists and orthopedists) since 2000. Much of the original PRP use centered around orhtopedic surgical procedures, such as spinal fusions and joint replacements,however PRP has also enjoyed extensive use among maxillofacial and plastic surgeons and dermatologists.

==Pathophysiology==
[[Image:Rotator cuff.jpg|thumb|left|Rotator Cuff]]After an injury, the repair response of musculoskeletal tissues starts with the formation of a blood clot and degranulation of platelets, which releases growth factors and cytokines at the site. This microenvironment results activation of inflammatory cells and proliferation of local progenitor cells. In most cases, fibroblastic scar tissue is formed. In some settings, however, such as in a fracture callus, these conditions can also facilitate the formation of new bone tissue.

Transforming growth factor beta (TGF-b), platelet-derived growth factor (PDGF), insulin-like growth factor (IGF), vascular endothelial growth factors (VEGF), epidermal growth factor (EGF) and fibroblast growth factor-2 (FGF-2) are growth factors that can be found at injury sites during wound healing. In addition to soft tissue repair (muscle, tendon, ligament and supporting joint structures), PRP has been shown to enhance one or more phases of osteogenesis, early angiogenesis and revascularization.

Studies also recognize the possibility that the effect of the clot microenvironment or concentrates of PDFGs on fracture repair might be either positive or negative. The nature of this effect, like that of many graft materials, depends on the clinical setting, particularly the graft site’s local environment of cells in which PRP or associated factors are placed.

In summary, available data suggest that PRP is valuable in enhancing soft-tissue repair and in wound healing. The clinical role of PRP in bone repair remains controversial however. PRP is not uniformly successful as an adjuvant to bone grafting procedures. PRP may promote or inhibit bone formation, depending on the setting in which it is used and the quality of the PRP.

==Example musculoskeletal conditions and symptoms treated with PRP==
[[Image:Fibulo-talo ligament strain.jpg|thumb|left|Fibulo-Talo Ligament Strain]]
* Sports injuries
* Joint pain associated with arthritis
* Ligamentous strain
* Tendionosis, Tendinopathy
* Reflex muscle spasm
* Recurrent swelling or fullness involving a joint or muscular region
* Popping, clicking, grinding, or catching sensations with movement
* Spinal pain (musculoskeletal; non neurogenic in origin)
* Distinct tender points and “jump signs” along the bone at tendon or ligament attachments
* Sclerotomal numbness, tingling, aching, or burning, referred into an upper or lower extremity
* Recurrent, referred headache, face pain, jaw pain, ear pain

==Treatment==
[[Image:Platelet injection.jpg|thumb|left|Platelet Injection]]In most instances PRP is not the first treatment employed. Other traditional interventions such as restorative therapies, medication, anesthetic injection and [Prolotherapy] are frequently employed first. Most musculoskeletal physicians will use Prolotherapy prior to PRP when considering regenerative treatment for muscle, tendon, ligament or supporting joint structures, however individual considerations exist. Examples where PRP might be utilized first include professional athletes that need rapid wound healing time, more severe cases and instances where multiple problems exist.

PRP is an effective alternative to invasive [[arthroscopic surgery]], including those cases that have failed or that simply are not remedial to arthroscopy. When contraindications exist for joint replacement (obesity, age, medical co morbidity) PRP can also be a beneficial alternative however in these cases PRP is more commonly used as an activator in conjunction with autologous stem cell grafting.

The PRP process involves drawing blood, spinning it down to separate out growth factor rich platelets, then injecting the platelet rich plasma into the injured area. To make the injection more comfortable, local anesthetic (numbing medicine) or nerve blocks are performed first. To help ensure accuracy of placement, Ultrasound guidance is employed (see [Diagnostic musculoskeletal ultrasound]).

Most patients don’t require anything more then acetaminophen for pain from the procedure. Often, following a PRP injection, an "achy" soreness is felt. This "soreness" is a positive sign that healing has been set in motion. The soreness can last for several days but gradually decreases as healing and tissue repair occurs. It is important that anti-inflammatory medications such as Ibuprofen, Aleve and Aspirin be avoided following PRP treatments.

These medicines may block the effects of the PRP injection. While many patients find it best to rest the area for several days after PRP, as long as you are responsible you can resume normal activities following I treatment. You should avoid anything other then light activity however for at least several days after injection.

Depending on your response to treatment, one to three PRP injections may be required. Following the initial treatment a follow up visit will usually be scheduled within 2-3 weeks. At that time a decision may be made regarding the need for additional treatment. In general, chronic or severe injuries require more treatment then mild injuries. Restorative therapy including exercise or physical therapy may be prescribed as well.

==References==
* [http://www.piedmontpmr.com/platelet-rich-plasma-prp-treatment-through-natural-healing-3 PRP]
* [http://www.prlog.org/10266301-platelet-rich-plasma-therapy-used-by-dr-steven-sampson-to-speed-healing-of-knee-elbow-injuries.html PRP speeds healing of knee and elbow injuries]
* [http://www3.interscience.wiley.com/journal/114077425/abstract?CRETRY=1&SRETRY=0 Use of PRP in bone repair]
* [http://www.treatingpain.com/medlibrary/prp-journal-articles.html PRP Journal Articles]

== External links ==
* [http://www.piedmontpmr.com/platelet-rich-plasma-prp-treatment-through-natural-healing-3 Overview]
* [http://www.prolotherapy.com/prpinfo.htm What is PRP?]
* [http://www.aaos.org/news/bulletin/sep07/research2.asp AAOS]
* [http://www.treatingpain.com/diagnosis-and-treatments/platelet-rich-plasma.html PRP]
* [http://www.treatingpain.com/diagnosis-and-treatments/vid_prp.html PRP Animations]

{{SIB}}

{{WH}}
{{WS}}

Platelet rich plasma

2014-10-04T18:19:05Z

Bobby Schwartz: /* Example musculoskeletal conditions and symptoms treated with PRP */

{{SI}}

'''Editor-in-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.]; Mayo Friedlis, M.D. [mailto:Mfriedlis@aol.com], Physical Medicine and Pain Management Speicialist, Capitol Spine and Pain Centers, Fairfax, VA

{{EJ}}

==Overview==
PRP is an autologous blood therapy that stimulates your body’s natural healing process through the injection of its own growth factors into injured areas. Research and clinical data show that PRP injections are extremely safe, with minimal risk for any adverse reaction or complication. Because PRP is produced from your own blood, there is no concern for rejection or disease transmission. There is a small risk of infection from any injection into the body, but this is rare. Some research suggests that PRP may have an anti-bacterial property which protects against possible infection.

Your body naturally recruits platelets and white blood cells from the blood to initiate a healing response. Under normal conditions, platelets store numerous growth factors which are released in response to signals from the injured tissue. Special PRP devices concentrate platelets from whole blood. When the PRP is injected into the damaged tissue growth factor release is enhanced so that natural healing is accelerated. Desired results include by enhancing the body's natural healing capacity, and a more rapid, more efficient, more thorough restoration of tissue to a healthy state [http://www.piedmontpmr.com/platelet-rich-plasma-prp-treatment-through-natural-healing-3].

==History==
PRP was initially developed in the 1970s. It enjoyed increasing use in hospital and outpatient surgical settings in the 1980's and began to be utilized in physician offices for musculoskeletal procedures in the 1990's. Technological advances have enabled the administration of PRP to become more popular among musculoskeletal physicians (physiatrists and orthopedists) since 2000. Much of the original PRP use centered around orhtopedic surgical procedures, such as spinal fusions and joint replacements,however PRP has also enjoyed extensive use among maxillofacial and plastic surgeons and dermatologists.

==Pathophysiology==
[[Image:Rotator cuff.jpg|thumb|left|Rotator Cuff]]After an injury, the repair response of musculoskeletal tissues starts with the formation of a blood clot and degranulation of platelets, which releases growth factors and cytokines at the site. This microenvironment results activation of inflammatory cells and proliferation of local progenitor cells. In most cases, fibroblastic scar tissue is formed. In some settings, however, such as in a fracture callus, these conditions can also facilitate the formation of new bone tissue.

Transforming growth factor beta (TGF-b), platelet-derived growth factor (PDGF), insulin-like growth factor (IGF), vascular endothelial growth factors (VEGF), epidermal growth factor (EGF) and fibroblast growth factor-2 (FGF-2) are growth factors that can be found at injury sites during wound healing. In addition to soft tissue repair (muscle, tendon, ligament and supporting joint structures), PRP has been shown to enhance one or more phases of osteogenesis, early angiogenesis and revascularization.

Studies also recognize the possibility that the effect of the clot microenvironment or concentrates of PDFGs on fracture repair might be either positive or negative. The nature of this effect, like that of many graft materials, depends on the clinical setting, particularly the graft site’s local environment of cells in which PRP or associated factors are placed.

In summary, available data suggest that PRP is valuable in enhancing soft-tissue repair and in wound healing. The clinical role of PRP in bone repair remains controversial however. PRP is not uniformly successful as an adjuvant to bone grafting procedures. PRP may promote or inhibit bone formation, depending on the setting in which it is used and the quality of the PRP.

==Example musculoskeletal conditions and symptoms treated with PRP==
[[Image:Fibulo-talo ligament strain.jpg|thumb|left|Fibulo-Talo Ligament Strain]]
* Sports injuries
* Joint pain associated with arthritis
* Ligamentous strain
* Tendionosis, Tendinopathy
* Reflex muscle spasm
* Recurrent swelling or fullness involving a joint or muscular region
* Popping, clicking, grinding, or catching sensations with movement
* Spinal pain (musculoskeletal; non neurogenic in origin)
* Distinct tender points and “jump signs” along the bone at tendon or ligament attachments
* Sclerotomal numbness, tingling, aching, or burning, referred into an upper or lower extremity
* Recurrent, referred headache, face pain, jaw pain, ear pain

==Treatment==
[[Image:Platelet injection.jpg|thumb|left|Platelet Injection]]In most instances PRP is not the first treatment employed. Other traditional interventions such as restorative therapies, medication, anesthetic injection and [Prolotherapy] are frequently employed first. Most musculoskeletal physicians will use Prolotherapy prior to PRP when considering regenerative treatment for muscle, tendon, ligament or supporting joint structures, however individual considerations exist. Examples where PRP might be utilized first include professional athletes that need rapid wound healing time, more severe cases and instances where multiple problems exist.

PRP is an effective alternative to invasive [[arthroscopic surgery]], including those cases that have failed or that simply are not remedial to arthroscopy. When contraindications exist for joint replacement (obesity, age, medical co morbidity)PRP is a beneficial alternative as well.

The PRP process involves drawing blood, spinning it down to separate out growth factor rich platelets, then injecting the platelet rich plasma into the injured area. To make the injection more comfortable, local anesthetic (numbing medicine) or nerve blocks are performed first. To help ensure accuracy of placement, Ultrasound guidance is employed (see [Diagnostic musculoskeletal ultrasound]).

Most patients don’t require anything more then acetaminophen for pain from the procedure. Often, following a PRP injection, an "achy" soreness is felt. This "soreness" is a positive sign that healing has been set in motion. The soreness can last for several days but gradually decreases as healing and tissue repair occurs. It is important that anti-inflammatory medications such as Ibuprofen, Aleve and Aspirin be avoided following PRP treatments.

These medicines may block the effects of the PRP injection. While many patients find it best to rest the area for several days after PRP, as long as you are responsible you can resume normal activities following I treatment. You should avoid anything other then light activity however for at least several days after injection.

Depending on your response to treatment, one to three PRP injections may be required. Following the initial treatment a follow up visit will usually be scheduled within 2-3 weeks. At that time a decision may be made regarding the need for additional treatment. In general, chronic or severe injuries require more treatment then mild injuries. Restorative therapy including exercise or physical therapy may be prescribed as well.

==References==
* [http://www.piedmontpmr.com/platelet-rich-plasma-prp-treatment-through-natural-healing-3 PRP]
* [http://www.prlog.org/10266301-platelet-rich-plasma-therapy-used-by-dr-steven-sampson-to-speed-healing-of-knee-elbow-injuries.html PRP speeds healing of knee and elbow injuries]
* [http://www3.interscience.wiley.com/journal/114077425/abstract?CRETRY=1&SRETRY=0 Use of PRP in bone repair]
* [http://www.treatingpain.com/medlibrary/prp-journal-articles.html PRP Journal Articles]

== External links ==
* [http://www.piedmontpmr.com/platelet-rich-plasma-prp-treatment-through-natural-healing-3 Overview]
* [http://www.prolotherapy.com/prpinfo.htm What is PRP?]
* [http://www.aaos.org/news/bulletin/sep07/research2.asp AAOS]
* [http://www.treatingpain.com/diagnosis-and-treatments/platelet-rich-plasma.html PRP]
* [http://www.treatingpain.com/diagnosis-and-treatments/vid_prp.html PRP Animations]

{{SIB}}

{{WH}}
{{WS}}

Peripheral arterial disease laboratory findings

2014-10-04T18:17:23Z

Bobby Schwartz: /* Laboratory Findings */

__NOTOC__
{{Peripheral arterial disease}}

{{CMG}}; [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.]; '''Associate Editor-In-Chief:''' {{CZ}}

Please help WikiDoc by adding more content here. It's easy! Click [[Help:How_to_Edit_a_Page|here]] to learn about editing.

==Laboratory Findings==
<table border="1">
<tr><td>'''Clinical Presentation'''</td><td>'''Noninvasive Vascular Test'''</td></tr>
<tr><td>Asymptomatic lower extremity PAD</td><td>[[ABI]] (with stress studies for functional claudication)</td></tr>
<tr><td>[[Claudication]]</td><td>[[ABI]], PVR, or segmental pressures; Duplex ultrasound; Exercise test with ABI; [[PE]] to assess functional status</td></tr>
<tr><td>Possible pseudoclaudication</td><td>[[Exercise test]] with ABI; [[EMG]] and [[MRI]] for neurogenic etiologies</td></tr>
<tr><td>Possible sympathetic pain syndromes</td><td>[[Thermography]] (Sympathetic Skin Response Testing) for [[RSD]] and [[CRPS]]
<tr><td>Postoperative vein graft follow-up</td><td>[[Duplex ultrasound]]</td></tr>
<tr><td>Femoral pseudoaneurysm, iliac or popliteal aneurysm</td><td>[[Duplex ultrasound]]</td></tr>
<tr><td>Suspected [[aortic aneurysm]]; serial [[AAA]] follow-up</td><td>Abdominal [[ultrasound]], CTA, or [[MRA]]</td></tr>
<tr><td>Candidate for revascularization</td><td>[[Duplex ultrasound]], [[MR angiography]], or CTA</td></tr>
</table>

==References==
{{reflist|2}}

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[[Category:Needs content]]
[[Category:Disease]]
[[Category:Cardiology]]
[[Category:Peripheral Arterial Disease]]

Neck pain overview

2014-10-04T18:11:18Z

Bobby Schwartz: /* Causes */

__NOTOC__
{{Neck pain}}

'''Editor-In-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com],[http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.]
==Overview==
'''Neck pain''' is a common problem, with two-thirds of the population having neck pain at some point in their lives.<ref name="pmid17347239">{{cite journal |author=Binder AI |title=Cervical spondylosis and neck pain |journal=BMJ |volume=334 |issue=7592 |pages=527-31 |year=2007 |pmid=17347239|doi=10.1136/bmj.39127.608299.80}}</ref> It is increasing in both intensity, frequency and severity of episodes. As people are increasingly sedentary, live fast-paced and hectic lives, they place more stress and strain on the upper back and neck regions of their spines.

The head is supported by the lower neck and upper back, and it is these areas that commonly cause neck pain. The top three joints in the neck allow for most movement of your neck and head. The lower joints in the neck and those of the upper back create a supportive structure for your head to sit on. If this support system is affected adversly, then the muscles in the area will tighten, leading to neck pain.

Neck pain may also arise from many other physical and emotional health issues.
==Causes==
Neck pain, although felt in the neck, can be caused by numerous other spinal issues. For example, neck pain may arise due to muscular tightness in both the neck and upper back. Joint disruption and ligamentous strain in the neck and upper back can create [[pain]], as can sympathtetically mediated pain. Neck pain is a frequent cause of[http://www.piedmontpmr.com/neck-pain-relief-2 cervicogenic headache] or[http://www.piedmontpmr.com/migraine Migraine].

==Natural History, Complications and Prognosis==
About one-half of episodes resolve within one year. About 10% of cases become chronic.
==Diagnosis==
===Physical Examination===
The physician will examine the back and conduct neurologic tests to determine the cause of pain and appropriate treatment.
===X Ray===
[[X-ray]] imaging includes conventional and enhanced methods that can help diagnose the cause and site of back pain. A conventional x-ray, often the first imaging technique used, looks for [[fracture|broken bone]]s or an injured [[vertebra]]. A technician passes a concentrated beam of low-dose ionized radiation through the neck and takes pictures that, within minutes, clearly show the bony structure and any vertebral misalignment or [[fracture]]s. Tissue masses such as injured [[muscle]]s and [[ligament]]s or painful conditions such as a bulging disc are not visible on conventional x-rays. This fast, noninvasive, painless procedure is usually performed in a doctor’s office or at a clinic.
===CT===
[[Computerized tomography]] (CT) is a quick and painless process used when disc rupture, spinal stenosis, or damage to vertebrae is suspected as a cause of neck pain. X-rays are passed through the body at various angles and are detected by a computerized scanner to produce two-dimensional slices (1 mm each) of internal structures of the neck. This diagnostic exam is generally conducted at an imaging center or hospital.
===MRI===
[[Magnetic resonance imaging]] (MRI) is used to evaluate the lumbar region for bone degeneration or injury or disease in tissues and [[nerve]]s, [[muscle]]s, [[ligament]]s, and [[blood vessel]]s. MRI scanning equipment creates a magnetic field around the body strong enough to temporarily realign water molecules in the [[tissue]]s. Radio waves are then passed through the body to detect the “relaxation” of the molecules back to a random alignment and trigger a resonance signal at different angles within the body. A computer processes this resonance into either a three-dimensional picture or a two-dimensional “slice” of the tissue being scanned, and differentiates between [[bone]], [[soft tissue]]s and fluid-filled spaces by their water content and structural properties. This noninvasive procedure is often used to identify a condition requiring prompt surgical treatment.
===Ultrasound===
[[Diagnostic musculoskeletal ultrasound]] imaging, also called ultrasound scanning or sonography, uses high-frequency sound waves to obtain images inside the body. The sound wave echoes are recorded and displayed as a real-time visual image. Ultrasound imaging can show tears in ligaments, muscles, tendons, and other soft tissue masses in the back.
==References==
{{reflist|2}}

[[Category:Pain]]
[[Category:Primary care]]
[[Category:Signs and symptoms]]

{{WH}}
{{WS}}

Low back pain

2014-10-04T18:06:30Z

Bobby Schwartz: /* Diagnosis */

__NOTOC__
{{Low back pain}}
'''For patient information on Acute low back pain, click [[Acute low back pain (patient information)|here]]'''

'''For patient information on Chronic low back pain, click [[Chronic low back pain (patient information)|here]]'''

'''Editor-In-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.]; '''Associate Editor-In-Chief:''' {{CZ}}

{{SK}} Lumbar pain; low back pain/Swelling; lower back pain
== [[Low back pain overview|Overview]] ==
== [[Low back pain pathophysiology|Pathophysiology]] ==
== [[Low back pain causes|Causes]] ==
== [[Low back pain differential diagnosis|Differentiating Low back pain from other Diseases]] ==
== [[Low back pain epidemiology and demographics|Epidemiology and Demographics]] ==
== [[Low back pain risk factors|Risk Factors]] ==
== [[Low back pain natural history, complications and prognosis|Natural History, Complications and Prognosis]] ==
==Diagnosis==
[[Low back pain history and symptoms|History and Symptoms]] | [[Low back pain physical examination|Physical Examination]] | [[Low back pain laboratory findings|Laboratory Findings]] | [[Low back pain x ray|X Ray]] | [[Low back pain CT|CT]] | [[Low back pain MRI|MRI]] | [[Low back pain ultrasound|Ultrasound]] | [[Low back pain other imaging findings|Other Imaging Findings]] | [[Thermography|Musculoskeletal Thermography]] | [[Low back pain other diagnostic studies|Other Diagnostic Studies]]

==Treatment==
[[Low back pain conservative management|Conservative Management]] | [[Low back pain surgery|Surgery]] | [[Low back pain primary prevention|Primary Prevention]] | [[Low back pain cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Low back pain future or investigational therapies|Future or Investigational Therapies]]

==Case Studies==
[[Low back pain case study one|Case #1]]
==Related Chapters==
* [[Back pain|Back Pain]]
* [[Upper back pain|Upper Back Pain]]
* [[Chronic pain|Chronic Pain]]
* [[Spinal disc herniation|Spinal Disc Herniation]]
* [[Degenerative disc disease|Degenerative Disc Disease]]
* [[Coccydynia|Coccydynia (Coccyx Pain, Tailbone Pain)]]
* [[Sciatica]]
* [[Failed back syndrome|Failed Back Syndrome]]
* [[Bertolotti's syndrome|Bertolotti's Syndrome]]

{{Diseases of the musculoskeletal system and connective tissue}}

[[Category:Disability]]
[[Category:Symptoms]]
[[Category:Orthopedics]]
[[Category:Rheumatology]]
[[Category:Emergency medicine]]
[[Category:Primary care]]
[[Category:Signs and symptoms]]

[[zh:下背痛]]

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Low back pain

2014-10-04T18:05:47Z

Bobby Schwartz: /* Diagnosis */

__NOTOC__
{{Low back pain}}
'''For patient information on Acute low back pain, click [[Acute low back pain (patient information)|here]]'''

'''For patient information on Chronic low back pain, click [[Chronic low back pain (patient information)|here]]'''

'''Editor-In-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.]; '''Associate Editor-In-Chief:''' {{CZ}}

{{SK}} Lumbar pain; low back pain/Swelling; lower back pain
== [[Low back pain overview|Overview]] ==
== [[Low back pain pathophysiology|Pathophysiology]] ==
== [[Low back pain causes|Causes]] ==
== [[Low back pain differential diagnosis|Differentiating Low back pain from other Diseases]] ==
== [[Low back pain epidemiology and demographics|Epidemiology and Demographics]] ==
== [[Low back pain risk factors|Risk Factors]] ==
== [[Low back pain natural history, complications and prognosis|Natural History, Complications and Prognosis]] ==
==Diagnosis==
[[Low back pain history and symptoms|History and Symptoms]] | [[Low back pain physical examination|Physical Examination]] | [[Low back pain laboratory findings|Laboratory Findings]] | [[Low back pain x ray|X Ray]] | [[Low back pain CT|CT]] | [[Low back pain MRI|MRI]] | [[Low back pain ultrasound|Ultrasound]] | [[Low back pain other imaging findings|Other Imaging Findings]] | [[Thermography|Musculoskeletal Thermography]] [[Low back pain other diagnostic studies|Other Diagnostic Studies]]

==Treatment==
[[Low back pain conservative management|Conservative Management]] | [[Low back pain surgery|Surgery]] | [[Low back pain primary prevention|Primary Prevention]] | [[Low back pain cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Low back pain future or investigational therapies|Future or Investigational Therapies]]

==Case Studies==
[[Low back pain case study one|Case #1]]
==Related Chapters==
* [[Back pain|Back Pain]]
* [[Upper back pain|Upper Back Pain]]
* [[Chronic pain|Chronic Pain]]
* [[Spinal disc herniation|Spinal Disc Herniation]]
* [[Degenerative disc disease|Degenerative Disc Disease]]
* [[Coccydynia|Coccydynia (Coccyx Pain, Tailbone Pain)]]
* [[Sciatica]]
* [[Failed back syndrome|Failed Back Syndrome]]
* [[Bertolotti's syndrome|Bertolotti's Syndrome]]

{{Diseases of the musculoskeletal system and connective tissue}}

[[Category:Disability]]
[[Category:Symptoms]]
[[Category:Orthopedics]]
[[Category:Rheumatology]]
[[Category:Emergency medicine]]
[[Category:Primary care]]
[[Category:Signs and symptoms]]

[[zh:下背痛]]

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Headache overview

2014-10-04T18:00:34Z

Bobby Schwartz: /* Causes */

__NOTOC__
{{Headache}}
'''Editor-In-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.]; '''Associate Editor-In-Chief''': {{CZ}}
==Overview==
A '''headache''' is a condition of pain in the [[head]]; sometimes [[neck]] or upper back pain may also be interpreted as a headache. It ranks amongst the most common local pain complaints.
==Historical Perspective==
The first recorded classification system that resembles the modern ones was published by [[Thomas Willis]], in ''De Cephalalgia'' in 1672. In 1787 [[Christian Baur]] generally divided headaches into [[idiopathic]] (primary headaches) and [[symptomatic]] (secondary ones), and defined 84 categories.
==Pathophysiology==
The [[brain]] in itself is not sensitive to [[Pain and nociception|pain]], because it lacks pain-sensitive nerve fibers. Several areas of the head can hurt, including a network of nerves which extend over the scalp and certain nerves in the face, mouth, and throat. The [[meninges]] and the blood vessels do have pain perception. Headaches often result from traction to or irritation of the [[meninges]] and [[blood vessel]]s. The muscles of the head may similarly be sensitive to [[pain]].
==Causes==
The vast majority of headaches are benign and self-limiting. Common causes are [[tension headache|tension]], [[Neck pain]], [[migraine]], eye strain, [[dehydration|dehydration]], low blood sugar, and [[sinusitis]]. The vast majority of chronic headaches are multifactoral in nature. Much rarer are headaches due to life-threatening conditions such as[[meningitis]], [[encephalitis]], [[cerebral aneurysm]]s, [[hypertensive emergency|extremely high blood pressure]], and [[brain tumor]]s. When the headache occurs in conjunction with a [[head injury]] the cause is usually quite evident. A large percentage of headaches among females are caused by ever-fluctuating [[estrogen]] during [[menstruation|menstrual]] years. This can occur prior to, during or even midcycle menstruation.

==Natural History, Complications and Prognosis==
The prognosis of headache depends on the underlying cause.
==Diagnosis==
===Laboratory Findings===
[[Blood test]]s may help narrow down the [[differential diagnosis]], but are rarely confirmatory of specific headache forms.
===CT===
[[Computed tomography]] (CT/CAT) scans of the brain or sinuses are commonly performed.
===MRI===
[[Magnetic resonance imaging]] (MRI) of the brain and sinuses are done in specific settings.
==Treatment==
===Medical Therapy===
Headaches may be successfully treated through medical therapies such as [[analgesisa]] and, in some cases, a tandem approach with implanted electrodes.
===Primary Prevention===
Some forms of headache, such as [[migraine]], may be amenable to preventative treatment.

==References==
{{reflist|2}}

[[Category:Headaches]]
[[Category:Neurological disorders]]
[[Category:Signs and symptoms]]
[[Category:Neurology]]
[[Category:Emergency medicine]]
[[Category:Primary care]]

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Diagnostic musculoskeletal ultrasound

2014-10-04T17:51:57Z

Bobby Schwartz: /* Diagnostic Applications */

{{SI}}

'''Editor-In-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.]

__NOTOC__
==Overview==
Diagnostic Musculoskeletal Ultrasound involves the use of [[Medical ultrasonography]] to assess a variety of disorders of the musculoskeletal system. It is far less expensive then MRI,is non invasive, does not involve the use of ionizing radiation and is readily accepted by patients.
In physics the term "ultrasound" applies to all acoustic energy with a frequency above human hearing (20,000 hertz or 20 kilohertz). Typical diagnostic sonographic scanners operate in the frequency range of 2 to 18 megahertz, hundreds of times greater than this limit. The choice of frequency is a trade-off between spatial resolution of the image and imaging depth: lower frequencies produce less resolution but image deeper into the body.

[[Image:Ecrl perc tenotomy.jpg|thumb|left|Ultrasound guided percutaneous tenotomy of the ECRL T=tendon, E=epidcondyle, R=radius]]
The capability for accurate diagnosis of musculoskeletal conditions has dramatically increased in recent years. In some cases, such as the ability to evaluate motion of tendons and muscles in real-time, it provides valuable information not available from any other modality. In addition, Diagnostic Musculoskeletal Ultrasound has become a valuable guidance tool for procedures such as intra-articular injection, peripheral and spinal nerve block, and percutaneous tenotomy. Disadvantages, such as learning curve, ease of interpretation and image quality have diminished as technology and expertise has increased. Diagnostic Musculoskeletal Ultrasound has become a valuable asset in the diagnostic armamentarium of musculoskeletal injury and pathology.

==Diagnostic Applications==
Diagnostic Musculoskeletal Ultrasonography is becoming widely used in medicine. It is possible to perform diagnosis or therapeutic procedures with the guidance of ultrasound (for instance percutaneous tenotomy, guided injections, biopsies or drainage of fluid collections). Medical professional sonographers typically use a hand-held probe (called a transducer) that is placed directly on and moved over the patient. A water-based gel is used to couple the ultrasound between the transducer and patient.

Muscoloskeletal structures such as muscles, tendons, nerve and ligament are imaged at a higher frequencies (7-18 MHz) if they are superficial as these frequencies provide better axial and lateral resolution. Deeper structures are imaged at a lower frequencies (5-10MHz) with lower axial and lateral resolution but greater penetration. Most ultrasound equipment today is capable of imaging over a broad range of frequencies, however specific probes are utilized when different centers of focus (or frequency) are desired.

Medical sonography is used in, for example:
*Ligament injuries
*Tendonopathies and tendonosis
*Muscle injury and atrophy
*Peripheral nerve injury
*Arthropathy
*Cyst and solid mass evaluaiton
*Guidance for injection
*Guidance for percutaneous tenotomy
*Guidance for stem cell and platelet rich plasma (PRP) grafting

[[Image:Shoulder_dx_us.jpg|thumb|left|Example of shoulder probe placement]]
[[Image:Dx_us_calcified_subscapularis_tendon.jpg|thumb|left|Calcified subscapularis tendon]]
[[Image:30_degree_oblique_abnl_L12a.jpg|thumb|left|Lumbar paraspinal multifidus edema at L12]]
[[Image:Prepatellar_bursa.jpg|thumb|left|Prepatellar bursits of the knee]]
Common areas of study in musculoskeletal ultrasound include the shoulder, wrist and knee, however numerous other applications exist. Virtually any joint, muscle, tendon, ligament or peripheral nerve can be studied. While newer technology for spinal column evaluation with the GE Logiq E9 has been reported, this application has not yet been widely accepted.<ref>Macios A, "Talk to Me", Radiology Today, 3/23/09;20-23</ref> There are, however numerous references that support the use of musculoskeletal ultrasound for the evalution of paraspinal musculature and interspinous ligament as well as for guidance in spinal injection. At least one peer reviewed blinded study has been published that demonstrated an 85% correlation rate between paraspinal musculoskeletal ultrasound and paraspinal MRI [http://wikidoc.org/index.php/Image:Diagnostic_Musculoskeletal_Paraspinal_Ultrasound_full.pdf Schwartz, 1999]

== Strengths of sonography ==
* It images [[muscle]] and [[soft tissue]] very well and is particularly useful for delineating the interfaces between solid and fluid-filled spaces.
* It renders "live" images, where the operator can dynamically select the most useful section for diagnosing and documenting changes, often enabling rapid diagnoses.
* It shows the structure of the tissue under study.
* It has no known long-term side effects and rarely causes any discomfort to the patient.
* Equipment is widely available and comparatively flexible.
* Small, easily carried scanners are available; examinations can be performed at the bedside.
* Relatively inexpensive compared to other modes of investigation (e.g. [[computed tomography|computed X-ray tomography]], [[Dual energy X-ray absorptiometry|DEXA]] or [[magnetic resonance imaging]]).

== Weaknesses of ultrasonic imaging ==
* Sonographic devices have trouble penetrating [[bone]].
* Even in the absence of bone or air, the depth penetration of ultrasound is limited, making it difficult to image structures deep in the body, especially in obese patients.
* The method is operator-dependent. A high level of skill and experience is needed to acquire good-quality images and make accurate diagnoses.

==Risks and side-effects==
Ultrasonography is generally considered a "safe" imaging modality.<ref>{{cite journal | last=Merritt | first=CR | title=Ultrasound safety: what are the issues? |journal=Radiology | volume=173 | issue=2 | pages=304–306 |date=Nov 1989 | pmid=2678243 | url=http://radiology.rsnajnls.org/cgi/reprint/173/2/304 | accessdate=2008-01-22 }}</ref> However slight detrimental effects have been occasionally observed (see below).

Diagnostic ultrasound studies of the fetus are generally considered to be safe during pregnancy. This diagnostic procedure should be performed only when there is a valid medical indication, and the lowest possible ultrasonic exposure setting should be used to gain the necessary diagnostic information under the "as low as reasonably achievable" or [[ALARA]] principle.

===Studies on the safety of ultrasound===

*A study at the [[Yale Medical School]] found a correlation between prolonged and frequent use of ultrasound and abnormal neuronal migration in mice.<ref>{{cite journal | author = Ang ES Jr, Gluncic V, Duque A, Schafer ME, Rakic P | title = Prenatal exposure to ultrasound waves impacts neuronal migration in mice |journal = Proc Natl Acad Sci U S A | volume = 103 | issue = 34 | pages = 12903–10 |date = 2006 | pmid = 16901978 | url = http://www.pnas.org/cgi/content/full/103/34/12903}}</ref>
*A meta-analysis of several ultrasonography studies found no statistically significant harmful effects from ultrasonography, but mentioned that there was a lack of data on long-term substantive outcomes such as neurodevelopment.<ref>{{cite journal |author=Bricker L, Garcia J, Henderson J, ''et al'' |title=Ultrasound screening in pregnancy: a systematic review of the clinical effectiveness, cost-effectiveness and women's views |journal=Health technology assessment (Winchester, England) |volume=4 |issue=16 |pages=i-vi, 1-193 |year=2000 |pmid=11070816 |doi= |url=http://www.hta.ac.uk/execsumm/summ416.htm}}</ref>

==References==
{{reflist|2}}
* Musculoskeletal Ultrasound, edited by: Holsbeeck M, Introcaso J, Mosby Year Book, 1991
* Ultrasonography of the Musculoskeletal System, edited by: Montana M, Richardson M. The Radiologic Clinics of North America, vol. 26, no. 1, January 1988
* Schwartz R, Rohan J, Hayden F, "Diagnostic Paraspinal Musculoskeletal Ultrasonography". Journal Of Back And Musculoskeletal Rehabilitation, IOS Press, vol.12, no.1, pg.25-33, 1999
* Guidelines and Gamuts in Musculoskeletal Ultrasound, edited by: Chhem R, Cardinal E, WIley-Liss, 1999

==External links==
* [http://www.aium.org American Institute of Ultrasound in Medicine] Professional Association
* [http://radiologyinfo.org/en/sitemap/modal-alias.cfm?modal=US Procedures in Ultrasound (Sonography)] for patients, from RadiologyInfo.org
* [http://www.asum.com.au/open/safety/issues.htm Ultrasound Safety Issues]
*[http://tdirad1.googlepages.com/ Musculoskeletal Ultrasound Society]

{{WH}}
{{WS}}

Brain stem

2014-10-04T17:48:39Z

Bobby Schwartz: /* Physical signs of brainstem disease */

{{Infobox Brain|
Name = Brain stem |
Latin = truncus encephali |
GraySubject = 187 |
Image = Gray719.png |
Caption Hind- and mid-brains; postero-lateral view. |
IsPartOf = [[Brain]]|
Components = [[Medulla]], [[Pons]], [[Midbrain]]|
Artery = |
Vein = |
BrainInfoType = ancil |
BrainInfoNumber = 218 |
MeshName = Brain+Stem |
MeshNumber = A08.186.211.132 |
DorlandsPre = b_21 |
DorlandsSuf = 12195821 |
}}
'''Editor-in-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.]

The '''brain stem''' is the lower part of the [[brain]], adjoining and structurally continuous with the [[spinal cord]]. Most sources consider the [[pons]], [[medulla oblongata]], and [[midbrain]] all to be part of the brainstem.<ref>http://wordnet.princeton.edu/perl/webwn?s=brainstem</ref>

Differentiation of the brain stem from the [[telencephalon|cerebrum]] is complex, with regard to both anatomy and taxonomy. Some taxonomies describe the brain stem as the medulla and mesencephalon, whereas others include [[diencephalic]] regions.

==General anatomy==
===Ventral view/medulla and pons===
The most medial part of the medulla is the anterior median fissure. Moving laterally on each side are the pyramids. The pyramids contain the fibers of the [[corticospinal]] tract, or the upper motor neuronal axons as they head inferiorly to synapse on lower motor neuronal cell bodies within the [[ventral horn]] of the spinal cord.<br />
The anterolateral sulcus is lateral to the pyramids. Emerging from the anterolateral sulci are the [[hypoglossal nerve]] (CN XII) rootlets. Lateral to these rootlets and the anterolateral sulci are the [[Olivary body|olives]]. The olives are swellings in the medulla containing underlying inferior olivary nuclei (containing various nuclei and afferent fibers).

Lateral (and dorsal) to the olives are the rootlets for cranial nerves IX and X ([[glossopharyngeal]] and [[vagus]], respectively). The pyramids end at the [[pontomedullary junction]], noted most obviously by the large [[basal pons]]. Between the basal pons, cranial nerve 6, 7 and 8 emerge (medial to lateral). These cranial nerves are the [[abducens nerve]], [[facial nerve]] and the [[vestibulocochlear nerve]], respectively. At the level of the midpons, the large [[trigeminal nerve]], CN V, emerges. At the rostral pons, the [[occulomotor nerve]] emerges at the midline. Laterally, the [[trochlear nerve]] has emerged after emerging out of the dorsal rostral pons and wrapping around to the anterior.

===Dorsal view/medulla and pons===
The most medial part of the medulla is the posterior median fissure. Moving laterally on each side is the [[fasciculus gracilis]], and lateral to that is the [[fasciculus cuneatus]]. Superior to each of these, and directly inferior to the [[obex]], are the gracile tubercles and cuteanus tubercles, respectively. Underlying these are their respective nuclei. The obex marks the end of the 4th ventricle and the beginning of the [[central canal]]. The posterior intermediate sulci separates the fasciculi gracilis from the fasciculi cuneatus. Lateral to the fasciculi cuneatus is the [[lateral funiculus]]. <br />

Superior to the obex is the floor of the 4th ventricle. In the floor of the 4th ventricle, various nuclei can be visualized by the small bumps that they make in the overlying tissue. In the midline and directly superior to the obex is the [[vagal trigone]] and superior to that it the [[hypoglossal trigone]]. Underlying each of these are motor nuclei for the respective cranial nerves. Superior to these trigones are fibers running laterally in both directions. These fibers are known collectively as the striae medullares.

Continuing in a [[rostral]] direction, the large bumps are called the facial colliculi. Each [[facial colliculus]], contrary to their names, do not contain the facial nerve nuclei. Instead, they have facial nerve axons traversing superficial to underlying abducens (CN VI) nuclei. Lateral to all these bumps previously discussed is an indented line, or [[sulcus]] that runs rostrally, and is known as the [[sulcus limitans]]. This separates the medial motor neurons from the lateral sensory neurons. Lateral to the sulcus limitans is the area collectively known as the [[vestibular area]], which is involved in special sensation.

Moving rostrally, the inferior, middle, and superior cerebellar peduncles are found connecting the midbrain to the cerebellum. Directly rostral to the superior cerebellar peduncle, there is the superior medullary velum and then the two trochlear nerves. This marks the end of the pons as the [[inferior colliculus]] is directly rostral and marks the caudal midbrain.

Spinal Cord to Medulla Transitional Landmark: From a ventral view, there can be seen a [[decussation]] of fibers between the two [[pyramids]]. This decussation marks the transition from medulla to spinal cord. Superior to the decussation is the medulla and inferior to it is the spinal cord.

===Midbrain===
The midbrain is divided into three parts. The first is the [[tectum]], which is "roof" in [[Latin]]. The tectum includes the superior and inferior colliculi and is the dorsal covering of the cerebral aqueduct. The [[inferior colliculus]], involved in the special sense of hearing sends its inferior brachium to the [[medial geniculate body]] of the [[diencephalon]]. Superior to the inferior colliculus, the [[superior colliculus]] marks the rostral midbrain. It is involved in the special sense of vision and sends its superior brachium to the [[lateral geniculate body]] of the diencephalon. The second part is the [[tegmentum]] and is ventral to the cerebral aqueduct. Several nuclei, tracts and the reticular formation is contained here. Last, the ventral side is comprised of paired [[cerebral peduncles]]. These transmit axons of upper motor neurons.

===Midbrain internal structures===
[[Periaqueductal Gray]]: The area around the cerebral aqueduct, which contains various neurons involved in the pain desensitization pathway. Neurons synapse here and, when stimulated, cause activation of neurons in the [[raphe nucleus magnus]], which then project down into the dorsal horn of the spinal cord and prevent pain sensation transmission.<br />
Occulomotor nerve nucleus: This is the nucleus of CN III.<br />
Trochlear nerve nucleus: This is the nucleus of CN IV.<br />
[[Red Nucleus]]: This is a motor nucleus that sends a descending tract to the lower motor neurons.<br />
[[Substantia nigra]]: This is a concentration of neurons in the ventral portion of the midbrain that uses dopamine as its neurotransmitter and is involved in both motor function and emotion. Its dysfunction is implicated in [[Parkinson's Disease]].<br />
[[Reticular formation]]: This is a large area in the midbrain that is involved in various important functions of the midbrain. In particular, it contains lowermotor neurons, is involved in the pain desensitization pathway, is involved in the arousal and consciousness systems, and contains the [[locus ceruleus]], which is involved in intensive alertness modulation and in [[autonomic]] reflexes.<br />
[[Central tegmental]] tract: Directly anterior to the floor of the 4th ventricle, this is a pathway by which many tracts project up to the cortex and down to the spinal cord.<br />

==Embryology==
The adult human brainstem emerges from two of the three primary vesicles formed of the [[neural tube]]. The [[mesencephalon]] is the second of the three primary vesicles, and does not further differentiate into a secondary vesicle. This will become the midbrain. The third primary vesicle, the [[rhombencephalon]], will further differentiate into two secondary vesicles, the [[metencephalon]] and the [[myelencephalon]]. The metencephalon will become the cerebellum and the pons. The myelencephalon will become the medulla.

==Physiology==
There are three main functions of the brainstem. The first is its role in conduit functions. That is, all information related from the body to the cerebrum and cerebellum and vice versa, must traverse the brain stem. The ascending pathways coming from the body to the brain are the sensory pathways, and include the [[spinothalamic tract]] for pain and temperature sensation and the dorsal column, fasciculus gracilis, and cuneatus for touch, [[proprioception]], and pressure sensation (both of the body).

The facial sensations have similar pathways, and will travel in the spinothalamic tract and the [[medial lemniscus]] also). Descending tracts are upper motor neurons destined to synapse on lower motor neurons in the [[ventral horn]] and [[intermediate horn]] of the spinal cord. In addition, there are upper motor neurons that originate in the brainstem's vestibular, red, tactile, and reticular nuclei, which also descend and synapse in the spinal cord.

Second, the cranial nerves 3-12 emerge from the brain stem. Third, the brain stem has integrative functions (it is involved in cardiovascular system control, respiratory control, pain sensitivity control, alertness, and consciousness). Thus, brain stem damage is a very serious and often life-threatening problem.

The practical results of an improperly functioning brainstem are not just related to physical injury. Behavioral and physical signs can also manifest when there is incomplete pons or mid brain development. Such underdevelopment can affect behavior, academic performance, coordination, anxiety, speech, and focus. Habilitation, the process of first occurrence rehabilitation, makes use of programmatic exercise with the goals of completing development through inducement of neural plasticity

==Physical signs of brainstem disease==
Diseases of the brainstem can result to abnormalities in the function of cranial nerves, which may lead to visual disturbances, pupil abnormalities, changes in sensation, muscle weakness, hearing problems, vertigo, swallowing and speech difficulty, voice change, and co-ordination problems. Less obvious cases may complain of poor reading comprehension, lack of focus, altered vigilance, clumsiness, or poor social skills. Often physical signs to an untrained examiner are not obvious as challenge testing (to reduce cortical compensations) are required during examination. Localizing neurological lesions in the brainstem may be very precise with imaging studies, although the clinical utility of such localization relies upon a clear understanding of brainstem anatomical structures on their functions.

==Physical rehabilitation of brainstem disease==
While rehabilitation of brainstem disorders has traditionally belonged to the domain of physiatry or neurology more recently publicly accessible programs have become available that incorporate concepts which promote neural plasticity. <ref>http://www.asktheneurologist.com/lectures-brainstem.html</ref>
At least one hospital system, Bon Sequours, St. Francis in Greenville, SC, has incorporated a movement based restorative therapy programs that focus on brainstem neuroplasticity for the treatment of common conditions such as Fibromyalgia.

== See also ==
* [[Cranial nerve nucleus]]

==References==
{{reflist|2}}

==External links==

* [http://www.piedmontpmr.com/Education Improvement in Function: A Clinical Practice Model]
* [http://www.brainhighways.com Brain Highways: A Novel Approach to Brainstem Plasticity]
* [http://piedmontpmr.com/fibromyalgia-relieving-pain-and-fatigue/ Incorporating Three Dimensional Exercise in Fibromyalgia Care]

==Additional Resources==
{{refbegin|2}}
* http://www.neuroskills.com/tbi/bbstem.shtml
* http://www.cancerhelp.org.uk/help/default.asp?page=5019
* http://www.meddean.luc.edu/lumen/Meded/Neuro/frames/nlBSsL/nl40fr.htm
* http://biology.about.com/library/organs/brain/blbrainstem.htm
* http://www.waiting.com/brainanatomy.html
* http://www.martindalecenter.com/MedicalAnatomy_3_SAD.html
{{refend}}

<br>

[[Category:Brain]]

[[bg:Продълговат мозък]]
[[da:Hjernestamme]]
[[de:Hirnstamm]]
[[es:Tronco del encéfalo]]
[[fr:Tronc cérébral]]
[[it:Tronco encefalico]]
[[he:גזע המוח]]
[[lt:Galvos smegenų kamienas]]
[[nl:Hersenstam]]
[[ja:脳幹]]
[[no:Hjernestammen]]
[[pl:Pień mózgu]]
[[pt:Tronco cerebral]]
[[ru:Мозговой ствол]]
[[simple:Brain stem]]
[[fi:Aivorunko]]
[[sv:Hjärnstammen]]
[[zh:腦幹]]

{{jb1}}
{{WH}}
{{WS}}

Brain stem

2014-10-04T17:47:09Z

Bobby Schwartz: /* External links */

{{Infobox Brain|
Name = Brain stem |
Latin = truncus encephali |
GraySubject = 187 |
Image = Gray719.png |
Caption Hind- and mid-brains; postero-lateral view. |
IsPartOf = [[Brain]]|
Components = [[Medulla]], [[Pons]], [[Midbrain]]|
Artery = |
Vein = |
BrainInfoType = ancil |
BrainInfoNumber = 218 |
MeshName = Brain+Stem |
MeshNumber = A08.186.211.132 |
DorlandsPre = b_21 |
DorlandsSuf = 12195821 |
}}
'''Editor-in-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.]

The '''brain stem''' is the lower part of the [[brain]], adjoining and structurally continuous with the [[spinal cord]]. Most sources consider the [[pons]], [[medulla oblongata]], and [[midbrain]] all to be part of the brainstem.<ref>http://wordnet.princeton.edu/perl/webwn?s=brainstem</ref>

Differentiation of the brain stem from the [[telencephalon|cerebrum]] is complex, with regard to both anatomy and taxonomy. Some taxonomies describe the brain stem as the medulla and mesencephalon, whereas others include [[diencephalic]] regions.

==General anatomy==
===Ventral view/medulla and pons===
The most medial part of the medulla is the anterior median fissure. Moving laterally on each side are the pyramids. The pyramids contain the fibers of the [[corticospinal]] tract, or the upper motor neuronal axons as they head inferiorly to synapse on lower motor neuronal cell bodies within the [[ventral horn]] of the spinal cord.<br />
The anterolateral sulcus is lateral to the pyramids. Emerging from the anterolateral sulci are the [[hypoglossal nerve]] (CN XII) rootlets. Lateral to these rootlets and the anterolateral sulci are the [[Olivary body|olives]]. The olives are swellings in the medulla containing underlying inferior olivary nuclei (containing various nuclei and afferent fibers).

Lateral (and dorsal) to the olives are the rootlets for cranial nerves IX and X ([[glossopharyngeal]] and [[vagus]], respectively). The pyramids end at the [[pontomedullary junction]], noted most obviously by the large [[basal pons]]. Between the basal pons, cranial nerve 6, 7 and 8 emerge (medial to lateral). These cranial nerves are the [[abducens nerve]], [[facial nerve]] and the [[vestibulocochlear nerve]], respectively. At the level of the midpons, the large [[trigeminal nerve]], CN V, emerges. At the rostral pons, the [[occulomotor nerve]] emerges at the midline. Laterally, the [[trochlear nerve]] has emerged after emerging out of the dorsal rostral pons and wrapping around to the anterior.

===Dorsal view/medulla and pons===
The most medial part of the medulla is the posterior median fissure. Moving laterally on each side is the [[fasciculus gracilis]], and lateral to that is the [[fasciculus cuneatus]]. Superior to each of these, and directly inferior to the [[obex]], are the gracile tubercles and cuteanus tubercles, respectively. Underlying these are their respective nuclei. The obex marks the end of the 4th ventricle and the beginning of the [[central canal]]. The posterior intermediate sulci separates the fasciculi gracilis from the fasciculi cuneatus. Lateral to the fasciculi cuneatus is the [[lateral funiculus]]. <br />

Superior to the obex is the floor of the 4th ventricle. In the floor of the 4th ventricle, various nuclei can be visualized by the small bumps that they make in the overlying tissue. In the midline and directly superior to the obex is the [[vagal trigone]] and superior to that it the [[hypoglossal trigone]]. Underlying each of these are motor nuclei for the respective cranial nerves. Superior to these trigones are fibers running laterally in both directions. These fibers are known collectively as the striae medullares.

Continuing in a [[rostral]] direction, the large bumps are called the facial colliculi. Each [[facial colliculus]], contrary to their names, do not contain the facial nerve nuclei. Instead, they have facial nerve axons traversing superficial to underlying abducens (CN VI) nuclei. Lateral to all these bumps previously discussed is an indented line, or [[sulcus]] that runs rostrally, and is known as the [[sulcus limitans]]. This separates the medial motor neurons from the lateral sensory neurons. Lateral to the sulcus limitans is the area collectively known as the [[vestibular area]], which is involved in special sensation.

Moving rostrally, the inferior, middle, and superior cerebellar peduncles are found connecting the midbrain to the cerebellum. Directly rostral to the superior cerebellar peduncle, there is the superior medullary velum and then the two trochlear nerves. This marks the end of the pons as the [[inferior colliculus]] is directly rostral and marks the caudal midbrain.

Spinal Cord to Medulla Transitional Landmark: From a ventral view, there can be seen a [[decussation]] of fibers between the two [[pyramids]]. This decussation marks the transition from medulla to spinal cord. Superior to the decussation is the medulla and inferior to it is the spinal cord.

===Midbrain===
The midbrain is divided into three parts. The first is the [[tectum]], which is "roof" in [[Latin]]. The tectum includes the superior and inferior colliculi and is the dorsal covering of the cerebral aqueduct. The [[inferior colliculus]], involved in the special sense of hearing sends its inferior brachium to the [[medial geniculate body]] of the [[diencephalon]]. Superior to the inferior colliculus, the [[superior colliculus]] marks the rostral midbrain. It is involved in the special sense of vision and sends its superior brachium to the [[lateral geniculate body]] of the diencephalon. The second part is the [[tegmentum]] and is ventral to the cerebral aqueduct. Several nuclei, tracts and the reticular formation is contained here. Last, the ventral side is comprised of paired [[cerebral peduncles]]. These transmit axons of upper motor neurons.

===Midbrain internal structures===
[[Periaqueductal Gray]]: The area around the cerebral aqueduct, which contains various neurons involved in the pain desensitization pathway. Neurons synapse here and, when stimulated, cause activation of neurons in the [[raphe nucleus magnus]], which then project down into the dorsal horn of the spinal cord and prevent pain sensation transmission.<br />
Occulomotor nerve nucleus: This is the nucleus of CN III.<br />
Trochlear nerve nucleus: This is the nucleus of CN IV.<br />
[[Red Nucleus]]: This is a motor nucleus that sends a descending tract to the lower motor neurons.<br />
[[Substantia nigra]]: This is a concentration of neurons in the ventral portion of the midbrain that uses dopamine as its neurotransmitter and is involved in both motor function and emotion. Its dysfunction is implicated in [[Parkinson's Disease]].<br />
[[Reticular formation]]: This is a large area in the midbrain that is involved in various important functions of the midbrain. In particular, it contains lowermotor neurons, is involved in the pain desensitization pathway, is involved in the arousal and consciousness systems, and contains the [[locus ceruleus]], which is involved in intensive alertness modulation and in [[autonomic]] reflexes.<br />
[[Central tegmental]] tract: Directly anterior to the floor of the 4th ventricle, this is a pathway by which many tracts project up to the cortex and down to the spinal cord.<br />

==Embryology==
The adult human brainstem emerges from two of the three primary vesicles formed of the [[neural tube]]. The [[mesencephalon]] is the second of the three primary vesicles, and does not further differentiate into a secondary vesicle. This will become the midbrain. The third primary vesicle, the [[rhombencephalon]], will further differentiate into two secondary vesicles, the [[metencephalon]] and the [[myelencephalon]]. The metencephalon will become the cerebellum and the pons. The myelencephalon will become the medulla.

==Physiology==
There are three main functions of the brainstem. The first is its role in conduit functions. That is, all information related from the body to the cerebrum and cerebellum and vice versa, must traverse the brain stem. The ascending pathways coming from the body to the brain are the sensory pathways, and include the [[spinothalamic tract]] for pain and temperature sensation and the dorsal column, fasciculus gracilis, and cuneatus for touch, [[proprioception]], and pressure sensation (both of the body).

The facial sensations have similar pathways, and will travel in the spinothalamic tract and the [[medial lemniscus]] also). Descending tracts are upper motor neurons destined to synapse on lower motor neurons in the [[ventral horn]] and [[intermediate horn]] of the spinal cord. In addition, there are upper motor neurons that originate in the brainstem's vestibular, red, tactile, and reticular nuclei, which also descend and synapse in the spinal cord.

Second, the cranial nerves 3-12 emerge from the brain stem. Third, the brain stem has integrative functions (it is involved in cardiovascular system control, respiratory control, pain sensitivity control, alertness, and consciousness). Thus, brain stem damage is a very serious and often life-threatening problem.

The practical results of an improperly functioning brainstem are not just related to physical injury. Behavioral and physical signs can also manifest when there is incomplete pons or mid brain development. Such underdevelopment can affect behavior, academic performance, coordination, anxiety, speech, and focus. Habilitation, the process of first occurrence rehabilitation, makes use of programmatic exercise with the goals of completing development through inducement of neural plasticity

==Physical signs of brainstem disease==
Diseases of the brainstem can result to abnormalities in the function of cranial nerves, which may lead to visual disturbances, pupil abnormalities, changes in sensation, muscle weakness, hearing problems, vertigo, swallowing and speech difficulty, voice change, and co-ordination problems. Less obvious cases may complain of poor reading comprehension, lack of focus, altered vigilance, clumsiness, or poor social skills. Often physical signs to an untrained examiner are not obvious as challenge testing (to reduce cortical compensations) are required during examination.

Localizing neurological lesions in the brainstem may be very precise with imaging studies, although the clinical utility of such localization relies upon a clear understanding of brainstem anatomical structures on their functions. While rehabilitation of brainstem disorders has traditionally belonged to the domain of physiatry or neurology more recently publicly accessible programs have become available that incorporate concepts which promote neural plasticity. <ref>http://www.asktheneurologist.com/lectures-brainstem.html</ref>
At least one hospital system, Bon Sequours, St. Francis in Greenville, SC, has incorporated a movement based restorative therapy programs that focus on brainstem neuroplasticity for the treatment of common conditions such as Fibromyalgia.

== See also ==
* [[Cranial nerve nucleus]]

==References==
{{reflist|2}}

==External links==

* [http://www.piedmontpmr.com/Education Improvement in Function: A Clinical Practice Model]
* [http://www.brainhighways.com Brain Highways: A Novel Approach to Brainstem Plasticity]
* [http://piedmontpmr.com/fibromyalgia-relieving-pain-and-fatigue/ Incorporating Three Dimensional Exercise in Fibromyalgia Care]

==Additional Resources==
{{refbegin|2}}
* http://www.neuroskills.com/tbi/bbstem.shtml
* http://www.cancerhelp.org.uk/help/default.asp?page=5019
* http://www.meddean.luc.edu/lumen/Meded/Neuro/frames/nlBSsL/nl40fr.htm
* http://biology.about.com/library/organs/brain/blbrainstem.htm
* http://www.waiting.com/brainanatomy.html
* http://www.martindalecenter.com/MedicalAnatomy_3_SAD.html
{{refend}}

<br>

[[Category:Brain]]

[[bg:Продълговат мозък]]
[[da:Hjernestamme]]
[[de:Hirnstamm]]
[[es:Tronco del encéfalo]]
[[fr:Tronc cérébral]]
[[it:Tronco encefalico]]
[[he:גזע המוח]]
[[lt:Galvos smegenų kamienas]]
[[nl:Hersenstam]]
[[ja:脳幹]]
[[no:Hjernestammen]]
[[pl:Pień mózgu]]
[[pt:Tronco cerebral]]
[[ru:Мозговой ствол]]
[[simple:Brain stem]]
[[fi:Aivorunko]]
[[sv:Hjärnstammen]]
[[zh:腦幹]]

{{jb1}}
{{WH}}
{{WS}}

Brain stem

2014-10-04T17:43:27Z

Bobby Schwartz: /* External links */

{{Infobox Brain|
Name = Brain stem |
Latin = truncus encephali |
GraySubject = 187 |
Image = Gray719.png |
Caption Hind- and mid-brains; postero-lateral view. |
IsPartOf = [[Brain]]|
Components = [[Medulla]], [[Pons]], [[Midbrain]]|
Artery = |
Vein = |
BrainInfoType = ancil |
BrainInfoNumber = 218 |
MeshName = Brain+Stem |
MeshNumber = A08.186.211.132 |
DorlandsPre = b_21 |
DorlandsSuf = 12195821 |
}}
'''Editor-in-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.]

The '''brain stem''' is the lower part of the [[brain]], adjoining and structurally continuous with the [[spinal cord]]. Most sources consider the [[pons]], [[medulla oblongata]], and [[midbrain]] all to be part of the brainstem.<ref>http://wordnet.princeton.edu/perl/webwn?s=brainstem</ref>

Differentiation of the brain stem from the [[telencephalon|cerebrum]] is complex, with regard to both anatomy and taxonomy. Some taxonomies describe the brain stem as the medulla and mesencephalon, whereas others include [[diencephalic]] regions.

==General anatomy==
===Ventral view/medulla and pons===
The most medial part of the medulla is the anterior median fissure. Moving laterally on each side are the pyramids. The pyramids contain the fibers of the [[corticospinal]] tract, or the upper motor neuronal axons as they head inferiorly to synapse on lower motor neuronal cell bodies within the [[ventral horn]] of the spinal cord.<br />
The anterolateral sulcus is lateral to the pyramids. Emerging from the anterolateral sulci are the [[hypoglossal nerve]] (CN XII) rootlets. Lateral to these rootlets and the anterolateral sulci are the [[Olivary body|olives]]. The olives are swellings in the medulla containing underlying inferior olivary nuclei (containing various nuclei and afferent fibers).

Lateral (and dorsal) to the olives are the rootlets for cranial nerves IX and X ([[glossopharyngeal]] and [[vagus]], respectively). The pyramids end at the [[pontomedullary junction]], noted most obviously by the large [[basal pons]]. Between the basal pons, cranial nerve 6, 7 and 8 emerge (medial to lateral). These cranial nerves are the [[abducens nerve]], [[facial nerve]] and the [[vestibulocochlear nerve]], respectively. At the level of the midpons, the large [[trigeminal nerve]], CN V, emerges. At the rostral pons, the [[occulomotor nerve]] emerges at the midline. Laterally, the [[trochlear nerve]] has emerged after emerging out of the dorsal rostral pons and wrapping around to the anterior.

===Dorsal view/medulla and pons===
The most medial part of the medulla is the posterior median fissure. Moving laterally on each side is the [[fasciculus gracilis]], and lateral to that is the [[fasciculus cuneatus]]. Superior to each of these, and directly inferior to the [[obex]], are the gracile tubercles and cuteanus tubercles, respectively. Underlying these are their respective nuclei. The obex marks the end of the 4th ventricle and the beginning of the [[central canal]]. The posterior intermediate sulci separates the fasciculi gracilis from the fasciculi cuneatus. Lateral to the fasciculi cuneatus is the [[lateral funiculus]]. <br />

Superior to the obex is the floor of the 4th ventricle. In the floor of the 4th ventricle, various nuclei can be visualized by the small bumps that they make in the overlying tissue. In the midline and directly superior to the obex is the [[vagal trigone]] and superior to that it the [[hypoglossal trigone]]. Underlying each of these are motor nuclei for the respective cranial nerves. Superior to these trigones are fibers running laterally in both directions. These fibers are known collectively as the striae medullares.

Continuing in a [[rostral]] direction, the large bumps are called the facial colliculi. Each [[facial colliculus]], contrary to their names, do not contain the facial nerve nuclei. Instead, they have facial nerve axons traversing superficial to underlying abducens (CN VI) nuclei. Lateral to all these bumps previously discussed is an indented line, or [[sulcus]] that runs rostrally, and is known as the [[sulcus limitans]]. This separates the medial motor neurons from the lateral sensory neurons. Lateral to the sulcus limitans is the area collectively known as the [[vestibular area]], which is involved in special sensation.

Moving rostrally, the inferior, middle, and superior cerebellar peduncles are found connecting the midbrain to the cerebellum. Directly rostral to the superior cerebellar peduncle, there is the superior medullary velum and then the two trochlear nerves. This marks the end of the pons as the [[inferior colliculus]] is directly rostral and marks the caudal midbrain.

Spinal Cord to Medulla Transitional Landmark: From a ventral view, there can be seen a [[decussation]] of fibers between the two [[pyramids]]. This decussation marks the transition from medulla to spinal cord. Superior to the decussation is the medulla and inferior to it is the spinal cord.

===Midbrain===
The midbrain is divided into three parts. The first is the [[tectum]], which is "roof" in [[Latin]]. The tectum includes the superior and inferior colliculi and is the dorsal covering of the cerebral aqueduct. The [[inferior colliculus]], involved in the special sense of hearing sends its inferior brachium to the [[medial geniculate body]] of the [[diencephalon]]. Superior to the inferior colliculus, the [[superior colliculus]] marks the rostral midbrain. It is involved in the special sense of vision and sends its superior brachium to the [[lateral geniculate body]] of the diencephalon. The second part is the [[tegmentum]] and is ventral to the cerebral aqueduct. Several nuclei, tracts and the reticular formation is contained here. Last, the ventral side is comprised of paired [[cerebral peduncles]]. These transmit axons of upper motor neurons.

===Midbrain internal structures===
[[Periaqueductal Gray]]: The area around the cerebral aqueduct, which contains various neurons involved in the pain desensitization pathway. Neurons synapse here and, when stimulated, cause activation of neurons in the [[raphe nucleus magnus]], which then project down into the dorsal horn of the spinal cord and prevent pain sensation transmission.<br />
Occulomotor nerve nucleus: This is the nucleus of CN III.<br />
Trochlear nerve nucleus: This is the nucleus of CN IV.<br />
[[Red Nucleus]]: This is a motor nucleus that sends a descending tract to the lower motor neurons.<br />
[[Substantia nigra]]: This is a concentration of neurons in the ventral portion of the midbrain that uses dopamine as its neurotransmitter and is involved in both motor function and emotion. Its dysfunction is implicated in [[Parkinson's Disease]].<br />
[[Reticular formation]]: This is a large area in the midbrain that is involved in various important functions of the midbrain. In particular, it contains lowermotor neurons, is involved in the pain desensitization pathway, is involved in the arousal and consciousness systems, and contains the [[locus ceruleus]], which is involved in intensive alertness modulation and in [[autonomic]] reflexes.<br />
[[Central tegmental]] tract: Directly anterior to the floor of the 4th ventricle, this is a pathway by which many tracts project up to the cortex and down to the spinal cord.<br />

==Embryology==
The adult human brainstem emerges from two of the three primary vesicles formed of the [[neural tube]]. The [[mesencephalon]] is the second of the three primary vesicles, and does not further differentiate into a secondary vesicle. This will become the midbrain. The third primary vesicle, the [[rhombencephalon]], will further differentiate into two secondary vesicles, the [[metencephalon]] and the [[myelencephalon]]. The metencephalon will become the cerebellum and the pons. The myelencephalon will become the medulla.

==Physiology==
There are three main functions of the brainstem. The first is its role in conduit functions. That is, all information related from the body to the cerebrum and cerebellum and vice versa, must traverse the brain stem. The ascending pathways coming from the body to the brain are the sensory pathways, and include the [[spinothalamic tract]] for pain and temperature sensation and the dorsal column, fasciculus gracilis, and cuneatus for touch, [[proprioception]], and pressure sensation (both of the body).

The facial sensations have similar pathways, and will travel in the spinothalamic tract and the [[medial lemniscus]] also). Descending tracts are upper motor neurons destined to synapse on lower motor neurons in the [[ventral horn]] and [[intermediate horn]] of the spinal cord. In addition, there are upper motor neurons that originate in the brainstem's vestibular, red, tactile, and reticular nuclei, which also descend and synapse in the spinal cord.

Second, the cranial nerves 3-12 emerge from the brain stem. Third, the brain stem has integrative functions (it is involved in cardiovascular system control, respiratory control, pain sensitivity control, alertness, and consciousness). Thus, brain stem damage is a very serious and often life-threatening problem.

The practical results of an improperly functioning brainstem are not just related to physical injury. Behavioral and physical signs can also manifest when there is incomplete pons or mid brain development. Such underdevelopment can affect behavior, academic performance, coordination, anxiety, speech, and focus. Habilitation, the process of first occurrence rehabilitation, makes use of programmatic exercise with the goals of completing development through inducement of neural plasticity

==Physical signs of brainstem disease==
Diseases of the brainstem can result to abnormalities in the function of cranial nerves, which may lead to visual disturbances, pupil abnormalities, changes in sensation, muscle weakness, hearing problems, vertigo, swallowing and speech difficulty, voice change, and co-ordination problems. Less obvious cases may complain of poor reading comprehension, lack of focus, altered vigilance, clumsiness, or poor social skills. Often physical signs to an untrained examiner are not obvious as challenge testing (to reduce cortical compensations) are required during examination.

Localizing neurological lesions in the brainstem may be very precise with imaging studies, although the clinical utility of such localization relies upon a clear understanding of brainstem anatomical structures on their functions. While rehabilitation of brainstem disorders has traditionally belonged to the domain of physiatry or neurology more recently publicly accessible programs have become available that incorporate concepts which promote neural plasticity. <ref>http://www.asktheneurologist.com/lectures-brainstem.html</ref>
At least one hospital system, Bon Sequours, St. Francis in Greenville, SC, has incorporated a movement based restorative therapy programs that focus on brainstem neuroplasticity for the treatment of common conditions such as Fibromyalgia.

== See also ==
* [[Cranial nerve nucleus]]

==References==
{{reflist|2}}

==External links==

* [http://www.piedmontpmr.com/Education Improvement in Function: A Clinical Practice Model]
* [http://www.brainhighways.com Brain Highways: A Novel Approach to Brainstem Plasticity]
* [http://piedmontpmr.com/fibromyalgia-relieving-pain-and-fatigue/]

==Additional Resources==
{{refbegin|2}}
* http://www.neuroskills.com/tbi/bbstem.shtml
* http://www.cancerhelp.org.uk/help/default.asp?page=5019
* http://www.meddean.luc.edu/lumen/Meded/Neuro/frames/nlBSsL/nl40fr.htm
* http://biology.about.com/library/organs/brain/blbrainstem.htm
* http://www.waiting.com/brainanatomy.html
* http://www.martindalecenter.com/MedicalAnatomy_3_SAD.html
{{refend}}

<br>

[[Category:Brain]]

[[bg:Продълговат мозък]]
[[da:Hjernestamme]]
[[de:Hirnstamm]]
[[es:Tronco del encéfalo]]
[[fr:Tronc cérébral]]
[[it:Tronco encefalico]]
[[he:גזע המוח]]
[[lt:Galvos smegenų kamienas]]
[[nl:Hersenstam]]
[[ja:脳幹]]
[[no:Hjernestammen]]
[[pl:Pień mózgu]]
[[pt:Tronco cerebral]]
[[ru:Мозговой ствол]]
[[simple:Brain stem]]
[[fi:Aivorunko]]
[[sv:Hjärnstammen]]
[[zh:腦幹]]

{{jb1}}
{{WH}}
{{WS}}

Brain stem

2014-10-04T17:40:21Z

Bobby Schwartz: /* Physical signs of brainstem disease */

{{Infobox Brain|
Name = Brain stem |
Latin = truncus encephali |
GraySubject = 187 |
Image = Gray719.png |
Caption Hind- and mid-brains; postero-lateral view. |
IsPartOf = [[Brain]]|
Components = [[Medulla]], [[Pons]], [[Midbrain]]|
Artery = |
Vein = |
BrainInfoType = ancil |
BrainInfoNumber = 218 |
MeshName = Brain+Stem |
MeshNumber = A08.186.211.132 |
DorlandsPre = b_21 |
DorlandsSuf = 12195821 |
}}
'''Editor-in-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.]

The '''brain stem''' is the lower part of the [[brain]], adjoining and structurally continuous with the [[spinal cord]]. Most sources consider the [[pons]], [[medulla oblongata]], and [[midbrain]] all to be part of the brainstem.<ref>http://wordnet.princeton.edu/perl/webwn?s=brainstem</ref>

Differentiation of the brain stem from the [[telencephalon|cerebrum]] is complex, with regard to both anatomy and taxonomy. Some taxonomies describe the brain stem as the medulla and mesencephalon, whereas others include [[diencephalic]] regions.

==General anatomy==
===Ventral view/medulla and pons===
The most medial part of the medulla is the anterior median fissure. Moving laterally on each side are the pyramids. The pyramids contain the fibers of the [[corticospinal]] tract, or the upper motor neuronal axons as they head inferiorly to synapse on lower motor neuronal cell bodies within the [[ventral horn]] of the spinal cord.<br />
The anterolateral sulcus is lateral to the pyramids. Emerging from the anterolateral sulci are the [[hypoglossal nerve]] (CN XII) rootlets. Lateral to these rootlets and the anterolateral sulci are the [[Olivary body|olives]]. The olives are swellings in the medulla containing underlying inferior olivary nuclei (containing various nuclei and afferent fibers).

Lateral (and dorsal) to the olives are the rootlets for cranial nerves IX and X ([[glossopharyngeal]] and [[vagus]], respectively). The pyramids end at the [[pontomedullary junction]], noted most obviously by the large [[basal pons]]. Between the basal pons, cranial nerve 6, 7 and 8 emerge (medial to lateral). These cranial nerves are the [[abducens nerve]], [[facial nerve]] and the [[vestibulocochlear nerve]], respectively. At the level of the midpons, the large [[trigeminal nerve]], CN V, emerges. At the rostral pons, the [[occulomotor nerve]] emerges at the midline. Laterally, the [[trochlear nerve]] has emerged after emerging out of the dorsal rostral pons and wrapping around to the anterior.

===Dorsal view/medulla and pons===
The most medial part of the medulla is the posterior median fissure. Moving laterally on each side is the [[fasciculus gracilis]], and lateral to that is the [[fasciculus cuneatus]]. Superior to each of these, and directly inferior to the [[obex]], are the gracile tubercles and cuteanus tubercles, respectively. Underlying these are their respective nuclei. The obex marks the end of the 4th ventricle and the beginning of the [[central canal]]. The posterior intermediate sulci separates the fasciculi gracilis from the fasciculi cuneatus. Lateral to the fasciculi cuneatus is the [[lateral funiculus]]. <br />

Superior to the obex is the floor of the 4th ventricle. In the floor of the 4th ventricle, various nuclei can be visualized by the small bumps that they make in the overlying tissue. In the midline and directly superior to the obex is the [[vagal trigone]] and superior to that it the [[hypoglossal trigone]]. Underlying each of these are motor nuclei for the respective cranial nerves. Superior to these trigones are fibers running laterally in both directions. These fibers are known collectively as the striae medullares.

Continuing in a [[rostral]] direction, the large bumps are called the facial colliculi. Each [[facial colliculus]], contrary to their names, do not contain the facial nerve nuclei. Instead, they have facial nerve axons traversing superficial to underlying abducens (CN VI) nuclei. Lateral to all these bumps previously discussed is an indented line, or [[sulcus]] that runs rostrally, and is known as the [[sulcus limitans]]. This separates the medial motor neurons from the lateral sensory neurons. Lateral to the sulcus limitans is the area collectively known as the [[vestibular area]], which is involved in special sensation.

Moving rostrally, the inferior, middle, and superior cerebellar peduncles are found connecting the midbrain to the cerebellum. Directly rostral to the superior cerebellar peduncle, there is the superior medullary velum and then the two trochlear nerves. This marks the end of the pons as the [[inferior colliculus]] is directly rostral and marks the caudal midbrain.

Spinal Cord to Medulla Transitional Landmark: From a ventral view, there can be seen a [[decussation]] of fibers between the two [[pyramids]]. This decussation marks the transition from medulla to spinal cord. Superior to the decussation is the medulla and inferior to it is the spinal cord.

===Midbrain===
The midbrain is divided into three parts. The first is the [[tectum]], which is "roof" in [[Latin]]. The tectum includes the superior and inferior colliculi and is the dorsal covering of the cerebral aqueduct. The [[inferior colliculus]], involved in the special sense of hearing sends its inferior brachium to the [[medial geniculate body]] of the [[diencephalon]]. Superior to the inferior colliculus, the [[superior colliculus]] marks the rostral midbrain. It is involved in the special sense of vision and sends its superior brachium to the [[lateral geniculate body]] of the diencephalon. The second part is the [[tegmentum]] and is ventral to the cerebral aqueduct. Several nuclei, tracts and the reticular formation is contained here. Last, the ventral side is comprised of paired [[cerebral peduncles]]. These transmit axons of upper motor neurons.

===Midbrain internal structures===
[[Periaqueductal Gray]]: The area around the cerebral aqueduct, which contains various neurons involved in the pain desensitization pathway. Neurons synapse here and, when stimulated, cause activation of neurons in the [[raphe nucleus magnus]], which then project down into the dorsal horn of the spinal cord and prevent pain sensation transmission.<br />
Occulomotor nerve nucleus: This is the nucleus of CN III.<br />
Trochlear nerve nucleus: This is the nucleus of CN IV.<br />
[[Red Nucleus]]: This is a motor nucleus that sends a descending tract to the lower motor neurons.<br />
[[Substantia nigra]]: This is a concentration of neurons in the ventral portion of the midbrain that uses dopamine as its neurotransmitter and is involved in both motor function and emotion. Its dysfunction is implicated in [[Parkinson's Disease]].<br />
[[Reticular formation]]: This is a large area in the midbrain that is involved in various important functions of the midbrain. In particular, it contains lowermotor neurons, is involved in the pain desensitization pathway, is involved in the arousal and consciousness systems, and contains the [[locus ceruleus]], which is involved in intensive alertness modulation and in [[autonomic]] reflexes.<br />
[[Central tegmental]] tract: Directly anterior to the floor of the 4th ventricle, this is a pathway by which many tracts project up to the cortex and down to the spinal cord.<br />

==Embryology==
The adult human brainstem emerges from two of the three primary vesicles formed of the [[neural tube]]. The [[mesencephalon]] is the second of the three primary vesicles, and does not further differentiate into a secondary vesicle. This will become the midbrain. The third primary vesicle, the [[rhombencephalon]], will further differentiate into two secondary vesicles, the [[metencephalon]] and the [[myelencephalon]]. The metencephalon will become the cerebellum and the pons. The myelencephalon will become the medulla.

==Physiology==
There are three main functions of the brainstem. The first is its role in conduit functions. That is, all information related from the body to the cerebrum and cerebellum and vice versa, must traverse the brain stem. The ascending pathways coming from the body to the brain are the sensory pathways, and include the [[spinothalamic tract]] for pain and temperature sensation and the dorsal column, fasciculus gracilis, and cuneatus for touch, [[proprioception]], and pressure sensation (both of the body).

The facial sensations have similar pathways, and will travel in the spinothalamic tract and the [[medial lemniscus]] also). Descending tracts are upper motor neurons destined to synapse on lower motor neurons in the [[ventral horn]] and [[intermediate horn]] of the spinal cord. In addition, there are upper motor neurons that originate in the brainstem's vestibular, red, tactile, and reticular nuclei, which also descend and synapse in the spinal cord.

Second, the cranial nerves 3-12 emerge from the brain stem. Third, the brain stem has integrative functions (it is involved in cardiovascular system control, respiratory control, pain sensitivity control, alertness, and consciousness). Thus, brain stem damage is a very serious and often life-threatening problem.

The practical results of an improperly functioning brainstem are not just related to physical injury. Behavioral and physical signs can also manifest when there is incomplete pons or mid brain development. Such underdevelopment can affect behavior, academic performance, coordination, anxiety, speech, and focus. Habilitation, the process of first occurrence rehabilitation, makes use of programmatic exercise with the goals of completing development through inducement of neural plasticity

==Physical signs of brainstem disease==
Diseases of the brainstem can result to abnormalities in the function of cranial nerves, which may lead to visual disturbances, pupil abnormalities, changes in sensation, muscle weakness, hearing problems, vertigo, swallowing and speech difficulty, voice change, and co-ordination problems. Less obvious cases may complain of poor reading comprehension, lack of focus, altered vigilance, clumsiness, or poor social skills. Often physical signs to an untrained examiner are not obvious as challenge testing (to reduce cortical compensations) are required during examination.

Localizing neurological lesions in the brainstem may be very precise with imaging studies, although the clinical utility of such localization relies upon a clear understanding of brainstem anatomical structures on their functions. While rehabilitation of brainstem disorders has traditionally belonged to the domain of physiatry or neurology more recently publicly accessible programs have become available that incorporate concepts which promote neural plasticity. <ref>http://www.asktheneurologist.com/lectures-brainstem.html</ref>
At least one hospital system, Bon Sequours, St. Francis in Greenville, SC, has incorporated a movement based restorative therapy programs that focus on brainstem neuroplasticity for the treatment of common conditions such as Fibromyalgia.

== See also ==
* [[Cranial nerve nucleus]]

==References==
{{reflist|2}}

==External links==

* [http://www.piedmontpmr.com/Education Improvement in Function: A Clinical Practice Model]
* [http://www.brainhighways.com Brain Highways: A Novel Approach to Brainstem Plasticity]

==Additional Resources==
{{refbegin|2}}
* http://www.neuroskills.com/tbi/bbstem.shtml
* http://www.cancerhelp.org.uk/help/default.asp?page=5019
* http://www.meddean.luc.edu/lumen/Meded/Neuro/frames/nlBSsL/nl40fr.htm
* http://biology.about.com/library/organs/brain/blbrainstem.htm
* http://www.waiting.com/brainanatomy.html
* http://www.martindalecenter.com/MedicalAnatomy_3_SAD.html
{{refend}}

<br>

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Biophysics

2014-10-04T17:32:49Z

Bobby Schwartz:

'''Editor-in-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.];

'''Associate Editor-In-Chief:''' [mailto:aschwartz@neuro.fsu.edu][[Austin Schwartz,]] Department of Biophysics, Florida State University, Tallahassee, Florida

'''Biophysics''' (also '''biological physics''') is an [[interdisciplinary]] [[science]] that employs and develops theories and methods of the [[physical science]]s for the investigation of [[biology|biological]] systems. Studies included under the umbrella of biophysics span all [[Structure#Biological_structure|levels of biological organization]], from the molecular scale to whole organisms and ecosystems. Biophysical research shares significant overlap with [[biochemistry]], [[nanotechnology]], [[bioengineering]] and [[systems biology]].

Molecular biophysics typically addresses biological questions that are similar to those in [[biochemistry]] and [[molecular biology]], but the questions are approached quantitatively. Scientists in this field conduct research concerned with understanding the interactions between the various systems of a cell, including the interactions between DNA, RNA and protein biosynthesis, as well as how these interactions are regulated. A great variety of techniques are used to answer these questions. For example, through the use of the biophysical and biochemical techniques such as patch-clamp, electrophysiolgy, immunoprecipitation and western blot, the regulation of ion channels can be studied and in turn their cellular and large scale effects can be better understood.

[[Fluorescent]] imaging techniques, as well as [[electron microscopy]], [[x-ray crystallography]] and [[atomic force microscopy]] (AFM) are often used to visualize structures of biological significance. Direct manipulation of molecules using [[optical tweezers]] or AFM can also be used to monitor biological events where forces and distances are at the nanoscale. Molecular biophysicists often consider complex biological events as systems of interacting units which can be understood through [[statistical mechanics]], [[thermodynamics]] and [[chemical kinetics]]. By drawing knowledge and experimental techniques from a wide variety of disciplines, biophysicists are often able to directly observe, model or even manipulate the structures and interactions of individual [[molecules]] or complexes of molecules.

In addition to traditional (i.e. molecular) biophysical topics like [[structural biology]] or enzyme [[chemical kinetics|kinetics]], modern biophysics encompasses an extraordinarily broad range of research. It is becoming increasingly common for biophysicists to apply the models and experimental techniques derived from [[physics]], as well as [[mathematics]] and [[statistics]], to larger systems such as tissues, organs, [[population biology|populations]] and [[ecosystem]]s.

==Focus as a subfield==

Biophysics often does not have university-level departments of its own, but have presence as groups across departments within the fields of [[biology]], [[biochemistry]], [[chemistry]], [[computer science]], [[mathematics]], [[medicine]], [[pharmacology]], [[physiology]], [[physics]], and [[neuroscience]]. What follows is a list of examples of how each department applies its efforts toward the study of biophysics. This list is hardly all inclusive. Nor does each subject of study belong exclusively to any particular department. Each academic institution makes its own rules and there is much overlap between departments.

*[[Biology]] and [[molecular biology]] - Almost all forms of biophysics efforts are included in some biology department somewhere. To include some: [[gene regulation]], single protein dynamics, bioenergetics, [[patch clamp]]ing, [[biomechanics]].
*[[Structural biology]] - angstrom-resolution structures of proteins, nucleic acids, lipids, carbohydrates, and complexes thereof.
*[[Biochemistry]] and [[chemistry]] - biomolecular structure, siRNA, nucleic acid structure, structure-activity relationships.
*[[Computer science]] - [[Neural network]]s, Biomolecular and drug databases.
*[[Computational chemistry]] - [[Molecular dynamics]] simulation, [[Docking (molecular)|Molecular docking]], [[Quantum chemistry]]
*[[Bioinformatics]] - [[sequence alignment]], [[structural alignment]], [[Protein structure prediction]]
*[[Mathematics]] - graph/network theory, population modeling, dynamical systems, [[phylogenetics]].
*[[Medicine]] and [[neuroscience]] - tackling neural networks experimentally (brain slicing) as well as theoretically (computer models), membrane permitivity, gene therapy, understanding tumors.
*[[Pharmacology]] and [[physiology]] - channel biology, biomolecular interactions, cellular membranes, polyketides.
*[[Physics]] - Biomolecular free energy, stochastic processes, covering dynamics.

Many [[biophysical techniques]] are unique to this field. Research efforts in biophysics are often initiated by scientists who were traditional physicists, chemists, and biologists by training.

== Topics in biophysics and related fields ==
<div style="-moz-column-count:4; column-count:4;">
* [[Animal locomotion]]
* [[Bioacoustics]]
* [[Biochemical systems theory]]
* [[Biofilms]]
* [[Biological membrane]]s
* [[Biological thermodynamics|Bioenergetics]]
* [[Biomechanics]]
* [[Biomineralisation]]
* [[Bionics]]
* [[Biosensor]] and [[Bioelectronics]]
* [[Cell division]]
* [[Cell membrane]]s
* [[Cell migration]]
* [[Cell signalling]]
* [[Ion channel|Channels]], [[transmembrane receptor|receptors]] and [[Molecular transporter|transporter]]s
* [[Cryobiology]]
* [[Dynamical system]]s
* [[Electrophysiology]]
* [[Enzyme kinetics]]
* [[Evolution]]
* [[Evolutionarily stable strategy]]
* [[Evolutionary algorithms]]
* [[Evolutionary computing]]
* [[Evolutionary theory]]
* [[Game theory]]
* [[Gravitational biology]]
* [[Mathematical biology]]
* [[Metabolic control analysis]]
* [[Microscopy]]
* [[Molecular biophysics]]
* [[Molecular motors]]
* [[Muscle]] and [[contractility]]
* [[Negentropy]]
* [[Neural encoding]]
* [[Neuroimaging]]
* [[Nucleic acid]]s
* [[Origin of Life]]
* [[Phospholipids]]
* [[Photobiophysics]] and [[biophotonics]]
* [[Polysulphur membranes]]
* [[Protein]]s
* [[Punctuated equilibrium]]
* [[Radiobiology]]
* [[Sensory systems]]
* [[Signals (biology)|Signaling]]
* [[Spectroscopy]], [[imaging]], etc.
* [[Supramolecular assemblies]]
* [[Systems biology]]
* [[Systems neuroscience]]
* [[Tensegrity]]
* [[Theoretical biology]]
</div>

== Famous biophysicists ==

* [[Luigi Galvani]], discoverer of [[bioelectricity]]
* [[Hermann von Helmholtz]], first to measure the velocity of [[nerve impulse]]s; studied [[hearing (sense)|hearing]] and [[visual perception|vision]]
* [[Alan Hodgkin]] & [[Andrew Huxley]], [[mathematical model|mathematical theory]] of how [[ion]] fluxes produce [[action potential|nerve impulses]]
* [[Georg von Békésy]], research on the human ear
* [[Bernard Katz]], discovered how [[synapse]]s work
* [[Hermann Joseph Muller|Hermann J. Muller]], discovered that [[X-rays]] cause [[mutation]]s
* [[Linus Pauling]] & [[Robert Corey]], co-discoverers of the [[alpha helix]] and [[beta sheet]] structures in [[protein]]s
* [[J. D. Bernal]], [[X-ray crystallography]] of [[plant virus]]es and [[protein]]s
* [[Rosalind Franklin]], [[Maurice Wilkins]], [[James D. Watson]] and [[Francis Crick]], pioneers of [[DNA]] [[crystallography]] and co-discoverers of the structure of [[DNA]]. Francis Crick later participated in the [[Crick, Brenner et al. experiment]] which established the basis for understanding the [[genetic code]]
* [[Max Perutz]] & [[John Kendrew]], pioneers of [[protein]] [[crystallography]]
* [[Allan McLeod Cormack|Allan Cormack]] & [[Godfrey Hounsfield]], development of [[computed tomography|computer assisted tomography]]
* [[Paul Lauterbur]] & [[Peter Mansfield]], development of [[magnetic resonance imaging]]
* [[Seiji Ogawa]], development of [[fMRI|functional magnetic resonance imaging]]

== Other notable biophysicists ==

* [[Adolf Eugen Fick]], responsible for [[Fick's law of diffusion]] and a method to determine [[cardiac output]].
* [[Howard Berg]], characterized properties of [[bacterial]] [[chemotaxis]]
* [[Steven Block]], observed the motions of enzymes such as [[kinesin]] and [[RNA polymerase]] with [[optical tweezers]]
* [[Carlos Bustamante]], known for single-molecule biophysics of [[molecular motors]] and biological [[polymer physics]]
* [[Steven Chu]], Nobel Laureate who helped develop optical trapping techniques used by many biophysicists
* [[Friedrich Dessauer]], research on radiation, especially [[X-ray]]s
* [[Julio Fernandez]]
* [[John J. Hopfield]], worked on error correction in Transcription and Translation (kinetic proof-reading), and associative memory models ([[Hopfield net]])
* [[Martin Karplus]], research on [[molecular dynamics|molecular dynamical]] simulations of biological macromolecules.
* [[Franklin Offner]], professor emeritus at [[Northwestern University]] of professor of biophysics, biomedical engineering and electronics who developed a modern prototype of the [[electroencephalograph]] and [[electrocardiograph]] called the dynograph
* [[Benoit Roux]]
* [[Mikhail Volkenshtein]], [[Revaz Dogonadze]] & [[Zurab Urushadze]], authors of the 1st [[Quantum mechanics|Quantum-Mechanical]] (Physical) Model of Enzyme Catalysis, supported a theory that enzyme catalysis use quantum-mechanical effects such as [[Quantum tunneling|tunneling]].
* [[John P. Wikswo]], research on biomagnetism
* [[Douglas Warrick]], specializing in [[bird flight]] ([[hummingbird]]s and [[pigeon]]s)
* [[Ernest C. Pollard]] — founder of the [[Biophysical Society]]
* [[Marvin Makinen]], pioneer of the structural basis of [[enzyme]] action
* [[Gopalasamudram Narayana Iyer Ramachandran]], developer of the Ramachandran plot and pioneer of the collagen triple-helix structure prediction
* [[Doug Barrick]], repeat protein folding

== References ==
* Perutz M.F. Proteins and Nucleic Acids, Elsevier, Amsterdam, 1962
* {{cite journal | author=Perutz MF | title=The haemoglobin molecule | journal=Proceedings of the Royal Society of London. Series B | volume=173 | issue=31 | year=1969 | pages=113-40}} PMID 4389425
* Dogonadze R.R. and Urushadze Z.D. Semi-Classical Method of Calculation of Rates of Chemical Reactions Proceeding in Polar Liquids.- ''J.Electroanal.Chem.'', 32, 1971, pp. 235-245
* Volkenshtein M.V., Dogonadze R.R., Madumarov A.K., Urushadze Z.D. and Kharkats Yu.I. Theory of Enzyme Catalysis.- ''Molekuliarnaya Biologia'' (Moscow), 6, 1972, pp. 431-439 (In Russian, English summary)
* {{Cite book
| author = [[Rodney M. J. Cotterill]]
| title = Biophysics : An Introduction
| publisher = [[Wiley]]
| year = 2002
| isbn = 978-0471485384
}}
* Sneppen K. and Zocchi G., ''Physics in Molecular Biology'', [[Cambridge University Press]], 2005. ISBN 0-521-84419-3
* Glaser R., Biophysics, Springer, 2001, ISBN 3-540-67088-2

== See also ==

* [[List of publications in biology#Biophysics|Important publications in biophysics (biology)]]
* [[list of publications in physics#Biophysics|important publications in biophysics (physics)]]

== External links ==
{{WVD}}
* [http://www.biophysics.org/ Biophysical Society]
* [http://www.physiome.ox.ac.uk/ The Wellcome Trust Physiome Project] - Links

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Bioelectromagnetics

2014-10-04T17:30:19Z

Bobby Schwartz:

'''Editor-in-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.];

'''Associate Editor-In-Chief:''' [mailto:aschwartz@neuro.fsu.edu][[Austin Schwartz,]] Department of Biophysics, Florida State University, Tallahassee, Florida

{{For|the scientific journal|Bioelectromagnetics (journal)}}

'''Bioelectromagnetics''' is the study of how [[electromagnetic fields]] interact with and influence biological processes; almost the same as [[radiobiology|radiobiology]] of [[non-ionizing radiation|non-ionizing radiation]]. Common areas of investigation include the mechanism of animal migration and navigation using the geomagnetic field, studying the potential effects of man-made sources of electromagnetic fields, such as those produced by the [[electricity distribution|power distribution system]] and [[mobile phones]], and developing novel therapies to treat various conditions.

While several treatments based on the use of magnetic fields have been reported in peer-reviewed journals, the only ones that have been approved by the FDA are the use of pulsed magnetic fields to aid non-union bone fractures. [[Transcranial magnetic stimulation]] is currently under active study in multiple research centers, and will likely become an approved therapy in the future. Laser therapy treatments, which depend on the energy derived from photons, are sometimes referred to as photo-electromagnetic in character. Numerous references exist in literature regarding the bioelecrtromagnetic effects of photon therapy.

Bioelectromagnetics is not to be confused with [[bioelectromagnetism]], which deals with the ability of life to produce its own electromagnetism.

== Introduction: general features of observed interactions ==
=== Thermal vs nonthermal nature ===
Most of the molecules that make up the human body interact only weakly with [[electromagnetic fields]] (EMF) that are in the [[radiofrequency]] or [[extremely low frequency]] bands. One basic interaction is the absorption of energy from the EMF, which can cause tissue to heat up; more intense field exposures will produce greater heating. This heat deposition can lead to biological effects ranging from discomfort to protein denaturation to burns. Many nations and regulatory bodies (for example, the International Commission on Non-Ionizing Radiation Protection) have established safety guidelines to limit the EMF exposure to a non-thermal level, which can either be defined as heating only to the point where the excess heat can be dissipated/radiated away, or as some small temperature increase that is not detectable with current instruments (such as a heating of less than 0.1°C).

However, many studies have shown that biological effects may be present for these non-thermal exposures. Various mechanisms have been proposed to explain biological effects from non-thermal exposures (Binhi, 2002), and there may be several mechanisms at work underlying the differing phenomena observed. Biological effects of weak electromagnetic fields are the subject of study in [[magnetobiology|magnetobiology]].

=== Behavioral effects ===
Many subtle, and at times, not-so-subtle effects on behaviour have been reported from exposure to magnetic fields, with a particular focus in research on pulsed magnetic fields. The specific pulseform used appears to be an important factor for the behavioural effect seen. For instance, a pulsed magnetic field originally designed for magnetic resonance spectroscopic imaging was found to alleviate symptoms in bipolar patients (Rohan et al, 2004), while another MRI pulse had no effect. A whole-body exposure to a pulsed magnetic field was found to alter standing balance (Thomas et al, 2001) and pain perception (Shupak et al, 2004) in other studies.

=== TMS (and related) ===
A strong changing magnetic field can induce electrical currents in conductive tissue, such as the brain. Since the magnetic field will penetrate tissue, it can be generated outside of the head to induce currents within, hence [[Transcranial magnetic stimulation]]. These currents will depolarize neurons in a selected part of the brain, leading to changes in the patterns of neural activation. Essentially, the effect of TMS is to change the information content in the neurons. There is no structural or heating effect that may damage the tissue; only natural signals ([[action potentials]]) are generated in the target area. If there are any risks, these are due to the arrival of action potentials to synapses and the natural activation of the postsynaptic cell.

A number of scientists and clinicians are attempting to use TMS to replace [[electroconvulsive therapy]] (ECT) to treat disorders such as severe depression. Instead of one strong electric shock through the head as in ECT, a large number of relatively weak pulses are delivered in TMS treatment, typically at the rate of about 10 pulses per second.

If very strong pulses at a rapid rate are delivered to the brain, the induced currents can cause convulsions. Sometimes this is done deliberately in order to treat depression such as in ECT.

=== Molecular Effects ===

Low frequency weak magnetic fields have been shown to cause millivolt changes in membrane potential, however the mechanism for this effect is yet to be understood (Mathie et al, 2003).
== See also ==
*[[Bioelectromagnetism]]
*[[Biophysics]]
*[[Specific absorption rate]] and [[Electromagnetic radiation and health]].
*[[Mobile phone radiation and health]]
*[[Michael Persinger]]

== References ==
=== Organizations ===
* [http://www.bioelectromagnetics.org The Bioelectromagnetics Society] (BEMS)
* [http://www.ebea.org/ European BioElectomagnetics Association] (EBEA)
* [http://www.stanford.edu/group/sprbm/ Society for Physical Regulation in Biology and Medicine] (SPRBM) (formerly the Bioelectrical Repair and Growth Society, BRAGS)
* [http://www.isbem.org International Society for Bioelectromagnetism] (ISBEM)

=== Books ===
* Robert O. Becker and Andrew A. Marino, [http://www.ortho.lsuhsc.edu/Faculty/Marino/EL/ELTOC.html Electromagnetism and Life], State University of New York Press, Albany, 1982 (ISBN 0-87395-561-7)
* Robert O. Becker, The Body Electric: Electromagnetism and the Foundation of Life, William Morrow & Co, 1985 (ISBN 0-688-00123-8)
* Robert O. Becker, Cross Currents: The Promise of Electromedicine, the Perils of Electropollution, Tarcher, 1989 (ISBN 0-87477-536-1)
* Jaakko Malmivuo and Robert Plonsey, [http://butler.cc.tut.fi/~malmivuo/bem/bembook/ Bioelectromagnetism: Principles and Applications of Bioelectric and Biomagnetic Fields], Oxford University Press, 1995 (ISBN 0-19-505823-2)
* David O. Carpenter and Sinerik Ayrapetyan, Biological Effects of Electric and Magnetic Fields, Volume 1 : Sources and Mechanisms, Academic Press, 1994 (ISBN 0-12-160261-3)
* David O. Carpenter and Sinerik Ayrapetyan, Biological Effects of Electric and Magnetic Fields : Beneficial and Harmful Effects (Vol 2), Academic Press, 1994 (ISBN 0-12-160261-3)
* A. Chiabrera (Editor), Interactions Between Electromagnetic Fields and Cells, Springer, 1985 (ISBN 0-306-42083-X)
* Mary E. O'Connor (Editor), et al, Emerging Electromagnetic Medicine, Springer, 1990 (ISBN 0-387-97224-2)
* William F. Horton and Saul Goldberg, Power Frequency Magnetic Fields and Public Health, CRC Press, 1995 (ISBN 0-8493-9420-1)
* Riadh W. Y. Habash, Electromagnetic Fields and Radiation: Human Bioeffects and Safety, Marcel Dekker, 2001 (ISBN 0-8247-0677-3)
* Ho Mae-Wan, et al, Bioelectrodynamics and Biocommunication, World Scientific, 1994 (ISBN 981-02-1665-3)
* Paul Brodeur, Currents of Death, Simon & Schuster, 2000 (ISBN 0-7432-1308-4) 
* Binhi V.N. Magnetobiology: Underlying Physical Problems. San Diego: Academic Press, 2002. ISBN 0-12-100071-0. http://www.elsevier.com/wps/find/bookdescription.cws_home/699798/description

=== Journals ===
* ''[http://www3.interscience.wiley.com/cgi-bin/jhome/34135 Bioelectromagnetics]'', Wiley, 1985-present, (ISSN 0197-8462)
* ''[http://www.sciencedirect.com/science/journal/15675394 Bioelectrochemistry]'', Elsevier, 1974-present, (ISSN 1567-5394)
* ''[http://www.ijbem.org International Journal of Bioelectromagnetism]'', ISBEM, 1999-present, (ISSN 1456-7865)
* ''BioMagnetic Research and Technology'' [http://www.biomagres.com/]
* ''[http://www.maik.ru/cgi-bin/journal.pl?name=biophys&page=online Biofizika]'' ("Biophysics", in Russian) (ISSN 0006-3509)
* ''Radiatsionnaya Bioliogiya Radioecologia'' ("Radiation Biology and Radioecology", in Russian) (ISSN 0869-8031)

=== Journal Articles ===
*Rohan et al., 2004. Am J Psychiatry. 161(1):93-8.
*Shupak et al., 2004. Neurosci Lett. 363(2):157-62.
*Thomas et al., 2001. Neurosci Lett. 309(1):17-20.
*Mathie et al. 2003. Radiat Prot Dosimetry. 106(4): 311-315.
[[Category:Biophysics]]
[[Category:Physiology]]
[[Category:Radiobiology]]
[[ru:Магнитобиология]]
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Alternative medicine

2014-10-04T17:20:55Z

Bobby Schwartz: /* Contemporary use of alternative medicine */

'''Editor-in-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.];

<div style="float:right;clear:right;width:210px;margin:0 0 1em 1em;">
<table border=1><tr><th bgcolor="#98FB98">
'''Alternative Medicine'''</th></tr>
<tr><td align="center">This article is part of the [[Terms and concepts in alternative medicine#CAM|CAM]] series of articles.</td></tr>
<tr><td colspan="2" align="center" bgcolor="#98FB98">'''[[:Category:Alternative medicine|CAM Article Index]]'''</td></tr>
</table>
</div>

{{Alternative medical systems}}

{{SI}}
==Overview==
{{See also|Complementary medicine}}

'''Alternative medicine''' has been described as "any of various systems of healing or treating disease (as [[chiropractic]], [[homeopathy]], or [[faith healing]]) not included in the traditional [[medicine|medical]] curricula taught in the United States and Britain".<ref>Merriam-Webster online. [http://www.m-w.com/dictionary/alternative+medicine Definition] retrieved 16 April 2007</ref>

Alternative medicine practices are often based in belief systems not derived from modern science. Alternative medicines may therefore incorporate spiritual, metaphysical, or religious underpinnings, untested practices, non-Western medical traditions, or newly developed approaches to healing.

If an alternative medical approach, initially regarded as untested, is subsequently shown to be safe and effective, it may then be adopted by conventional practitioners and no longer considered "alternative".
{{see|List of branches of alternative medicine}}

== Criticisms of the term ==

Alternative medicine is commonly categorised together with [[complementary medicine]] under the umbrella term '[[complementary and alternative medicine]]' (CAM for short). Some scientists reject this and the above classifications and to varying degrees reject the term "alternative medicine" itself.

The following three commentators argue for classifying treatments based on the objectively verifiable criteria of the [[scientific method]], not based on the changing curricula of various medical schools or social sphere of usage. They advocate a classification based on [[evidence-based medicine]], i.e., scientifically proven evidence of efficacy (or lack thereof). According to them it is possible for a method to change categories (proven vs. nonproven) in either direction, based on increased knowledge of its effectiveness or lack thereof:

*[[Marcia Angell]], former editor-in-chief of the [[New England Journal of Medicine]], states that "...since many alternative remedies have recently found their way into the medical mainstream [there] cannot be two kinds of medicine - conventional and alternative. There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work. Once a treatment has been tested rigorously, it no longer matters whether it was considered alternative at the outset. If it is found to be reasonably safe and effective, it will be accepted."<ref name="Angell">[http://content.nejm.org/cgi/content/extract/339/12/839 Alternative medicine--the risks of untested and unregulated remedies.] Angell M, Kassirer JP. ''N Engl J Med'' 1998;339:839.</ref>

*George D. Lundberg, former editor of the [[Journal of the American Medical Association]] (JAMA), and Phil B. Fontanarosa, Senior Editor of JAMA, state: "There is no alternative medicine. There is only scientifically proven, evidence-based medicine supported by solid data or unproven medicine, for which scientific evidence is lacking. Whether a therapeutic practice is 'Eastern' or 'Western,' is unconventional or mainstream, or involves mind-body techniques or molecular genetics is largely irrelevant except for historical purposes and cultural interest. As believers in science and evidence, we must focus on fundamental issues—namely, the patient, the target disease or condition, the proposed or practiced treatment, and the need for convincing data on safety and therapeutic efficacy."<ref name="Fontanarosa">[http://jama.ama-assn.org/cgi/content/extract/280/18/1618 Alternative medicine meets science.] Fontanarosa P.B., and Lundberg G.D. ''JAMA''. 1998; 280: 1618-1619.</ref>

*Richard Dawkins, Professor of the Public Understanding of Science at Oxford,<ref name="simonyi">[http://www.simonyi.ox.ac.uk/index.shtml Simonyi Professorship web site]</ref> defines alternative medicine as a "...set of practices which cannot be tested, refuse to be tested, or consistently fail tests. If a healing technique is demonstrated to have curative properties in properly controlled [[Blind experiment|double-blind trials]], it ceases to be alternative. It simply...becomes medicine."<ref name="Holloway">[http://books.guardian.co.uk/reviews/scienceandnature/0,6121,894941,00.html A callous world.] Richard Holloway. Book review Richard Dawkins ''A Devil's Chaplain''. The Guardian, February 15, 2003.</ref> He also states that "There is no alternative medicine. There is only medicine that works and medicine that doesn't work."<ref>{{cite book | last = Dawkins | first = Richard | author = Richard Dawkins | year = 003 | title = A Devil's Chaplain | publisher = Weidenfeld & Nicolson}}</ref>

Other well-known proponents of evidence-based medicine, such as the [[Cochrane Collaboration]] and [[Edzard Ernst]], Professor of Complementary Medicine at the University of Exeter, use the term "alternative medicine" but agree with the above commentators that all treatments, whether "mainstream" or "alternative", ought to be held to standards of the scientific method.<ref>[http://www.compmed.umm.edu/Cochrane/index.html The Cochrane Collaboration Complementary Medicine Field.] Retrieved 5 August 2006.</ref><ref>[http://www.healthwatch-uk.org/awardwinners/edzardernst.html The HealthWatch Award 2005:] Prof. Edzard Ernst, ''Complementary medicine: the good the bad and the ugly.'' Retrieved 5 August 2006</ref><ref>"Complementary medicine is diagnosis, treatment and/or prevention which complements mainstream medicine by contributing to a common whole, by satisfying a demand not met by orthodoxy or by diversifying the conceptual frameworks of medicine." Ernst et al ''British General Practitioner'' 1995; 45:506.</ref> Oxford University Press publishes a peer-reviewed journal entitled ''Evidence-based Complementary and Alternative Medicine'' (eCAM).<ref>''[http://www.oxfordjournals.org/our_journals/ecam/about.html Evidence-based Complementary and Alternative Medicine]''</ref>

Some commentators maintain that some or all fields of alternative medicine are pseudoscientific, or contain significant pseudoscientific elements. In the late 20th century systematic investigation of the evidence-base proceeded, and at least one university department of alternative and complementary medicine was established, at the University of Exeter under Professor [[Edzard Ernst]] for this purpose.

== Regulation ==
Jurisdiction differs concerning which branches of alternative medicine are legal, which are regulated, and which (if any) are provided by a government-controlled [[Publicly funded health care|health service]] or reimbursed by a [[Health insurance|private health medical insurance company]].

In article 34 (''Specific legal obligations'') of the General Comment No. 14 (2000) on '''''The right to the highest attainable standard of health''''' of the Committee on Economic, Social and Cultural Rights (United Nations), it is stated that
<blockquote>
''Obligations to ''respect'' (the right to health) include a State's obligation to refrain from prohibiting or impeding '''traditional preventive care''', '''healing practices''' and '''medicines''', from marketing unsafe drugs '''and from applying coercive medical treatments''''' <ref>COMMITTEE ON ECONOMIC, SOCIAL AND CULTURAL RIGHTS. General Comment No. 14 (2000) The right to the highest attainable standard of health : . 11/08/2000. E/C.12/2000/4. http://www.unhchr.ch/tbs/doc.nsf/(symbol)/E.C.12.2000.4.en</ref>
</blockquote>

A number of alternative medicine advocates disagree with the restrictions of government agencies that approve medical treatments (such as the American [[Food and Drug Administration]]) and the agencies' adherence to experimental evaluation methods. They claim that this impedes those seeking to bring useful and effective treatments and approaches to the public, and protest that their contributions and discoveries are unfairly dismissed, overlooked or suppressed. Alternative medicine providers often argue that health fraud should be dealt with appropriately when it occurs.

In India, which is the home of several alternative systems of medicines, [[Ayurveda]], Siddha, [[Unani]], and [[Homeopathy]] are licenced by the government, despite lack of reputable scientific evidence. [[Naturopathy]] will also be licensed soon because several Universities now offer bachelors degrees in it. Other activities connected with AM/CM, such as [[Panchakarma]] and [[massage therapy]] related to [[Ayurveda]] are also licenced by the government now. Research into and licensing of these activities is carried out by the Department of Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy (AYUSH).<ref name=AYUSH>[http://indianmedicine.nic.in/ Department of Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy (AYUSH)]</ref>

== Contemporary use of alternative medicine ==
Many people utilize mainstream medicine for [[diagnosis]] and basic information, while turning to alternatives for what they believe to be health-enhancing measures. However, studies indicate that a majority of people use alternative approaches [[#Use of CAM as a complement to conventional medicine|''in conjunction with'']] conventional medicine. Several practitioners refer to this as Integrative Medicine, borrowing from the best of both worlds.

[[Edzard Ernst]] wrote in the Medical Journal of Australia that ''"about half the general population in developed countries use complementary and alternative medicine (CAM)''."<ref>Ernst E. "Obstacles to research in complementary and alternative medicine." ''Medical Journal of Australia'', 2003; 179 (6): 279-80. PMID 12964907 [http://www.mja.com.au/public/issues/179_06_150903/ern10442_fm-1.html MJA online]</ref> A survey released in May 2004 by the [[National Center for Complementary and Alternative Medicine]], part of the [[National Institutes of Health]] in the United States, found that in 2002, 36% of Americans used some form of alternative therapy in the past 12 months, 50% in a lifetime — a category that included yoga, meditation, herbal treatments and the [[Atkins diet]].<ref>{{cite paper | url = http://nccam.nih.gov/news/report.pdf | author = Barnes, P. M.; Powell-Griner, E.; McFann, K.; Nahin, R. L. | title = Complementary and Alternative Medicine Use Among Adults: United States, 2002 | date = 2004 | publisher = [[National Center for Health Statistics]]}}</ref> If prayer was counted as an alternative therapy, the figure rose to 62.1%. 25% of people who use CAM do so because medical professional suggested it.<ref name=CAM_reason>[http://nccam.nih.gov/news/images/camreason_large.gif Reasons people use CAM]</ref> Another study suggests a similar figure of 40%.<ref>Astin JA "Why patients use alternative medicine: results of a national study" ''JAMA'' 1998; '''279'''(19): 1548-1553</ref> A British telephone survey by the BBC of 1209 adults in 1998 shows that around 20% of adults in Britain had used alternative medicine in the past 12 months.

The use of alternative medicine appears to be increasing. A 1998 study showed that the use of alternative medicine had risen from 33.8% in 1990 to 42.1% in 1997.<ref>Eisenberg, DM, Davis RB, Ettner SL "Trends in alternative medicine use in the United States 1990-1997." ''JAMA'', 1998; '''280''':1569-1575. PMID 9820257</ref> In the United Kingdom, a 2000 report ordered by the House of Lords suggested that "...limited data seem to support the idea that CAM use in the United Kingdom is high and is increasing."<ref>[http://www.parliament.the-stationery-office.co.uk/pa/ld199900/ldselect/ldsctech/123/12301.htm House of Lords report on CAM]</ref>

=== Medical education ===
Increasing numbers of medical colleges have begun offering courses in alternative medicine. For example, the University of Arizona College of Medicine offers a program in Integrative Medicine under the leadership of Dr. Andrew Weil which trains physicians in various branches of alternative medicine which "...neither rejects conventional medicine, nor embraces alternative practices uncritically."<ref>[http://www.ahsc.arizona.edu/opa/horizons/1997/integrate.htm University of Arizona position on Alternative Medicine]</ref> In three separate research surveys that surveyed 729 schools in the United States (125 medical schools offering an MD degree, 19 medical schools offering a Doctor of Osteopathy degree, and 585 schools offering a nursing degree), 60% of the standard medical schools, 95% of osteopathic medical schools and 84.8% of the nursing schools teach some form of CAM.<ref>Wetzel MS, Eisenberg DM, Kaptchuk TJ. "Courses involving complementary and alternative medicine at US medical schools." ''JAMA'' 1998; 280 (9):784 -787. PMID 9729989 </ref><ref>Saxon DW, Tunnicliff G, Brokaw JJ, Raess BU. "Status of complementary and alternative medicine in the osteopathic medical school curriculum." ''J Am Osteopath Assoc'' 2004; 104 (3):121-6. PMID 15083987</ref><ref>Fenton MV, Morris DL. "The integration of holistic nursing practices and complementary and alternative modalities into curricula of schools of nursing." ''Altern Ther Health Med,'' 2003; 9 (4):62-7. PMID 12868254</ref> Accredited Naturopathic colleges and universities are increasing in number and popularity in the U.S.A. They offer the most complete medical training in complimentary medicines that is available today. See [[Naturopathic medicine]].

In Britain, no conventional medical schools offer courses that teach the clinical practice of alternative medicine. However, alternative medicine is taught in several unconventional schools as part of their curriculum. Teaching is based mostly on theory and understanding of alternative medicine, with emphasis on being able to communicate with alternative medicine specialists. To obtain competence in practicing clinical alternative medicine, qualifications must be obtained from individual medical societies. The student must have graduated and be a qualified doctor. The [http://www.medical-acupuncture.co.uk British Medical Acupuncture Society], which offers medical acupuncture certificates to doctors, is one such example, as is the College of Naturopathic Medicine UK and Ireland.

=== Public use in the US ===
The NCCAM surveyed the American public on complementary and alternative medicine use in 2002. According to the survey:<ref>{{cite paper | url = http://nccam.nih.gov/news/report.pdf
| author = Barnes, P. M.; Powell-Griner, E.; McFann, K.; Nahin, R. L. | title = Complementary and Alternative Medicine Use Among Adults: United States, 2002 | date = 2004 | publisher = National Center for Health Statistics}}</ref>
* 50 percent of U.S. adults age 18 years and over used some form of complementary and alternative medicine (CAM).<ref name=CAM_use>[http://nccam.nih.gov/news/images/camadult_large.gif CAM Use by U.S. Adults]</ref>
* When prayer specifically for health reasons is included in the definition of CAM, the number of adults using some form of CAM in 2002 rose to 62 percent.
* The majority of individuals (54.9%) used CAM in conjunction with conventional medicine.
* Most people use CAM to treat and/or prevent musculoskeletal conditions or other conditions associated with chronic or recurring pain.
* "The fact that only 14.8% of adults sought care from a licensed or certified CAM practitioner suggests that most individuals who use CAM prefer to treat themselves."
* "Women were more likely than men to use CAM. The largest sex differential is seen in the use of [[Terms and concepts in alternative medicine#Mind-Body Interventions|mind-body therapies]] including prayer specifically for health reasons".
* "Except for the groups of therapies that included prayer specifically for health reasons, use of CAM increased as education levels increased".
* The most common CAM therapies used in the USA in 2002 were prayer (45.2%), [[herbalism]] (18.9%), [[Terms and concepts in alternative medicine#Breathing Meditation|breathing meditation]] (11.6%), [[Meditation (alternative medicine)|meditation]] (7.6%), [[chiropractic medicine]] (7.5%), [[Yoga (alternative medicine)|yoga]] (5.1%), [[Body work (alternative medicine)|body work]] (5.0%), [[Terms and concepts in alternative medicine#Diet-based therapy|diet-based therapy]] (3.5%), [[Terms and concepts in alternative medicine#Progressive Relaxation|progressive relaxation]] (3.0%), [[Orthomolecular medicine|mega-vitamin therapy]] (2.8%) and [[Visualization (cam)|Visualization]] (2.1%)

== Support for alternative medicine ==
Alternative therapies provide some services not available from conventional medicine. Examples are [[patient empowerment]] and treatment methods that follow the [[biopsychosocial model]] of health <ref name ="vickers">Vickers A. "Alternative Cancer Cures: "Unproven" or "Disproven"?" ''CA Cancer J Clin'' 2004; '''54''': 110-118. [http://caonline.amcancersoc.org/cgi/content/full/54/2/110 Online]</ref>.

=== Efficacy ===
Advocates of alternative medicine hold that the various alternative treatment methods are effective in treating a wide range of major and minor medical conditions, and contend that recently published research (such as Michalsen, 2003,<ref>Michalsen A, Ludtke R, Buhring M. "Thermal hydrotherapy improves quality of life and hemodynamic function in patients with chronic heart failure." ''Am Heart J'', 2003; 146 (4):E11. PMID 14564334</ref> Gonsalkorale 2003,<ref>Gonsalkorale WM, Miller V, Afzal A, Whorwell PJ. "Long term benefits of hypnotherapy for irritable bowel syndrome." ''Gut'', 2003; 52 (11):1623-9. PMID 14570733</ref> and Berga 2003<ref>Berga SL, Marcus MD, Loucks TL. "Recovery of ovarian activity in women with functional hypothalamic amenorrhea who were treated with cognitive behavior therapy." ''Fertility and Sterility'' 2003; 80 (4): 976-981 [http://www.fertstert.org/article/PIIS0015028203011245/abstract Abstract]</ref>) proves the effectiveness of specific alternative treatments. They assert that a PubMed search revealed over 370,000 research papers classified as alternative medicine published in Medline-recognized journals since 1966 in the National Library of Medicine database. See also Kleijnen 1991,<ref>Kleijnen J, Knipschild P, ter Riet G. "Clinical trials of homoeopathy." ''BMJ'', 1991; 302:316-23. Erratum in: ''BMJ'', 1991; 302:818. PMID 1825800 </ref> and Linde 1997.<ref>Linde K, Clausius N, Ramirez G. "Are the clinical effects of homeopathy placebo effects? A meta-analysis of placebo-controlled trials." ''Lancet'', 1997; 350:834-43. Erratum in: Lancet 1998 Jan 17;351(9097):220. PMID 9310601</ref>

Advocates of alternative medicine hold that alternative medicine may provide health benefits through [[patient empowerment]], by offering more choices to the public, including treatments that are simply not available in conventional medicine:

:"Most Americans who consult alternative providers would probably jump at the chance to consult a physician who is well trained in scientifically based medicine and who is also open-minded and knowledgeable about the body's innate mechanisms of healing, the role of lifestyle factors in influencing health, and the appropriate uses of dietary supplements, herbs, and other forms of treatment, from osteopathic manipulation to Chinese and Ayurvedic medicine. In other words, they want competent help in navigating the confusing maze of therapeutic options that are available today, especially in those cases in which conventional approaches are relatively ineffective or harmful."<ref>Snyderman R & Weil AT. "Integrative medicine: bringing medicine back to its roots." ''Arch Intern Med'' 2002; 162:395-397.</ref>

[[Evidence-based medicine]] (EBM) applies the scientific method to medical practice, and aims for the ideal that healthcare professionals should make "conscientious, explicit, and judicious use of current best evidence" in their everyday practice. Prof. [[Edzard Ernst]] is a notable proponent of applying EBM to CAM.

Although advocates of alternative medicine acknowledge that the [[placebo effect]] may play a role in the benefits that some receive from alternative therapies, they point out that this does not diminish their validity. Researchers who judge treatments using the [[scientific method]] are concerned by this viewpoint, since it fails to address the possible inefficacy of alternative treatments.

=== Use of alternative medicine alongside to conventional medicine ===
A major objection to alternative medicine is that it is done ''in place of'' conventional medical treatments. As long as alternative treatments are used alongside conventional treatments, the majority of medical doctors find most forms of complementary medicine acceptable. Consistent with previous studies, the CDC recently reported that the majority of individuals in the United States (i.e., 54.9%) used CAM in conjunction with conventional medicine.

It is advisable for patients to inform their medical doctor when they are using alternative medicine, because some alternative treatments may interact with orthodox medical treatments, and such potential conflicts should be explored in the interest of the patient. However, many conventional practitioners are biased or uninformed about alternatives, and patients are often reluctant to share this information with their medical doctors since they fear it will hurt their [[doctor-patient relationship]].

The issue of alternative medicine interfering with conventional medical practices is minimized when it is turned to only after conventional treatments have been exhausted. Many patients feel that alternative medicine may help in coping with [[Chronic (medicine)|chronic illnesses]] for which conventional medicine offers no cure, only management. One such example is reducing [http://www.piedmontpmr.com/disease-management-reducing-total-load Total Load,] the total number of things that do not allow someone to get well. Over time, it has become more common for a patient's own MD to suggest alternatives when they cannot offer effective treatment.

== Criticism of alternative medicine ==
''See also [[List of branches of alternative medicine]] for specific criticisms of different types of CAM''

Due to the wide range of therapies that are considered to be "alternative medicine" few criticisms apply across the board, except possibly that of not being scientifically supported or even testable. Proponents of CAM typically address this basic criticism by arguing that it is a self-fulfilling prophecy: critics believe that there is no plausibility to CAMs because they find little or no proofs, while it is plausibility that should inform the scientific research for proofs.
<blockquote>
Proponents of alternative therapy have an obligation to provide grounds for '''biological plausibility''', such as sound '''theoretical''' or '''preclinical''' data, or for clinical plausibility, in the form of authentic, well-prepared '''case reports''', in order to justify the investment of time and energy in exploring the merits of a novel anticancer therapy. But plausibility, not proof, should be sufficient to initiate the process.
<ref name="pmid11232135">{{cite journal |author=Hoffer LJ |title=Proof versus plausibility: rules of engagement for the struggle to evaluate alternative cancer therapies |journal=CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne |volume=164 |issue=3 |pages=351-3 |year=2001 |pmid=11232135 |doi= |issn=}}</ref></blockquote>
In other words, proponents of CAMs argue that skeptics, in saying that theories or anecdotal and preclinical data do not constitute proof, merely state the obvious but do not actually ''engage'' in the evaluation of CAMs. Criticisms directed at specific branches of alternative medicine range from the fairly minor (conventional treatment is believed to be more effective in a particular area) to incompatibility with the known laws of physics (for example, in [[homeopathy]]). Critics argue that alternative medicine practitioners may not have an accredited [[medical degree]] or be licensed [[physician]]s or [[general practitioner]]s and make sweeping claims without demonstrated expertise. This cannot always be considered a serious criticism, because unless a new system of medicine becomes established, it does not receive accreditation of any kind, except by its own professional organizations. This is the route [[homeopathy]], [[ayurveda]], siddha, [[unani]], and [[naturopathy]] had to follow in those countries where it is now offered by accredited institutions. Proponents of the various forms of alternative medicine reject criticism as being founded in prejudice,financial self-interest, or ignorance. Refutations of criticism sometimes take the form of an appeal to nature.

=== Efficacy ===
==== Lack of proper testing ====

Although proponents of alternative medicine often cite the large number of studies which have been performed, critics point out that there are no statistics on exactly how many of those studies were controlled, double blind, peer-reviewed experiments, or how many produced results supporting alternative medicine or parts thereof. They contend that many forms of alternative medicine are rejected by conventional medicine because the efficacy of the treatments has not been demonstrated through double-blind [[randomized controlled trial]]s; in contrast, conventional drugs reach the market only after such trials have proved their efficacy.

Some argue that less research is carried out on alternative medicine because many alternative medicine techniques cannot be patented, and hence there is little financial incentive to study them. Drug research, by contrast, can be very lucrative, which has resulted in funding of trials by pharmaceutical companies. Many people, including conventional and alternative medical practitioners, contend that this funding has led to corruption of the scientific process for approval of drug usage, and that ghostwritten work has appeared in major peer-reviewed medical journals.<ref>Larkin M. "Whose article is it anyway?" ''Lancet'', 1999; '''354''':136. [http://www.thelancet.com/journal/vol354/iss9173/full/llan.354.9173.news.3708.1 Editorial]</ref><ref>Flanagin A, Carey LA, Fontanarosa PB. "Prevalence of articles with honorary authors and ghost authors in peer-reviewed medical journals." ''JAMA'', 1998; '''280'''(3):222-4. [http://jama.ama-assn.org/cgi/content/full/280/3/222 Full text]</ref> Increasing the funding for research of alternative medicine techniques was the purpose of the [[U.S. National Center for Complementary and Alternative Medicine|National Center for Complementary and Alternative Medicine]]. NCCAM and its predecessor, the Office of Alternative Medicine, have spent more than $200 million on such research since 1991. The German Federal Institute for Drugs and Medical Devices [[Commission E]] has studied many herbal remedies for efficacy.<ref>[http://www.csicop.org/si/2003-09/alternative-medicine.html CSICOP.org article on alternative medicine]</ref>

Some skeptics of alternative practices point out that a person may attribute symptomatic relief to an otherwise ineffective therapy due to the [[placebo effect]], the natural recovery from or the cyclical nature of an illness (the [[regression fallacy]]), or the possibility that the person never originally had a true illness.<ref>James Alcock PhD, ''Alternative Medicine and the Psychology of Belief'', The Scientific Review of Alternative Medicine, Fall/Winter 1999 Volume 3 ~ Number 2. [http://www.quackwatch.org/01QuackeryRelatedTopics/altpsych.html available online]</ref> CAM proponents point out this may also apply in cases where conventional treatments have been used. To this, CAM critics point out that this does not account for conventional medical success in double blind clinical trials. CAM proponents, however, don't typically question conventional medical successes revealed in double blind clinical trials.

=== Safety ===
Critics contend that some people have been hurt or killed directly from the various practices or indirectly by failed diagnoses or the subsequent avoidance of conventional medicine which they believe is redundant.

Alternative medicine critics agree with its proponents that people should be free to choose whatever method of healthcare they want, but stipulate that people must be informed as to the safety and efficacy of whatever method they choose. People who choose alternative medicine may think they are choosing a safe, effective medicine, while they may only be getting [[quackery|quack]] remedies. [[Grapefruit seed extract]] is an example of quackery when multiple studies demonstrate its universal antimicrobial effect is due to synthetic antimicrobial contamination.<ref name=Quackery>Ganzera M, Aberham A, Stuppner H. Development and validation of an HPLC/UV/MS method for simultaneous determination of 18 preservatives in grapefruit seed extract. Institute of Pharmacy, University of Innsbruck, Innrain 52, 6020 Innsbruck, Austria. ''J Agric Food Chem.'' 2006 May 31;54(11):3768-72. [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16719494&query_hl=2&itool=pubmed_docsum Abstract]</ref><ref name=Preservatives>Takeoka, G., Dao, L., Wong, R.Y., Lundin, R., Mahoney N. Identification of benzethonium chloride in commercial grapefruit seed extracts. ''J Agric Food Chem.'' 2001 49(7):3316–20. [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=11453769 Abstract]</ref><ref name=Manipulation>von Woedtke, T., Schlüter, B., Pflegel, P., Lindequist, U.; Jülich, W.-D. Aspects of the antimicrobial efficacy of grapefruit seed extract and its relation to preservative substances contained. ''Pharmazie'' 1999 54:452–456. [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10399191&query_hl=1 Abstract]</ref><ref name=Contamination>Sakamoto, S., Sato, K., Maitani, T., Yamada, T. Analysis of components in natural food additive “grapefruit seed extract” by HPLC and LC/MS. ''Bull. Natl. Inst. Health Sci.'' 1996, 114:38–42. [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9037863&query_hl=1 Abstract]</ref><ref name=Adulteration>Takeoka, G.R., Dao, L.T., Wong, R.Y., Harden L.A. Identification of benzalkonium chloride in commercial grapefruit seed extracts. ''J Agric Food Chem.'' 2005 53(19):7630–6. [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16159196&query_hl=1 Abstract]</ref>

==== Delay in seeking conventional medical treatment ====
Those who have had success with one alternative therapy for a minor ailment may be convinced of its efficacy and persuaded to extrapolate that success to some other alternative therapy for a more serious, possibly life-threatening illness. For this reason, critics contend that therapies that rely on the placebo effect to define success are very dangerous. According to Lilienfeld (2002) "unvalidated or scientifically unsupported mental health practices can lead individuals to forgo effective treatments" and refers to this as “opportunity cost.” Individuals who spend large amounts of time and money on ineffective treatments may be left with precious little of either, and may forfeit the opportunity to obtain treatments that could be more helpful. In short, even innocuous treatments can indirectly produce negative consequences[http://www.srmhp.org/0101/raison-detre.html].

==== Danger can be increased when used as a complement to conventional medicine ====
A Norwegian multicentre study examined the association between the use of alternative medicine and cancer survival. 515 patients using standard medical care for cancer were followed for eight years. 22% of those patients used alternative medicine concurrently with their standard care. The study revealed that death rates were 30% higher in alternative medicine users than in those who did not use alternative medicine (AM): ''"The use of AM seems to predict a shorter survival from cancer."''<ref name=Risberg>Risberg T, et al. ''Does use of alternative medicine predict survival from cancer?'' Eur J Cancer 2003 Feb;39(3):372-7 [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Retrieve&list_uids=12565991&dopt=Citation]</ref>

Associate Professor Alastair MacLennan of the Department of Obstetrics and Gynaecology in Adelaide University, Australia reports that a patient of his almost bled to death on the operating table. She had failed to mention she had been taking "natural" potions to "build up her strength" for the operation - one of them turned out to be a powerful anticoagulant which nearly caused her death. [http://benhills.com/articles/articles/MED06a.html]

To ''ABC Online'', MacLennan also gives another possible mechanism:

: "''And lastly there’s the cynicism and disappointment and depression that some patients get from going on from one alternative medicine to the next, and they find after three months the placebo effect wears off, and they’re disappointed and they move on to the next one, and they’re disappointed and disillusioned, and that can create depression and make the eventual treatment of the patient with anything effective difficult, because you may not get compliance, because they’ve seen the failure so often in the past''". [http://www.abc.net.au/rn/talks/8.30/helthrpt/stories/s195441.htm]

==== Danger from undesired side-effects ====
Conventional treatments are subjected to testing for undesired [[Adverse effect (medicine)|side-effects]] (which may not, however, be revealed to the public in a timely manner), whereas alternative treatments generally are not subjected to such testing at all. However, any treatment — whether conventional or alternative — that has a biological or psychological impact on a patient may also have potentially dangerous biological or psychological side-effects. Nevertheless, attempts to refute this fact with regard to alternative treatments sometimes use the ''appeal to nature'' fallacy, i.e. "that which is natural cannot be harmful".

Homeopathy, however, is regarded as being safe in terms of such side effects since, according to known physics and chemistry, it cannot possibly have more effect on the patient than simple water does.

==== Danger related to self-medication ====
Similar problems as those related to [[self-medication]] also apply to parts of alternative medicine. For example, an alternative medicine may instantly make symptoms better, but actually worsen problems in the long run. The result may be [[addiction]] and deteriorating health.

==== Issues of regulation ====
Critics contend that some branches of alternative medicine are often not properly regulated in some countries to identify who practices or know what training or expertise they may possess. Critics argue that the governmental regulation of any particular alternative therapy does necessitate that the therapy is effective. The most sensible course in such a case could be to simply ensure that the sold treatment is not dangerous, but the problem would then remain to know if it does what its proponents say it does.

=== Explanations for efficacy of alternative medicine===

There are both social/cultural and psychological reasons:

Social or cultural reasons:

*the low level of scientific literacy among the public at large<ref name=Beyerstein>Beyerstein BL. ''[http://www.sram.org/0302/bias.html Psychology and 'Alternative Medicine' Social and Judgmental Biases That Make Inert Treatments Seem to Work.]'' The Scientific Review of Alternative Medicine/ Fall/Winter 1999 Volume 3 ~ Number 2</ref>
*an increase in anti-intellectualism and antiscientific attitudes riding on the coattails of new age mysticism<ref name=Beyerstein>Beyerstein BL. ''[http://www.sram.org/0302/bias.html Psychology and 'Alternative Medicine' Social and Judgmental Biases That Make Inert Treatments Seem to Work.]'' The Scientific Review of Alternative Medicine/ Fall/Winter 1999 Volume 3 ~ Number 2</ref>
*vigorous marketing of extravagant claims by the "alternative" medical community<ref name=Beyerstein>Beyerstein BL. ''[http://www.sram.org/0302/bias.html Psychology and 'Alternative Medicine' Social and Judgmental Biases That Make Inert Treatments Seem to Work.]'' The Scientific Review of Alternative Medicine/ Fall/Winter 1999 Volume 3 ~ Number 2</ref>
*inadequate media scrutiny and attacking critics<ref name=Beyerstein>Beyerstein BL. ''[http://www.sram.org/0302/bias.html Psychology and 'Alternative Medicine' Social and Judgmental Biases That Make Inert Treatments Seem to Work.]'' The Scientific Review of Alternative Medicine/ Fall/Winter 1999 Volume 3 ~ Number 2</ref>
*increasing social malaise (conspiracy theories) and mistrust of <ref name=Beyerstein>Beyerstein BL. ''[http://www.sram.org/0302/bias.html Psychology and 'Alternative Medicine' Social and Judgmental Biases That Make Inert Treatments Seem to Work.]'' The Scientific Review of Alternative Medicine/ Fall/Winter 1999 Volume 3 ~ Number 2</ref>traditional authority figures - the antidoctor backlash
*dislike of the delivery methods of scientific biomedicine.<ref name=Beyerstein>Beyerstein BL. ''[http://www.sram.org/0302/bias.html Psychology and 'Alternative Medicine' Social and Judgmental Biases That Make Inert Treatments Seem to Work.]'' The Scientific Review of Alternative Medicine/ Fall/Winter 1999 Volume 3 ~ Number 2</ref>

Psychological reasons:

*the [[placebo effect]]
*the will to believe<ref name=Beyerstein>Beyerstein BL. ''[http://www.sram.org/0302/bias.html Psychology and 'Alternative Medicine' Social and Judgmental Biases That Make Inert Treatments Seem to Work.]'' The Scientific Review of Alternative Medicine/ Fall/Winter 1999 Volume 3 ~ Number 2</ref>
*self-serving biases that help maintain self-esteem and promote harmonious social functioning<ref name=Beyerstein>Beyerstein BL. ''[http://www.sram.org/0302/bias.html Psychology and 'Alternative Medicine' Social and Judgmental Biases That Make Inert Treatments Seem to Work.]'' The Scientific Review of Alternative Medicine/ Fall/Winter 1999 Volume 3 ~ Number 2</ref>
*demand characteristics - the obligation to respond in kind when someone does them a good turn<ref name=Beyerstein>Beyerstein BL. ''[http://www.sram.org/0302/bias.html Psychology and 'Alternative Medicine' Social and Judgmental Biases That Make Inert Treatments Seem to Work.]'' The Scientific Review of Alternative Medicine/ Fall/Winter 1999 Volume 3 ~ Number 2</ref>
*post hoc, ergo propter hoc fallacy ("after this, therefore because of this"; the basis of most superstitious beliefs)<ref name=Beyerstein>Beyerstein BL. ''[http://www.sram.org/0302/bias.html Psychology and 'Alternative Medicine' Social and Judgmental Biases That Make Inert Treatments Seem to Work.]'' The Scientific Review of Alternative Medicine/ Fall/Winter 1999 Volume 3 ~ Number 2</ref>
*psychological distortion, such as confirmation bias<ref name=Beyerstein>Beyerstein BL. ''[http://www.sram.org/0302/bias.html Psychology and 'Alternative Medicine' Social and Judgmental Biases That Make Inert Treatments Seem to Work.]'' The Scientific Review of Alternative Medicine/ Fall/Winter 1999 Volume 3 ~ Number 2</ref> and Cognitive dissonance (inability to respond to criticism of alternative medicine in order to reduce one's cognitive dissonance)

== Integrative medicine ==
Integrative medicine is a branch of alternative medicine which claims to limit itself to methods with strong scientific evidence of efficacy and safety. The main proponent of integrative medicine is Andrew T. Weil M.D., who founded the Program in Integrative Medicine at the University of Arizona in 1994 based on a phras coined by Elson Haas, MD. It is claimed that responsible alternative health product providers who have had medical studies conducted on their products often publish these studies online.

== Notes ==
<div class="references-small"><references/></div>

==References==
# Barnes P, Powell-Griner E, McFann K, Nahin R. "Complementary and Alternative Medicine Use Among Adults: United States, 2002." ''Advanced data from vital health and statistics'' 2004; Hyattsville, Maryland:NCHS [http://nccam.nih.gov/news/report.pdf Online]
# Benedetti F, Maggi G, Lopiano L. "Open Versus Hidden Medical Treatments: The Patient's Knowledge About a Therapy Affects the Therapy Outcome." ''Prevention & Treatment'', 2003; '''6'''(1), [http://journals.apa.org/prevention/volume6/pre0060001a.html APA online]
# Downing AM, Hunter DG. "Validating clinical reasoning: a question of perspective, but whose perspective?" ''Man Ther'', 2003; '''8'''(2): 117-9. PMID 12890440 [http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WN0-487KJXH-3&_coverDate=05%2F31%2F2003&_alid=110095405&_rdoc=1&_fmt=&_orig=search&_qd=1&_cdi=6948&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=8da5eb9e5359691e31c6cee489724da8 Manual Therapy Online]
# Eisenberg DM. "Advising patients who seek alternative medical therapies." ''Ann Intern Med'' 1997; '''127''':61-69. PMID 9214254
# Gunn IP. "A critique of Michael L. Millenson's book, Demanding medical excellence: doctors and accountability in the information age, and its relevance to CRNAs and nursing." ''AANA J'', 1998 '''66'''(6):575-82. Review. PMID 10488264
# Lazarou, J. Pomeranz, BH. Corey, PN. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies, J of the American Medical Association 1998, 279, 1200-1205.
# Tonelli MR. "The limits of evidence-based medicine." ''Respir Care'', 2001; '''46'''(12): 1435-40; discussion 1440-1. Review. PMID 11728302 [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11863470 PMID: 11863470]
# Zalewski Z. "Importance of Philosophy of Science to the History of Medical Thinking." ''CMJ'' 1999; '''40''': 8-13. [http://www.bsb.mefst.hr/cmj/1999/4001/400102.htm CMJ online]

== Further reading ==
=== Dictionary definitions ===
* [http://cancerweb.ncl.ac.uk/cgi-bin/omd?query=Complementary+medicine&action=Search+OMD Complementary medicine]

=== World Health Organization publication ===
* [http://www.who.int/bookorders/anglais/detart1.jsp?sesslan=1&codlan=1&codcol=15&codcch=614 WHO Global Atlas of Traditional, Complementary and Alternative Medicine]

=== Journals dedicated to alternative medicine research ===
* Alternative therapies in health and medicine. Aliso Viejo, CA : InnoVision Communications, c1995- NLM ID: [http://locatorplus.gov/cgi-bin/Pwebrecon.cgi?DB=local&v2=1&ti=1,1&Search_Arg=9502013&Search_Code=0359&CNT=20&SID=1 9502013]
* Alternative medicine review : a journal of clinical therapeutic. Sandpoint, Idaho : Thorne Research, Inc., c1996- NLM ID: [http://locatorplus.gov/cgi-bin/Pwebrecon.cgi?DB=local&v2=1&ti=1,1&Search_Arg=9705340&Search_Code=0359&CNT=20&SID=1 9705340]
* [http://www.biomedcentral.com/1472-6882 BMC complementary and alternative medicine]. London : BioMed Central, 2001- NLM ID: [http://locatorplus.gov/cgi-bin/Pwebrecon.cgi?DB=local&v2=1&ti=1,1&Search_Arg=101088661&Search_Code=0359&CNT=20&SID=1 101088661]
* Complementary therapies in medicine. Edinburgh ; New York : Churchill Livingstone, c1993- NLM ID: [http://locatorplus.gov/cgi-bin/Pwebrecon.cgi?DB=local&v2=1&ti=1,1&Search_Arg=9308777&Search_Code=0359&CNT=20&SID=1 9308777]
* [http://ecam.oxfordjournals.org/ Evidence based complementary and alternative medicine]
* [http://www.openmindjournals.com/EBInteg.html Evidence Based journal of Integrative medicine]
* [http://www.jintmed.com/ Journal of Integrative medicine.]
* [http://www.liebertpub.com/publication.aspx?pub_id=26 Journal for Alternative and Complementary Medicine: research on paradigm, practice, and policy.] New York, NY : Mary Ann Liebert, Inc., c1995-]
* [http://www.sram.org/index.html Scientific Review of Alternative Medicine (SRAM)]

=== Other works that discuss alternative medicine ===

* Diamond, J. ''Snake Oil and Other Preoccupations'', 2001, ISBN 0-09-942833-4 , foreword by Richard Dawkins reprinted in Dawkins, R., ''A Devil's Chaplain'', 2003, ISBN 0-7538-1750-0 .
* Dillard, James and Terra Ziporyn. ''Alternative Medicine for Dummies''. Foster City, CA: IDG Books Worldwide, Inc., 1998.
* Goldberg, Burton. Anderson, John & Trivieri, Larry “Alternative Medicine: The Definitive Guide”, Ten Speed Press, 2002 ISBN 978-1587611414
* Hand, Wayland D. 1980 "Folk Magical Medicine and Symbolism in the West", in ''Magical Medicine'', Berkeley: University of California Press, pp. 305-319.
* Illich, Ivan. ''Limits to Medicine''. ''Medical Nemesis: The expropriation of Health''. Penguin Books, 1976.
* Ninivaggi, F. J., ''An Elementary Textbook of Ayurveda: Medicine with a Six Thousand Year Old Tradition'', International Universities/Psychosocial Press, Madison, CT, 2001.
* Pert, Candace B., ''Molecules of Emotion: Why You Feel the Way You Feel'', Scribners, 1997, ISBN 0-684-84634-9
* Phillips Stevens Jr. Nov./Dec. 2001 "Magical Thinking in Complementary and Alternative Medicine", ''Skeptical Inquirer Magazine'', Nov.Dec 2001
* Planer, Felix E. 1988 ''Superstition'', Revised ed. Buffalo, New York: Prometheus Books
* Rosenfeld, Anna, ''Where Do Americans Go for Healthcare?'', Case Western Reserve University, Cleveland, Ohio, USA.
* Trudeau, Kevin, ''Natural Cures "They" Don't Want You to Know About'', Alliance Publishing Group, ISBN 0-9755995-9-3; Mass Market Edition, 2007.
* Trudeau, Kevin, ''More Natural "Cures" Revealed'', Alliance Publishing Group, 2006, ISBN 0-9755995-4-2.
* Wisneski, Leonard A. and Lucy Anderson, ''The Scientific Basis of Integrative Medicine'', CRC Press, 2005. ISBN 0-8493-2081-X.

==See also==
*[[Medicine#Criticism|Criticism of medicine]]
*[[Pseudoscience]]
*[[Traditional medicine]]

==External links==

* [http://nccam.nih.gov/ The National Center for Complementary and Alternative Medicine] - US National Institutes of Health
* [http://www.nlm.nih.gov/nccam/camonpubmed.html Complementary and Alternative Medicine on PubMed] - Alternative Medicine Research Database
* [http://www.umm.edu/altmed Complementary and Alternative Medicine Index](from the University of Maryland Medical Center) - Comprehensive guide covering conditions and treatments
* [http://www.altcancerinfo.org/ Alternative Cancer Information ] - Hub of Peer-Reviewed literature on Prevention of Metastasis for Patients Diagnosed with Cancer
* Web pages for [http://www.open2.net/alternativemedicine/index.html new BBC/Open University television series "Alternative Medicine"] that examines the evidence scientifically.
* [http://www.bl.uk/collections/business/compmein.html The British Library - finding information on the complementary medicines industry]
* [http://www.shamanism.com The Huichol Indians] - learn more about ancient alternative medicine.
* [http://www.piedmontpmr.com/disease-management-reducing-total-load Total Load] - An Integrated Clinical Practice Model

=== Criticism ===

* [http://www.pbs.org/saf/1210/index.html A Different Way to Heal?] and [http://www.pbs.org/saf/1210/video/watchonline.htm Videos] - PBS, Scientific American Frontiers Web Feature
* [http://www.theness.com/articles.asp?id=1 What is Complementary and Alternative Medicine?] - By Steven Novella, MD
* [http://www.skepdic.com/althelth.html Skepdic Article on Alternative Medicine]
* [http://www.pbs.org/kcet/closertotruth/explore/show_11.html Who Gets to Validate Alternative Medicine] - PBS article
* [http://www.disgustingly-healthy.com Biotherapy with leeches and maggots]

=== Advocacy ===
* [http://www.herbological.com/images/downloads/HH2.pdf Medline and the mainstream manufacture of misinformation] Critique of the criticisms of alternative medicine




[[Category:Accuracy disputes#{{{1|}}}|Alternative medicine]]
[[Category:Alternative medicine|*0]]

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Ultrasound guided injections

2013-07-04T21:55:46Z

Bobby Schwartz: /* Related Chapters */

'''Editor-in-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.];

==Overview of Ultrasound==
'''Ultrasound''' is cyclic [[sound]] pressure with a [[frequency]] greater than the upper limit of [[human]] [[hearing (sense)|hearing]]. Although this limit varies from person to person, it is approximately 20 [[Hertz|kilohertz]] (20,000 hertz) in healthy, young adults and thus, 20 kHz serves as a useful lower limit in describing ultrasound. Ultrasound is manually produced in many different fields, typically to penetrate a medium and measure the reflection signature or supply focused energy. The reflection signature can reveal details about the inner structure of the medium. The most well known application of this technique is its use in sonography to produce pictures of fetuses in the human womb. There are a vast number of other applications as well.

'''Medical sonography''' ('''ultrasonography''')''' is an ultrasound-based diagnostic medical imaging technique used to visualize muscles, tendons, and many internal organs, their size, structure and any pathological lesions with real time tomographic images. It is one of the most widely used diagnostic tools in modern medicine. The technology is relatively inexpensive and portable, especially when compared with modalities such as magnetic resonance imaging(MRI) and computed tomography (CT). As currently applied in the medical environment, ultrasound poses no known risks to the patient. Utilizing ultrasound for guidance during injections is a relatively recent development compared to its use in medical diagnosis. The adoption of ultrasound guidance in clinical practice is increasing however and can be attributed to improvements in imaging technology.

==Clinical Indications==

The use of Ultrasound in Medicine has become widespread in recent years. Once only available in a select few Universities advances in technology and price reduction have made this technology more available in both community hospitals and in the office setting. Common uses include as a diagnostic tool in the abdomen, vascular studies including both arteries and veins, a wide array of musculoskeletal applications, and with endocrine disease such as thyroid disorders. Due to its non ionzing imaging ability, relatively low cost, and ease of portability Ultrasound has become more prevalent as a guidance tool for procedures including biopsy, catheter placement, and aspiration.

Given these advancements it is not surprising that the use of ultrasound guidance for percutaneous tenotomy, joint injection, a variety of nerve blocks, and other soft tissue injections has become more common place as well. While there is extensive literature on the use of Ultrasound for guidance in spinal injections there is still controversy over its use for spinal conditions. This seems to stem more from previous overstatements of its effectiveness in replacing MRI for spinal conditions then due to the more current literature that make use of it for para and extra spinal conditions and guidance.

==Ultrasound Guided Injections==

There has been a significant increase in the use of Ultrasound guidance for injections in the past several years. Initial acceptance was confined to peripheral structures such as nerve, tendon, joint capsule and spaces, and ligament with more recent moves toward plexus and then spinal guidance. As technology continues to improve image quality the advantages of Ultrasound guidance over other imaging studies such as flouroscopy or CT has become more compelling. Cost and time savings, ease of access, and non ionizing radiation are a few of the clear benefits.A body of literature now exists that clearly demonstrates the utility of Ultrasound to effectively visualize vertebral bodies, articular processes, lamina, intrathecal and lamaninar spaces. Level 1 support for Ultrasound guidance has been established for lumbar zygoapophysial joint injections, medial branch and dorsal ramus block.

==Safety and Efficacy==

Ultrasound enjoys a rather unique position among imaging modalities due to its capabilities that do not rely upon non ionizing radiation as compared to flouroscopy or CT scanning. The presence of artificial joints or pacemakers are also not a problem with Ultrasound as compared to MRI. Ultrasound guidance for injections has proven itself to be very safe and offers clinicians in the emergency room, office setting, or in the operating room an opportunity to both identify the target structure accurately while providing a greater level of patient safety through avoidance of traumatizing unintended structures such as near by arteries.

==Controversies in Ultrasound Guidance for Injections==

While there is community agreement that certain kinds of spinal injections such as transformanal epidurals require an imaging modality such as flouroscopy despite a rather extensive body of literature supporting the use of Ultrasound guidance for paraspinal, sacroiliac, translaminar epidural steroids and caudal injections. Ultrasound guidance for spinal injections has still not gained full community support. None the less the trend is clear and overtime Ultrasound utilization for these procedures has only increased. It is difficult to understand how on the one had there may be no controversy over Ultrasound's capability to identify the target structure and concurrently on the other hand there are still those who dont embrace Ultrasound's utility in guidance for injection of the same structures.

==Related Chapters==

[[Musculoskeletal Ultrasound]]

[[Back Pain]]

[[Low back pain]]

[[Prolotherapy]]

[[Sacrum]]

==References==
Accuracy of Ultrasound-guided Nerve Blocks of the Cervical Zygopophysial Joints, A Seigenthaler, MD, et al, Anesthesiology, V117, no 2, 347-352, August 2012.

Ultrasonography in Pain Medicine: Opening the Third Eye,J. Ballantyne, MD, et al, Pain Clinical Updates, IASP, Vol XX, Issue 4, 1-7, June 2012.

The Am.J Phy. Med. Rehab. Vol 90, No. 10, Oct 2011, pages 860-867, "Ultrasound -Guided Injection Techniques for the Low Back and Hip Joint".

Anesthesiology, C 115, no 1, pg 94, July 2011.

Ultrasound Imaging for Regional Anesthesia: A Practical Guide Booklet, Third edition, Ultrasound for Regional Anesthesia.

US Guided SI Joint Injection Technique,Dominic Harmon, Pain Physician 2008; 11:543-547.

Advanced Ultrasound Imaging in Pain Medicine,Michael Gofeld, Pain Medicine News, Dec 2011, pgs 14-20.

The Changing role of Ultrasonography in Pain Medicine, Michael Gofeld, MD, Pain Medicine News, April 2012, Pgs 1-7.

Ultrasound-guided cervical selective nerve root Block: A flouroscopy controlled feasibility study. Narouze SN, Reg Anesth Pain Med. 2009; 34(4):343-348.

Ultrasound guided medial branch block in obese patients: A flouroscopy confirmed clinical feasibility study. Reg Anesth Pain Med, . 2009; 34(4):340-342

Ultrasonography in Pain Medicine: a critical review. Pain Pract. 2008:8(4):226-240

Ultrasonography of the hip and Lower extremity: Gerald Malanga, PMR Clinics of N America, 8/2010, vol 21, no 3; pgs 533-47.

Feasibility of ultrasound guided sacroiliac joint injection considering sonoanatomic landmarks at two different levels in cadavers and patients. Klauser, A. Arthritis Rheum 2008:59 (11): 1618-24'''

==External Links==
*[http://www.piedmontpmr.com/injectiontypes/ Injection Types]

Ultrasound guided injections

2013-07-04T21:55:16Z

Bobby Schwartz: /* Related Chapters */

'''Editor-in-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.];

==Overview of Ultrasound==
'''Ultrasound''' is cyclic [[sound]] pressure with a [[frequency]] greater than the upper limit of [[human]] [[hearing (sense)|hearing]]. Although this limit varies from person to person, it is approximately 20 [[Hertz|kilohertz]] (20,000 hertz) in healthy, young adults and thus, 20 kHz serves as a useful lower limit in describing ultrasound. Ultrasound is manually produced in many different fields, typically to penetrate a medium and measure the reflection signature or supply focused energy. The reflection signature can reveal details about the inner structure of the medium. The most well known application of this technique is its use in sonography to produce pictures of fetuses in the human womb. There are a vast number of other applications as well.

'''Medical sonography''' ('''ultrasonography''')''' is an ultrasound-based diagnostic medical imaging technique used to visualize muscles, tendons, and many internal organs, their size, structure and any pathological lesions with real time tomographic images. It is one of the most widely used diagnostic tools in modern medicine. The technology is relatively inexpensive and portable, especially when compared with modalities such as magnetic resonance imaging(MRI) and computed tomography (CT). As currently applied in the medical environment, ultrasound poses no known risks to the patient. Utilizing ultrasound for guidance during injections is a relatively recent development compared to its use in medical diagnosis. The adoption of ultrasound guidance in clinical practice is increasing however and can be attributed to improvements in imaging technology.

==Clinical Indications==

The use of Ultrasound in Medicine has become widespread in recent years. Once only available in a select few Universities advances in technology and price reduction have made this technology more available in both community hospitals and in the office setting. Common uses include as a diagnostic tool in the abdomen, vascular studies including both arteries and veins, a wide array of musculoskeletal applications, and with endocrine disease such as thyroid disorders. Due to its non ionzing imaging ability, relatively low cost, and ease of portability Ultrasound has become more prevalent as a guidance tool for procedures including biopsy, catheter placement, and aspiration.

Given these advancements it is not surprising that the use of ultrasound guidance for percutaneous tenotomy, joint injection, a variety of nerve blocks, and other soft tissue injections has become more common place as well. While there is extensive literature on the use of Ultrasound for guidance in spinal injections there is still controversy over its use for spinal conditions. This seems to stem more from previous overstatements of its effectiveness in replacing MRI for spinal conditions then due to the more current literature that make use of it for para and extra spinal conditions and guidance.

==Ultrasound Guided Injections==

There has been a significant increase in the use of Ultrasound guidance for injections in the past several years. Initial acceptance was confined to peripheral structures such as nerve, tendon, joint capsule and spaces, and ligament with more recent moves toward plexus and then spinal guidance. As technology continues to improve image quality the advantages of Ultrasound guidance over other imaging studies such as flouroscopy or CT has become more compelling. Cost and time savings, ease of access, and non ionizing radiation are a few of the clear benefits.A body of literature now exists that clearly demonstrates the utility of Ultrasound to effectively visualize vertebral bodies, articular processes, lamina, intrathecal and lamaninar spaces. Level 1 support for Ultrasound guidance has been established for lumbar zygoapophysial joint injections, medial branch and dorsal ramus block.

==Safety and Efficacy==

Ultrasound enjoys a rather unique position among imaging modalities due to its capabilities that do not rely upon non ionizing radiation as compared to flouroscopy or CT scanning. The presence of artificial joints or pacemakers are also not a problem with Ultrasound as compared to MRI. Ultrasound guidance for injections has proven itself to be very safe and offers clinicians in the emergency room, office setting, or in the operating room an opportunity to both identify the target structure accurately while providing a greater level of patient safety through avoidance of traumatizing unintended structures such as near by arteries.

==Controversies in Ultrasound Guidance for Injections==

While there is community agreement that certain kinds of spinal injections such as transformanal epidurals require an imaging modality such as flouroscopy despite a rather extensive body of literature supporting the use of Ultrasound guidance for paraspinal, sacroiliac, translaminar epidural steroids and caudal injections. Ultrasound guidance for spinal injections has still not gained full community support. None the less the trend is clear and overtime Ultrasound utilization for these procedures has only increased. It is difficult to understand how on the one had there may be no controversy over Ultrasound's capability to identify the target structure and concurrently on the other hand there are still those who dont embrace Ultrasound's utility in guidance for injection of the same structures.

==Related Chapters==

[[Musculoskeletal Ultrasound]].

[[Back Pain]].
[[Low back pain]].
[[Prolotherapy]].
[[Sacrum]].

==References==
Accuracy of Ultrasound-guided Nerve Blocks of the Cervical Zygopophysial Joints, A Seigenthaler, MD, et al, Anesthesiology, V117, no 2, 347-352, August 2012.

Ultrasonography in Pain Medicine: Opening the Third Eye,J. Ballantyne, MD, et al, Pain Clinical Updates, IASP, Vol XX, Issue 4, 1-7, June 2012.

The Am.J Phy. Med. Rehab. Vol 90, No. 10, Oct 2011, pages 860-867, "Ultrasound -Guided Injection Techniques for the Low Back and Hip Joint".

Anesthesiology, C 115, no 1, pg 94, July 2011.

Ultrasound Imaging for Regional Anesthesia: A Practical Guide Booklet, Third edition, Ultrasound for Regional Anesthesia.

US Guided SI Joint Injection Technique,Dominic Harmon, Pain Physician 2008; 11:543-547.

Advanced Ultrasound Imaging in Pain Medicine,Michael Gofeld, Pain Medicine News, Dec 2011, pgs 14-20.

The Changing role of Ultrasonography in Pain Medicine, Michael Gofeld, MD, Pain Medicine News, April 2012, Pgs 1-7.

Ultrasound-guided cervical selective nerve root Block: A flouroscopy controlled feasibility study. Narouze SN, Reg Anesth Pain Med. 2009; 34(4):343-348.

Ultrasound guided medial branch block in obese patients: A flouroscopy confirmed clinical feasibility study. Reg Anesth Pain Med, . 2009; 34(4):340-342

Ultrasonography in Pain Medicine: a critical review. Pain Pract. 2008:8(4):226-240

Ultrasonography of the hip and Lower extremity: Gerald Malanga, PMR Clinics of N America, 8/2010, vol 21, no 3; pgs 533-47.

Feasibility of ultrasound guided sacroiliac joint injection considering sonoanatomic landmarks at two different levels in cadavers and patients. Klauser, A. Arthritis Rheum 2008:59 (11): 1618-24'''

==External Links==
*[http://www.piedmontpmr.com/injectiontypes/ Injection Types]

Ultrasound guided injections

2013-07-04T21:54:44Z

Bobby Schwartz: /* Related Chapters */

'''Editor-in-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.];

==Overview of Ultrasound==
'''Ultrasound''' is cyclic [[sound]] pressure with a [[frequency]] greater than the upper limit of [[human]] [[hearing (sense)|hearing]]. Although this limit varies from person to person, it is approximately 20 [[Hertz|kilohertz]] (20,000 hertz) in healthy, young adults and thus, 20 kHz serves as a useful lower limit in describing ultrasound. Ultrasound is manually produced in many different fields, typically to penetrate a medium and measure the reflection signature or supply focused energy. The reflection signature can reveal details about the inner structure of the medium. The most well known application of this technique is its use in sonography to produce pictures of fetuses in the human womb. There are a vast number of other applications as well.

'''Medical sonography''' ('''ultrasonography''')''' is an ultrasound-based diagnostic medical imaging technique used to visualize muscles, tendons, and many internal organs, their size, structure and any pathological lesions with real time tomographic images. It is one of the most widely used diagnostic tools in modern medicine. The technology is relatively inexpensive and portable, especially when compared with modalities such as magnetic resonance imaging(MRI) and computed tomography (CT). As currently applied in the medical environment, ultrasound poses no known risks to the patient. Utilizing ultrasound for guidance during injections is a relatively recent development compared to its use in medical diagnosis. The adoption of ultrasound guidance in clinical practice is increasing however and can be attributed to improvements in imaging technology.

==Clinical Indications==

The use of Ultrasound in Medicine has become widespread in recent years. Once only available in a select few Universities advances in technology and price reduction have made this technology more available in both community hospitals and in the office setting. Common uses include as a diagnostic tool in the abdomen, vascular studies including both arteries and veins, a wide array of musculoskeletal applications, and with endocrine disease such as thyroid disorders. Due to its non ionzing imaging ability, relatively low cost, and ease of portability Ultrasound has become more prevalent as a guidance tool for procedures including biopsy, catheter placement, and aspiration.

Given these advancements it is not surprising that the use of ultrasound guidance for percutaneous tenotomy, joint injection, a variety of nerve blocks, and other soft tissue injections has become more common place as well. While there is extensive literature on the use of Ultrasound for guidance in spinal injections there is still controversy over its use for spinal conditions. This seems to stem more from previous overstatements of its effectiveness in replacing MRI for spinal conditions then due to the more current literature that make use of it for para and extra spinal conditions and guidance.

==Ultrasound Guided Injections==

There has been a significant increase in the use of Ultrasound guidance for injections in the past several years. Initial acceptance was confined to peripheral structures such as nerve, tendon, joint capsule and spaces, and ligament with more recent moves toward plexus and then spinal guidance. As technology continues to improve image quality the advantages of Ultrasound guidance over other imaging studies such as flouroscopy or CT has become more compelling. Cost and time savings, ease of access, and non ionizing radiation are a few of the clear benefits.A body of literature now exists that clearly demonstrates the utility of Ultrasound to effectively visualize vertebral bodies, articular processes, lamina, intrathecal and lamaninar spaces. Level 1 support for Ultrasound guidance has been established for lumbar zygoapophysial joint injections, medial branch and dorsal ramus block.

==Safety and Efficacy==

Ultrasound enjoys a rather unique position among imaging modalities due to its capabilities that do not rely upon non ionizing radiation as compared to flouroscopy or CT scanning. The presence of artificial joints or pacemakers are also not a problem with Ultrasound as compared to MRI. Ultrasound guidance for injections has proven itself to be very safe and offers clinicians in the emergency room, office setting, or in the operating room an opportunity to both identify the target structure accurately while providing a greater level of patient safety through avoidance of traumatizing unintended structures such as near by arteries.

==Controversies in Ultrasound Guidance for Injections==

While there is community agreement that certain kinds of spinal injections such as transformanal epidurals require an imaging modality such as flouroscopy despite a rather extensive body of literature supporting the use of Ultrasound guidance for paraspinal, sacroiliac, translaminar epidural steroids and caudal injections. Ultrasound guidance for spinal injections has still not gained full community support. None the less the trend is clear and overtime Ultrasound utilization for these procedures has only increased. It is difficult to understand how on the one had there may be no controversy over Ultrasound's capability to identify the target structure and concurrently on the other hand there are still those who dont embrace Ultrasound's utility in guidance for injection of the same structures.

==Related Chapters==

[[Musculoskeletal Ultrasound]];
[[Back Pain]].
[[Low back pain]].
[[Prolotherapy]].
[[Sacrum]].

==References==
Accuracy of Ultrasound-guided Nerve Blocks of the Cervical Zygopophysial Joints, A Seigenthaler, MD, et al, Anesthesiology, V117, no 2, 347-352, August 2012.

Ultrasonography in Pain Medicine: Opening the Third Eye,J. Ballantyne, MD, et al, Pain Clinical Updates, IASP, Vol XX, Issue 4, 1-7, June 2012.

The Am.J Phy. Med. Rehab. Vol 90, No. 10, Oct 2011, pages 860-867, "Ultrasound -Guided Injection Techniques for the Low Back and Hip Joint".

Anesthesiology, C 115, no 1, pg 94, July 2011.

Ultrasound Imaging for Regional Anesthesia: A Practical Guide Booklet, Third edition, Ultrasound for Regional Anesthesia.

US Guided SI Joint Injection Technique,Dominic Harmon, Pain Physician 2008; 11:543-547.

Advanced Ultrasound Imaging in Pain Medicine,Michael Gofeld, Pain Medicine News, Dec 2011, pgs 14-20.

The Changing role of Ultrasonography in Pain Medicine, Michael Gofeld, MD, Pain Medicine News, April 2012, Pgs 1-7.

Ultrasound-guided cervical selective nerve root Block: A flouroscopy controlled feasibility study. Narouze SN, Reg Anesth Pain Med. 2009; 34(4):343-348.

Ultrasound guided medial branch block in obese patients: A flouroscopy confirmed clinical feasibility study. Reg Anesth Pain Med, . 2009; 34(4):340-342

Ultrasonography in Pain Medicine: a critical review. Pain Pract. 2008:8(4):226-240

Ultrasonography of the hip and Lower extremity: Gerald Malanga, PMR Clinics of N America, 8/2010, vol 21, no 3; pgs 533-47.

Feasibility of ultrasound guided sacroiliac joint injection considering sonoanatomic landmarks at two different levels in cadavers and patients. Klauser, A. Arthritis Rheum 2008:59 (11): 1618-24'''

==External Links==
*[http://www.piedmontpmr.com/injectiontypes/ Injection Types]

Ultrasound guided injections

2013-07-04T21:54:28Z

Bobby Schwartz: /* Related Chapters */

'''Editor-in-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.];

==Overview of Ultrasound==
'''Ultrasound''' is cyclic [[sound]] pressure with a [[frequency]] greater than the upper limit of [[human]] [[hearing (sense)|hearing]]. Although this limit varies from person to person, it is approximately 20 [[Hertz|kilohertz]] (20,000 hertz) in healthy, young adults and thus, 20 kHz serves as a useful lower limit in describing ultrasound. Ultrasound is manually produced in many different fields, typically to penetrate a medium and measure the reflection signature or supply focused energy. The reflection signature can reveal details about the inner structure of the medium. The most well known application of this technique is its use in sonography to produce pictures of fetuses in the human womb. There are a vast number of other applications as well.

'''Medical sonography''' ('''ultrasonography''')''' is an ultrasound-based diagnostic medical imaging technique used to visualize muscles, tendons, and many internal organs, their size, structure and any pathological lesions with real time tomographic images. It is one of the most widely used diagnostic tools in modern medicine. The technology is relatively inexpensive and portable, especially when compared with modalities such as magnetic resonance imaging(MRI) and computed tomography (CT). As currently applied in the medical environment, ultrasound poses no known risks to the patient. Utilizing ultrasound for guidance during injections is a relatively recent development compared to its use in medical diagnosis. The adoption of ultrasound guidance in clinical practice is increasing however and can be attributed to improvements in imaging technology.

==Clinical Indications==

The use of Ultrasound in Medicine has become widespread in recent years. Once only available in a select few Universities advances in technology and price reduction have made this technology more available in both community hospitals and in the office setting. Common uses include as a diagnostic tool in the abdomen, vascular studies including both arteries and veins, a wide array of musculoskeletal applications, and with endocrine disease such as thyroid disorders. Due to its non ionzing imaging ability, relatively low cost, and ease of portability Ultrasound has become more prevalent as a guidance tool for procedures including biopsy, catheter placement, and aspiration.

Given these advancements it is not surprising that the use of ultrasound guidance for percutaneous tenotomy, joint injection, a variety of nerve blocks, and other soft tissue injections has become more common place as well. While there is extensive literature on the use of Ultrasound for guidance in spinal injections there is still controversy over its use for spinal conditions. This seems to stem more from previous overstatements of its effectiveness in replacing MRI for spinal conditions then due to the more current literature that make use of it for para and extra spinal conditions and guidance.

==Ultrasound Guided Injections==

There has been a significant increase in the use of Ultrasound guidance for injections in the past several years. Initial acceptance was confined to peripheral structures such as nerve, tendon, joint capsule and spaces, and ligament with more recent moves toward plexus and then spinal guidance. As technology continues to improve image quality the advantages of Ultrasound guidance over other imaging studies such as flouroscopy or CT has become more compelling. Cost and time savings, ease of access, and non ionizing radiation are a few of the clear benefits.A body of literature now exists that clearly demonstrates the utility of Ultrasound to effectively visualize vertebral bodies, articular processes, lamina, intrathecal and lamaninar spaces. Level 1 support for Ultrasound guidance has been established for lumbar zygoapophysial joint injections, medial branch and dorsal ramus block.

==Safety and Efficacy==

Ultrasound enjoys a rather unique position among imaging modalities due to its capabilities that do not rely upon non ionizing radiation as compared to flouroscopy or CT scanning. The presence of artificial joints or pacemakers are also not a problem with Ultrasound as compared to MRI. Ultrasound guidance for injections has proven itself to be very safe and offers clinicians in the emergency room, office setting, or in the operating room an opportunity to both identify the target structure accurately while providing a greater level of patient safety through avoidance of traumatizing unintended structures such as near by arteries.

==Controversies in Ultrasound Guidance for Injections==

While there is community agreement that certain kinds of spinal injections such as transformanal epidurals require an imaging modality such as flouroscopy despite a rather extensive body of literature supporting the use of Ultrasound guidance for paraspinal, sacroiliac, translaminar epidural steroids and caudal injections. Ultrasound guidance for spinal injections has still not gained full community support. None the less the trend is clear and overtime Ultrasound utilization for these procedures has only increased. It is difficult to understand how on the one had there may be no controversy over Ultrasound's capability to identify the target structure and concurrently on the other hand there are still those who dont embrace Ultrasound's utility in guidance for injection of the same structures.

==Related Chapters==

[[Musculoskeletal Ultrasound]].
[[Back Pain]].
[[Low back pain]].
[[Prolotherapy]].
[[Sacrum]].

==References==
Accuracy of Ultrasound-guided Nerve Blocks of the Cervical Zygopophysial Joints, A Seigenthaler, MD, et al, Anesthesiology, V117, no 2, 347-352, August 2012.

Ultrasonography in Pain Medicine: Opening the Third Eye,J. Ballantyne, MD, et al, Pain Clinical Updates, IASP, Vol XX, Issue 4, 1-7, June 2012.

The Am.J Phy. Med. Rehab. Vol 90, No. 10, Oct 2011, pages 860-867, "Ultrasound -Guided Injection Techniques for the Low Back and Hip Joint".

Anesthesiology, C 115, no 1, pg 94, July 2011.

Ultrasound Imaging for Regional Anesthesia: A Practical Guide Booklet, Third edition, Ultrasound for Regional Anesthesia.

US Guided SI Joint Injection Technique,Dominic Harmon, Pain Physician 2008; 11:543-547.

Advanced Ultrasound Imaging in Pain Medicine,Michael Gofeld, Pain Medicine News, Dec 2011, pgs 14-20.

The Changing role of Ultrasonography in Pain Medicine, Michael Gofeld, MD, Pain Medicine News, April 2012, Pgs 1-7.

Ultrasound-guided cervical selective nerve root Block: A flouroscopy controlled feasibility study. Narouze SN, Reg Anesth Pain Med. 2009; 34(4):343-348.

Ultrasound guided medial branch block in obese patients: A flouroscopy confirmed clinical feasibility study. Reg Anesth Pain Med, . 2009; 34(4):340-342

Ultrasonography in Pain Medicine: a critical review. Pain Pract. 2008:8(4):226-240

Ultrasonography of the hip and Lower extremity: Gerald Malanga, PMR Clinics of N America, 8/2010, vol 21, no 3; pgs 533-47.

Feasibility of ultrasound guided sacroiliac joint injection considering sonoanatomic landmarks at two different levels in cadavers and patients. Klauser, A. Arthritis Rheum 2008:59 (11): 1618-24'''

==External Links==
*[http://www.piedmontpmr.com/injectiontypes/ Injection Types]

Ultrasound guided injections

2013-07-04T21:53:02Z

Bobby Schwartz: /* Related Chapters */

'''Editor-in-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.];

==Overview of Ultrasound==
'''Ultrasound''' is cyclic [[sound]] pressure with a [[frequency]] greater than the upper limit of [[human]] [[hearing (sense)|hearing]]. Although this limit varies from person to person, it is approximately 20 [[Hertz|kilohertz]] (20,000 hertz) in healthy, young adults and thus, 20 kHz serves as a useful lower limit in describing ultrasound. Ultrasound is manually produced in many different fields, typically to penetrate a medium and measure the reflection signature or supply focused energy. The reflection signature can reveal details about the inner structure of the medium. The most well known application of this technique is its use in sonography to produce pictures of fetuses in the human womb. There are a vast number of other applications as well.

'''Medical sonography''' ('''ultrasonography''')''' is an ultrasound-based diagnostic medical imaging technique used to visualize muscles, tendons, and many internal organs, their size, structure and any pathological lesions with real time tomographic images. It is one of the most widely used diagnostic tools in modern medicine. The technology is relatively inexpensive and portable, especially when compared with modalities such as magnetic resonance imaging(MRI) and computed tomography (CT). As currently applied in the medical environment, ultrasound poses no known risks to the patient. Utilizing ultrasound for guidance during injections is a relatively recent development compared to its use in medical diagnosis. The adoption of ultrasound guidance in clinical practice is increasing however and can be attributed to improvements in imaging technology.

==Clinical Indications==

The use of Ultrasound in Medicine has become widespread in recent years. Once only available in a select few Universities advances in technology and price reduction have made this technology more available in both community hospitals and in the office setting. Common uses include as a diagnostic tool in the abdomen, vascular studies including both arteries and veins, a wide array of musculoskeletal applications, and with endocrine disease such as thyroid disorders. Due to its non ionzing imaging ability, relatively low cost, and ease of portability Ultrasound has become more prevalent as a guidance tool for procedures including biopsy, catheter placement, and aspiration.

Given these advancements it is not surprising that the use of ultrasound guidance for percutaneous tenotomy, joint injection, a variety of nerve blocks, and other soft tissue injections has become more common place as well. While there is extensive literature on the use of Ultrasound for guidance in spinal injections there is still controversy over its use for spinal conditions. This seems to stem more from previous overstatements of its effectiveness in replacing MRI for spinal conditions then due to the more current literature that make use of it for para and extra spinal conditions and guidance.

==Ultrasound Guided Injections==

There has been a significant increase in the use of Ultrasound guidance for injections in the past several years. Initial acceptance was confined to peripheral structures such as nerve, tendon, joint capsule and spaces, and ligament with more recent moves toward plexus and then spinal guidance. As technology continues to improve image quality the advantages of Ultrasound guidance over other imaging studies such as flouroscopy or CT has become more compelling. Cost and time savings, ease of access, and non ionizing radiation are a few of the clear benefits.A body of literature now exists that clearly demonstrates the utility of Ultrasound to effectively visualize vertebral bodies, articular processes, lamina, intrathecal and lamaninar spaces. Level 1 support for Ultrasound guidance has been established for lumbar zygoapophysial joint injections, medial branch and dorsal ramus block.

==Safety and Efficacy==

Ultrasound enjoys a rather unique position among imaging modalities due to its capabilities that do not rely upon non ionizing radiation as compared to flouroscopy or CT scanning. The presence of artificial joints or pacemakers are also not a problem with Ultrasound as compared to MRI. Ultrasound guidance for injections has proven itself to be very safe and offers clinicians in the emergency room, office setting, or in the operating room an opportunity to both identify the target structure accurately while providing a greater level of patient safety through avoidance of traumatizing unintended structures such as near by arteries.

==Controversies in Ultrasound Guidance for Injections==

While there is community agreement that certain kinds of spinal injections such as transformanal epidurals require an imaging modality such as flouroscopy despite a rather extensive body of literature supporting the use of Ultrasound guidance for paraspinal, sacroiliac, translaminar epidural steroids and caudal injections. Ultrasound guidance for spinal injections has still not gained full community support. None the less the trend is clear and overtime Ultrasound utilization for these procedures has only increased. It is difficult to understand how on the one had there may be no controversy over Ultrasound's capability to identify the target structure and concurrently on the other hand there are still those who dont embrace Ultrasound's utility in guidance for injection of the same structures.

==Related Chapters==

[[Musculoskeletal Ultrasound]],
[[Back Pain]],
[[Low back pain]],
[[Prolotherapy]],
[[Sacrum]]

==References==
Accuracy of Ultrasound-guided Nerve Blocks of the Cervical Zygopophysial Joints, A Seigenthaler, MD, et al, Anesthesiology, V117, no 2, 347-352, August 2012.

Ultrasonography in Pain Medicine: Opening the Third Eye,J. Ballantyne, MD, et al, Pain Clinical Updates, IASP, Vol XX, Issue 4, 1-7, June 2012.

The Am.J Phy. Med. Rehab. Vol 90, No. 10, Oct 2011, pages 860-867, "Ultrasound -Guided Injection Techniques for the Low Back and Hip Joint".

Anesthesiology, C 115, no 1, pg 94, July 2011.

Ultrasound Imaging for Regional Anesthesia: A Practical Guide Booklet, Third edition, Ultrasound for Regional Anesthesia.

US Guided SI Joint Injection Technique,Dominic Harmon, Pain Physician 2008; 11:543-547.

Advanced Ultrasound Imaging in Pain Medicine,Michael Gofeld, Pain Medicine News, Dec 2011, pgs 14-20.

The Changing role of Ultrasonography in Pain Medicine, Michael Gofeld, MD, Pain Medicine News, April 2012, Pgs 1-7.

Ultrasound-guided cervical selective nerve root Block: A flouroscopy controlled feasibility study. Narouze SN, Reg Anesth Pain Med. 2009; 34(4):343-348.

Ultrasound guided medial branch block in obese patients: A flouroscopy confirmed clinical feasibility study. Reg Anesth Pain Med, . 2009; 34(4):340-342

Ultrasonography in Pain Medicine: a critical review. Pain Pract. 2008:8(4):226-240

Ultrasonography of the hip and Lower extremity: Gerald Malanga, PMR Clinics of N America, 8/2010, vol 21, no 3; pgs 533-47.

Feasibility of ultrasound guided sacroiliac joint injection considering sonoanatomic landmarks at two different levels in cadavers and patients. Klauser, A. Arthritis Rheum 2008:59 (11): 1618-24'''

==External Links==
*[http://www.piedmontpmr.com/injectiontypes/ Injection Types]

Ultrasound guided injections

2013-07-04T21:52:37Z

Bobby Schwartz: /* Overview of Ultrasound */

'''Editor-in-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.];

==Overview of Ultrasound==
'''Ultrasound''' is cyclic [[sound]] pressure with a [[frequency]] greater than the upper limit of [[human]] [[hearing (sense)|hearing]]. Although this limit varies from person to person, it is approximately 20 [[Hertz|kilohertz]] (20,000 hertz) in healthy, young adults and thus, 20 kHz serves as a useful lower limit in describing ultrasound. Ultrasound is manually produced in many different fields, typically to penetrate a medium and measure the reflection signature or supply focused energy. The reflection signature can reveal details about the inner structure of the medium. The most well known application of this technique is its use in sonography to produce pictures of fetuses in the human womb. There are a vast number of other applications as well.

'''Medical sonography''' ('''ultrasonography''')''' is an ultrasound-based diagnostic medical imaging technique used to visualize muscles, tendons, and many internal organs, their size, structure and any pathological lesions with real time tomographic images. It is one of the most widely used diagnostic tools in modern medicine. The technology is relatively inexpensive and portable, especially when compared with modalities such as magnetic resonance imaging(MRI) and computed tomography (CT). As currently applied in the medical environment, ultrasound poses no known risks to the patient. Utilizing ultrasound for guidance during injections is a relatively recent development compared to its use in medical diagnosis. The adoption of ultrasound guidance in clinical practice is increasing however and can be attributed to improvements in imaging technology.

==Clinical Indications==

The use of Ultrasound in Medicine has become widespread in recent years. Once only available in a select few Universities advances in technology and price reduction have made this technology more available in both community hospitals and in the office setting. Common uses include as a diagnostic tool in the abdomen, vascular studies including both arteries and veins, a wide array of musculoskeletal applications, and with endocrine disease such as thyroid disorders. Due to its non ionzing imaging ability, relatively low cost, and ease of portability Ultrasound has become more prevalent as a guidance tool for procedures including biopsy, catheter placement, and aspiration.

Given these advancements it is not surprising that the use of ultrasound guidance for percutaneous tenotomy, joint injection, a variety of nerve blocks, and other soft tissue injections has become more common place as well. While there is extensive literature on the use of Ultrasound for guidance in spinal injections there is still controversy over its use for spinal conditions. This seems to stem more from previous overstatements of its effectiveness in replacing MRI for spinal conditions then due to the more current literature that make use of it for para and extra spinal conditions and guidance.

==Ultrasound Guided Injections==

There has been a significant increase in the use of Ultrasound guidance for injections in the past several years. Initial acceptance was confined to peripheral structures such as nerve, tendon, joint capsule and spaces, and ligament with more recent moves toward plexus and then spinal guidance. As technology continues to improve image quality the advantages of Ultrasound guidance over other imaging studies such as flouroscopy or CT has become more compelling. Cost and time savings, ease of access, and non ionizing radiation are a few of the clear benefits.A body of literature now exists that clearly demonstrates the utility of Ultrasound to effectively visualize vertebral bodies, articular processes, lamina, intrathecal and lamaninar spaces. Level 1 support for Ultrasound guidance has been established for lumbar zygoapophysial joint injections, medial branch and dorsal ramus block.

==Safety and Efficacy==

Ultrasound enjoys a rather unique position among imaging modalities due to its capabilities that do not rely upon non ionizing radiation as compared to flouroscopy or CT scanning. The presence of artificial joints or pacemakers are also not a problem with Ultrasound as compared to MRI. Ultrasound guidance for injections has proven itself to be very safe and offers clinicians in the emergency room, office setting, or in the operating room an opportunity to both identify the target structure accurately while providing a greater level of patient safety through avoidance of traumatizing unintended structures such as near by arteries.

==Controversies in Ultrasound Guidance for Injections==

While there is community agreement that certain kinds of spinal injections such as transformanal epidurals require an imaging modality such as flouroscopy despite a rather extensive body of literature supporting the use of Ultrasound guidance for paraspinal, sacroiliac, translaminar epidural steroids and caudal injections. Ultrasound guidance for spinal injections has still not gained full community support. None the less the trend is clear and overtime Ultrasound utilization for these procedures has only increased. It is difficult to understand how on the one had there may be no controversy over Ultrasound's capability to identify the target structure and concurrently on the other hand there are still those who dont embrace Ultrasound's utility in guidance for injection of the same structures.

==Related Chapters==

[[Musculoskeletal Ultrasound]]
[[Back Pain]]
[[Low back pain]]
[[Prolotherapy]]
[[Sacrum]]

==References==
Accuracy of Ultrasound-guided Nerve Blocks of the Cervical Zygopophysial Joints, A Seigenthaler, MD, et al, Anesthesiology, V117, no 2, 347-352, August 2012.

Ultrasonography in Pain Medicine: Opening the Third Eye,J. Ballantyne, MD, et al, Pain Clinical Updates, IASP, Vol XX, Issue 4, 1-7, June 2012.

The Am.J Phy. Med. Rehab. Vol 90, No. 10, Oct 2011, pages 860-867, "Ultrasound -Guided Injection Techniques for the Low Back and Hip Joint".

Anesthesiology, C 115, no 1, pg 94, July 2011.

Ultrasound Imaging for Regional Anesthesia: A Practical Guide Booklet, Third edition, Ultrasound for Regional Anesthesia.

US Guided SI Joint Injection Technique,Dominic Harmon, Pain Physician 2008; 11:543-547.

Advanced Ultrasound Imaging in Pain Medicine,Michael Gofeld, Pain Medicine News, Dec 2011, pgs 14-20.

The Changing role of Ultrasonography in Pain Medicine, Michael Gofeld, MD, Pain Medicine News, April 2012, Pgs 1-7.

Ultrasound-guided cervical selective nerve root Block: A flouroscopy controlled feasibility study. Narouze SN, Reg Anesth Pain Med. 2009; 34(4):343-348.

Ultrasound guided medial branch block in obese patients: A flouroscopy confirmed clinical feasibility study. Reg Anesth Pain Med, . 2009; 34(4):340-342

Ultrasonography in Pain Medicine: a critical review. Pain Pract. 2008:8(4):226-240

Ultrasonography of the hip and Lower extremity: Gerald Malanga, PMR Clinics of N America, 8/2010, vol 21, no 3; pgs 533-47.

Feasibility of ultrasound guided sacroiliac joint injection considering sonoanatomic landmarks at two different levels in cadavers and patients. Klauser, A. Arthritis Rheum 2008:59 (11): 1618-24'''

==External Links==
*[http://www.piedmontpmr.com/injectiontypes/ Injection Types]

Ultrasound guided injections

2013-07-04T21:51:53Z

Bobby Schwartz: /* Controversies in Ultrasound Guidance for Injections */

'''Editor-in-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.];

==Overview of Ultrasound==
'''Ultrasound''' is cyclic [[sound]] pressure with a [[frequency]] greater than the upper limit of [[human]] [[hearing (sense)|hearing]]. Although this limit varies from person to person, it is approximately 20 [[Hertz|kilohertz]] (20,000 hertz) in healthy, young adults and thus, 20 kHz serves as a useful lower limit in describing ultrasound. Ultrasound is manually produced in many different fields, typically to penetrate a medium and measure the reflection signature or supply focused energy. The reflection signature can reveal details about the inner structure of the medium. The most well known application of this technique is its use in sonography to produce pictures of fetuses in the human womb. There are a vast number of other applications as well.

''''''Medical sonography''' ('''ultrasonography''')''' is an ultrasound-based diagnostic medical imaging technique used to visualize muscles, tendons, and many internal organs, their size, structure and any pathological lesions with real time tomographic images. It is one of the most widely used diagnostic tools in modern medicine. The technology is relatively inexpensive and portable, especially when compared with modalities such as magnetic resonance imaging(MRI) and computed tomography (CT). As currently applied in the medical environment, ultrasound poses no known risks to the patient. Utilizing ultrasound for guidance during injections is a relatively recent development compared to its use in medical diagnosis. The adoption of ultrasound guidance in clinical practice is increasing however and can be attributed to improvements in imaging technology.

==Clinical Indications==

The use of Ultrasound in Medicine has become widespread in recent years. Once only available in a select few Universities advances in technology and price reduction have made this technology more available in both community hospitals and in the office setting. Common uses include as a diagnostic tool in the abdomen, vascular studies including both arteries and veins, a wide array of musculoskeletal applications, and with endocrine disease such as thyroid disorders. Due to its non ionzing imaging ability, relatively low cost, and ease of portability Ultrasound has become more prevalent as a guidance tool for procedures including biopsy, catheter placement, and aspiration.

Given these advancements it is not surprising that the use of ultrasound guidance for percutaneous tenotomy, joint injection, a variety of nerve blocks, and other soft tissue injections has become more common place as well. While there is extensive literature on the use of Ultrasound for guidance in spinal injections there is still controversy over its use for spinal conditions. This seems to stem more from previous overstatements of its effectiveness in replacing MRI for spinal conditions then due to the more current literature that make use of it for para and extra spinal conditions and guidance.

==Ultrasound Guided Injections==

There has been a significant increase in the use of Ultrasound guidance for injections in the past several years. Initial acceptance was confined to peripheral structures such as nerve, tendon, joint capsule and spaces, and ligament with more recent moves toward plexus and then spinal guidance. As technology continues to improve image quality the advantages of Ultrasound guidance over other imaging studies such as flouroscopy or CT has become more compelling. Cost and time savings, ease of access, and non ionizing radiation are a few of the clear benefits.A body of literature now exists that clearly demonstrates the utility of Ultrasound to effectively visualize vertebral bodies, articular processes, lamina, intrathecal and lamaninar spaces. Level 1 support for Ultrasound guidance has been established for lumbar zygoapophysial joint injections, medial branch and dorsal ramus block.

==Safety and Efficacy==

Ultrasound enjoys a rather unique position among imaging modalities due to its capabilities that do not rely upon non ionizing radiation as compared to flouroscopy or CT scanning. The presence of artificial joints or pacemakers are also not a problem with Ultrasound as compared to MRI. Ultrasound guidance for injections has proven itself to be very safe and offers clinicians in the emergency room, office setting, or in the operating room an opportunity to both identify the target structure accurately while providing a greater level of patient safety through avoidance of traumatizing unintended structures such as near by arteries.

==Controversies in Ultrasound Guidance for Injections==

While there is community agreement that certain kinds of spinal injections such as transformanal epidurals require an imaging modality such as flouroscopy despite a rather extensive body of literature supporting the use of Ultrasound guidance for paraspinal, sacroiliac, translaminar epidural steroids and caudal injections. Ultrasound guidance for spinal injections has still not gained full community support. None the less the trend is clear and overtime Ultrasound utilization for these procedures has only increased. It is difficult to understand how on the one had there may be no controversy over Ultrasound's capability to identify the target structure and concurrently on the other hand there are still those who dont embrace Ultrasound's utility in guidance for injection of the same structures.

==Related Chapters==

[[Musculoskeletal Ultrasound]]
[[Back Pain]]
[[Low back pain]]
[[Prolotherapy]]
[[Sacrum]]

==References==
Accuracy of Ultrasound-guided Nerve Blocks of the Cervical Zygopophysial Joints, A Seigenthaler, MD, et al, Anesthesiology, V117, no 2, 347-352, August 2012.

Ultrasonography in Pain Medicine: Opening the Third Eye,J. Ballantyne, MD, et al, Pain Clinical Updates, IASP, Vol XX, Issue 4, 1-7, June 2012.

The Am.J Phy. Med. Rehab. Vol 90, No. 10, Oct 2011, pages 860-867, "Ultrasound -Guided Injection Techniques for the Low Back and Hip Joint".

Anesthesiology, C 115, no 1, pg 94, July 2011.

Ultrasound Imaging for Regional Anesthesia: A Practical Guide Booklet, Third edition, Ultrasound for Regional Anesthesia.

US Guided SI Joint Injection Technique,Dominic Harmon, Pain Physician 2008; 11:543-547.

Advanced Ultrasound Imaging in Pain Medicine,Michael Gofeld, Pain Medicine News, Dec 2011, pgs 14-20.

The Changing role of Ultrasonography in Pain Medicine, Michael Gofeld, MD, Pain Medicine News, April 2012, Pgs 1-7.

Ultrasound-guided cervical selective nerve root Block: A flouroscopy controlled feasibility study. Narouze SN, Reg Anesth Pain Med. 2009; 34(4):343-348.

Ultrasound guided medial branch block in obese patients: A flouroscopy confirmed clinical feasibility study. Reg Anesth Pain Med, . 2009; 34(4):340-342

Ultrasonography in Pain Medicine: a critical review. Pain Pract. 2008:8(4):226-240

Ultrasonography of the hip and Lower extremity: Gerald Malanga, PMR Clinics of N America, 8/2010, vol 21, no 3; pgs 533-47.

Feasibility of ultrasound guided sacroiliac joint injection considering sonoanatomic landmarks at two different levels in cadavers and patients. Klauser, A. Arthritis Rheum 2008:59 (11): 1618-24'''

==External Links==
*[http://www.piedmontpmr.com/injectiontypes/ Injection Types]

Ultrasound guided injections

2013-07-04T21:51:13Z

Bobby Schwartz: /* Related Chapters */

'''Editor-in-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.];

==Overview of Ultrasound==
'''Ultrasound''' is cyclic [[sound]] pressure with a [[frequency]] greater than the upper limit of [[human]] [[hearing (sense)|hearing]]. Although this limit varies from person to person, it is approximately 20 [[Hertz|kilohertz]] (20,000 hertz) in healthy, young adults and thus, 20 kHz serves as a useful lower limit in describing ultrasound. Ultrasound is manually produced in many different fields, typically to penetrate a medium and measure the reflection signature or supply focused energy. The reflection signature can reveal details about the inner structure of the medium. The most well known application of this technique is its use in sonography to produce pictures of fetuses in the human womb. There are a vast number of other applications as well.

''''''Medical sonography''' ('''ultrasonography''')''' is an ultrasound-based diagnostic medical imaging technique used to visualize muscles, tendons, and many internal organs, their size, structure and any pathological lesions with real time tomographic images. It is one of the most widely used diagnostic tools in modern medicine. The technology is relatively inexpensive and portable, especially when compared with modalities such as magnetic resonance imaging(MRI) and computed tomography (CT). As currently applied in the medical environment, ultrasound poses no known risks to the patient. Utilizing ultrasound for guidance during injections is a relatively recent development compared to its use in medical diagnosis. The adoption of ultrasound guidance in clinical practice is increasing however and can be attributed to improvements in imaging technology.

==Clinical Indications==

The use of Ultrasound in Medicine has become widespread in recent years. Once only available in a select few Universities advances in technology and price reduction have made this technology more available in both community hospitals and in the office setting. Common uses include as a diagnostic tool in the abdomen, vascular studies including both arteries and veins, a wide array of musculoskeletal applications, and with endocrine disease such as thyroid disorders. Due to its non ionzing imaging ability, relatively low cost, and ease of portability Ultrasound has become more prevalent as a guidance tool for procedures including biopsy, catheter placement, and aspiration.

Given these advancements it is not surprising that the use of ultrasound guidance for percutaneous tenotomy, joint injection, a variety of nerve blocks, and other soft tissue injections has become more common place as well. While there is extensive literature on the use of Ultrasound for guidance in spinal injections there is still controversy over its use for spinal conditions. This seems to stem more from previous overstatements of its effectiveness in replacing MRI for spinal conditions then due to the more current literature that make use of it for para and extra spinal conditions and guidance.

==Ultrasound Guided Injections==

There has been a significant increase in the use of Ultrasound guidance for injections in the past several years. Initial acceptance was confined to peripheral structures such as nerve, tendon, joint capsule and spaces, and ligament with more recent moves toward plexus and then spinal guidance. As technology continues to improve image quality the advantages of Ultrasound guidance over other imaging studies such as flouroscopy or CT has become more compelling. Cost and time savings, ease of access, and non ionizing radiation are a few of the clear benefits.A body of literature now exists that clearly demonstrates the utility of Ultrasound to effectively visualize vertebral bodies, articular processes, lamina, intrathecal and lamaninar spaces. Level 1 support for Ultrasound guidance has been established for lumbar zygoapophysial joint injections, medial branch and dorsal ramus block.

==Safety and Efficacy==

Ultrasound enjoys a rather unique position among imaging modalities due to its capabilities that do not rely upon non ionizing radiation as compared to flouroscopy or CT scanning. The presence of artificial joints or pacemakers are also not a problem with Ultrasound as compared to MRI. Ultrasound guidance for injections has proven itself to be very safe and offers clinicians in the emergency room, office setting, or in the operating room an opportunity to both identify the target structure accurately while providing a greater level of patient safety through avoidance of traumatizing unintended structures such as near by arteries.

==Controversies in Ultrasound Guidance for Injections==

While there is community agreement that certain kinds of spinal injections such as transformanal epidurals require an imaging modality such as flouroscopy despite a rather extensive body of literature supporting the use of Ultrasound guidance for paraspinal, sacroiliac, translaminar epidural steroids and caudal injections Ultrasound guidance for spinal injections has still not gained full community support. None the less the trend is clear and overtime Ultrasound utilization for these procedures has only increased. It is difficult to understand how on the one had there may be no controversy over Ultrasound's capability to identify the target structure and concurrently on the other hand there are still those who dont embrace Ultrasound's utility in guidance for injection of the same structures.

==Related Chapters==

[[Musculoskeletal Ultrasound]]
[[Back Pain]]
[[Low back pain]]
[[Prolotherapy]]
[[Sacrum]]

==References==
Accuracy of Ultrasound-guided Nerve Blocks of the Cervical Zygopophysial Joints, A Seigenthaler, MD, et al, Anesthesiology, V117, no 2, 347-352, August 2012.

Ultrasonography in Pain Medicine: Opening the Third Eye,J. Ballantyne, MD, et al, Pain Clinical Updates, IASP, Vol XX, Issue 4, 1-7, June 2012.

The Am.J Phy. Med. Rehab. Vol 90, No. 10, Oct 2011, pages 860-867, "Ultrasound -Guided Injection Techniques for the Low Back and Hip Joint".

Anesthesiology, C 115, no 1, pg 94, July 2011.

Ultrasound Imaging for Regional Anesthesia: A Practical Guide Booklet, Third edition, Ultrasound for Regional Anesthesia.

US Guided SI Joint Injection Technique,Dominic Harmon, Pain Physician 2008; 11:543-547.

Advanced Ultrasound Imaging in Pain Medicine,Michael Gofeld, Pain Medicine News, Dec 2011, pgs 14-20.

The Changing role of Ultrasonography in Pain Medicine, Michael Gofeld, MD, Pain Medicine News, April 2012, Pgs 1-7.

Ultrasound-guided cervical selective nerve root Block: A flouroscopy controlled feasibility study. Narouze SN, Reg Anesth Pain Med. 2009; 34(4):343-348.

Ultrasound guided medial branch block in obese patients: A flouroscopy confirmed clinical feasibility study. Reg Anesth Pain Med, . 2009; 34(4):340-342

Ultrasonography in Pain Medicine: a critical review. Pain Pract. 2008:8(4):226-240

Ultrasonography of the hip and Lower extremity: Gerald Malanga, PMR Clinics of N America, 8/2010, vol 21, no 3; pgs 533-47.

Feasibility of ultrasound guided sacroiliac joint injection considering sonoanatomic landmarks at two different levels in cadavers and patients. Klauser, A. Arthritis Rheum 2008:59 (11): 1618-24'''

==External Links==
*[http://www.piedmontpmr.com/injectiontypes/ Injection Types]

Ultrasound guided injections

2013-05-12T13:02:21Z

Bobby Schwartz:

'''Editor-in-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.];

==Overview of Ultrasound==
'''Ultrasound''' is cyclic [[sound]] pressure with a [[frequency]] greater than the upper limit of [[human]] [[hearing (sense)|hearing]]. Although this limit varies from person to person, it is approximately 20 [[Hertz|kilohertz]] (20,000 hertz) in healthy, young adults and thus, 20 kHz serves as a useful lower limit in describing ultrasound. Ultrasound is manually produced in many different fields, typically to penetrate a medium and measure the reflection signature or supply focused energy. The reflection signature can reveal details about the inner structure of the medium. The most well known application of this technique is its use in sonography to produce pictures of fetuses in the human womb. There are a vast number of other applications as well.

''''''Medical sonography''' ('''ultrasonography''')''' is an ultrasound-based diagnostic medical imaging technique used to visualize muscles, tendons, and many internal organs, their size, structure and any pathological lesions with real time tomographic images. It is one of the most widely used diagnostic tools in modern medicine. The technology is relatively inexpensive and portable, especially when compared with modalities such as magnetic resonance imaging(MRI) and computed tomography (CT). As currently applied in the medical environment, ultrasound poses no known risks to the patient. Utilizing ultrasound for guidance during injections is a relatively recent development compared to its use in medical diagnosis. The adoption of ultrasound guidance in clinical practice is increasing however and can be attributed to improvements in imaging technology.

==Clinical Indications==

The use of Ultrasound in Medicine has become widespread in recent years. Once only available in a select few Universities advances in technology and price reduction have made this technology more available in both community hospitals and in the office setting. Common uses include as a diagnostic tool in the abdomen, vascular studies including both arteries and veins, a wide array of musculoskeletal applications, and with endocrine disease such as thyroid disorders. Due to its non ionzing imaging ability, relatively low cost, and ease of portability Ultrasound has become more prevalent as a guidance tool for procedures including biopsy, catheter placement, and aspiration.

Given these advancements it is not surprising that the use of ultrasound guidance for percutaneous tenotomy, joint injection, a variety of nerve blocks, and other soft tissue injections has become more common place as well. While there is extensive literature on the use of Ultrasound for guidance in spinal injections there is still controversy over its use for spinal conditions. This seems to stem more from previous overstatements of its effectiveness in replacing MRI for spinal conditions then due to the more current literature that make use of it for para and extra spinal conditions and guidance.

==Ultrasound Guided Injections==

There has been a significant increase in the use of Ultrasound guidance for injections in the past several years. Initial acceptance was confined to peripheral structures such as nerve, tendon, joint capsule and spaces, and ligament with more recent moves toward plexus and then spinal guidance. As technology continues to improve image quality the advantages of Ultrasound guidance over other imaging studies such as flouroscopy or CT has become more compelling. Cost and time savings, ease of access, and non ionizing radiation are a few of the clear benefits.A body of literature now exists that clearly demonstrates the utility of Ultrasound to effectively visualize vertebral bodies, articular processes, lamina, intrathecal and lamaninar spaces. Level 1 support for Ultrasound guidance has been established for lumbar zygoapophysial joint injections, medial branch and dorsal ramus block.

==Safety and Efficacy==

Ultrasound enjoys a rather unique position among imaging modalities due to its capabilities that do not rely upon non ionizing radiation as compared to flouroscopy or CT scanning. The presence of artificial joints or pacemakers are also not a problem with Ultrasound as compared to MRI. Ultrasound guidance for injections has proven itself to be very safe and offers clinicians in the emergency room, office setting, or in the operating room an opportunity to both identify the target structure accurately while providing a greater level of patient safety through avoidance of traumatizing unintended structures such as near by arteries.

==Controversies in Ultrasound Guidance for Injections==

While there is community agreement that certain kinds of spinal injections such as transformanal epidurals require an imaging modality such as flouroscopy despite a rather extensive body of literature supporting the use of Ultrasound guidance for paraspinal, sacroiliac, translaminar epidural steroids and caudal injections Ultrasound guidance for spinal injections has still not gained full community support. None the less the trend is clear and overtime Ultrasound utilization for these procedures has only increased. It is difficult to understand how on the one had there may be no controversy over Ultrasound's capability to identify the target structure and concurrently on the other hand there are still those who dont embrace Ultrasound's utility in guidance for injection of the same structures.

==Related Chapters==

==References==
Accuracy of Ultrasound-guided Nerve Blocks of the Cervical Zygopophysial Joints, A Seigenthaler, MD, et al, Anesthesiology, V117, no 2, 347-352, August 2012.

Ultrasonography in Pain Medicine: Opening the Third Eye,J. Ballantyne, MD, et al, Pain Clinical Updates, IASP, Vol XX, Issue 4, 1-7, June 2012.

The Am.J Phy. Med. Rehab. Vol 90, No. 10, Oct 2011, pages 860-867, "Ultrasound -Guided Injection Techniques for the Low Back and Hip Joint".

Anesthesiology, C 115, no 1, pg 94, July 2011.

Ultrasound Imaging for Regional Anesthesia: A Practical Guide Booklet, Third edition, Ultrasound for Regional Anesthesia.

US Guided SI Joint Injection Technique,Dominic Harmon, Pain Physician 2008; 11:543-547.

Advanced Ultrasound Imaging in Pain Medicine,Michael Gofeld, Pain Medicine News, Dec 2011, pgs 14-20.

The Changing role of Ultrasonography in Pain Medicine, Michael Gofeld, MD, Pain Medicine News, April 2012, Pgs 1-7.

Ultrasound-guided cervical selective nerve root Block: A flouroscopy controlled feasibility study. Narouze SN, Reg Anesth Pain Med. 2009; 34(4):343-348.

Ultrasound guided medial branch block in obese patients: A flouroscopy confirmed clinical feasibility study. Reg Anesth Pain Med, . 2009; 34(4):340-342

Ultrasonography in Pain Medicine: a critical review. Pain Pract. 2008:8(4):226-240

Ultrasonography of the hip and Lower extremity: Gerald Malanga, PMR Clinics of N America, 8/2010, vol 21, no 3; pgs 533-47.

Feasibility of ultrasound guided sacroiliac joint injection considering sonoanatomic landmarks at two different levels in cadavers and patients. Klauser, A. Arthritis Rheum 2008:59 (11): 1618-24'''

==External Links==
*[http://www.piedmontpmr.com/injectiontypes/ Injection Types]