Friday, June 29, 2007
International Physiotherapy Day
On Saturday 8 September 2007, physiotherapists all over the world will be celebrating International Physiotherapy Day. This day was created by the World Confederation of Physiotherapists to recognise the work that physiotherapists do for their patients and their community, and to support them in their efforts to promote the profession and to advance their clinical expertise. This day marks the unity and solidarity of the Physiotherapy community from 92 countries around the world. The message is exercise is beneficial for everyone, at all ages and health status.
Wednesday, June 27, 2007
FROZEN SHOULDER
7 Steps to Overcoming Your Frozen Shoulder.
Tip #1 -
= Support the affected arm during activities of daily living.
= This includes driving, typing at the computer, sitting in a chair and relaxing in your
lazy boy at home.
= Gravity pulls the arm down when it is unsupported, and this
increases strain on the rotator cuff.
= It is best to use a soft pillow or cushion when
available.
= By reducing the pull of gravity throughout the day, you will naturally lessen the pain
and inflammation in your shoulder.
= While it will take effort on your part to not
violate this rule, I promise you it will make a difference.
Tip #2 -
= Use ice and heat accordingly to relieve pain and decrease stiffness.
= Heat is a great way to start the day and reduce stiffness.
= Your best bet is a warm
shower.
= Another method is applying a heating pack.
= Regardless, this will feel good,
reduce stiffness and better prepare you to move the arm in your morning routine.
= With regard to ice, I always suggest a frozen bag of veggies or professional soft wrap
that conforms to the shape of the shoulder.
= Be sure to support the arm as
mentioned previously while icing.
= Keep the ice on for 15-20 minutes and then off for
an hour.
= You may ice more than once per day if desired based on pain.
= I usually suggest icing before bed to improve sleep.
= I know you are asking yourself why put ice on a stiff shoulder.
=Ice really is helpful because it reduces inflammation.
= Heat feels good, but does not dramatically affect
the inflammation.
= Ice should be used after periods of increased activity (e.g. work or
play).
= So, if you have not been icing, begin using it daily to reduce pain and aid
healing.
Tip #3 -
= Avoid forcing the arm to move in painful ranges of motion unless
absolutely necessary.
= With a stiff frozen shoulder, the rotator cuff gets compressed when the arm is
elevated, rotated or extended beyond the point of joint mobility due to abnormal
joint mechanics and this often further aggravates the symptoms.
= This is problematic with getting dressed, fastening the seat belt or placing carry-on baggage in a plane.
= Depending on your pain state (acute, sub-acute or chronic) you may have pain in
different parts of the range of motion.
= Any significant pain with movement is a bad
thing and you should try to minimize or avoid it altogether.
= Rest from this abusive
motion is absolutely critical to resolving your inflammation and returning to preinjury
levels.
= However, this does not mean you should stop moving the arm in those directions at
all as that can cause you to lose even more mobility.
= Use moderation as your guide
and pay attention to the pain levels day to day!
Tip #4 -
= Do not perform single arm or overhead heavy lifting during periods
of inflammation.
= This position coupled with external loads will prolong your pain and slow the recovery
process.
= It is common for people to unknowingly abuse their shoulder with daily
activities including overhead lifting, carrying laptops, hauling briefcases and even
lifting luggage (especially overhead).
= I know you are asking how to avoid these positions.
= The best answer is to switch
arms or use both arms to execute lifting maneuvers when possible.
= Believe it or not,
even small loads and movements can significantly increase pain and inflammation.
= Minimizing the number of such activities is necessary to allow the injured tissue to
heal.
= Use pain as your guide with daily tasks, but be careful to avoid pushing, pulling or
lifting heavy objects with the affected arm.
= Try to use both arms and keep them as
close to the body as possible.
= This measure alone will accelerate healing and reduce
your pain.
Tip #5 -
= Perform arm pendulums (clockwise and counterclockwise circles)
daily.
= This gentle motion stimulates receptors in the shoulder joint and helps to increase
joint space and reduce pain.
= This is also a good warm-up activity prior to shoulder
exercises.
= You can eventually add a small weight or soup can to increase the effect.
= It is important to let the motion of the body direct the shoulder and not to forcefully
move the shoulder in circles.
= The arm should hang as though it were limp and follow
the lead of the body.
= I generally recommend doing 20-30 repetitions of this exercise 1-2 times per day.
= If
it causes pain, then reduce the radius of the circles or simply wait until it can be
done pain free.
= This is even more effective if you perform it after a warm shower or
applying moist heat to the shoulder for 10-15 minutes.
Tip #6 -
= Use a pillow under the arm at night to better support the injured
arm.
= Propping the arm up as opposed to letting it hang down against the bed will actually
reduce pull and tension on the shoulder and rotator cuff itself.
= Proper positioning will
keep the shoulder in a neutral position in line with the body and should feel very
comfortable.
= I also recommend trying to sleep on the unaffected side if possible, as lying on the
sore side compresses the shoulder and will typically increase pain and wake you.
= I know you are thinking it is impossible to stay in one position at night.
= You are
probably right.
= But, I encourage you to at least try these options when you are in
significant pain, as I know for sure that compression of the shoulder will make your
symptoms worse.
= That also equals more pain and less sleep.
= So, use a small to moderate sized pillow that achieves the optimal position described
above.
= Even if you move during sleep, a little break from the bad positions should
still aid in your recovery.
Tip #7 -
= Perform daily stretching and range of motion exercises.
= What if your shoulder is really sore? How does exercise aid healing? Exercise will
increase blood flow to the tissues and doing specific exercises will not only prevent
further motion loss and stiffness, but actually help you recover lost function and
mobility in your shoulder.
= It is not acceptable to do just any exercises.
= They need to be specific to the problem
you have and target the tight tissue in your shoulder.
= They must also be done at a
certain frequency, intensity and volume to reduce your pain.
= I have determined a
clinically proven formula for doing just this.
= Lower intensity and longer duration stretches coupled with specific cane range of
motion exercises are essential to promote healing, reduce inflammation and return
you to pre-injury activity levels again.
= More importantly, effective rehab exercises
will prevent future injuries and more pain and suffering.
= While there is no magic pill
or quick fix for a frozen shoulder, these exercises are guaranteed to help you get
better.
Tip #1 -
= Support the affected arm during activities of daily living.
= This includes driving, typing at the computer, sitting in a chair and relaxing in your
lazy boy at home.
= Gravity pulls the arm down when it is unsupported, and this
increases strain on the rotator cuff.
= It is best to use a soft pillow or cushion when
available.
= By reducing the pull of gravity throughout the day, you will naturally lessen the pain
and inflammation in your shoulder.
= While it will take effort on your part to not
violate this rule, I promise you it will make a difference.
Tip #2 -
= Use ice and heat accordingly to relieve pain and decrease stiffness.
= Heat is a great way to start the day and reduce stiffness.
= Your best bet is a warm
shower.
= Another method is applying a heating pack.
= Regardless, this will feel good,
reduce stiffness and better prepare you to move the arm in your morning routine.
= With regard to ice, I always suggest a frozen bag of veggies or professional soft wrap
that conforms to the shape of the shoulder.
= Be sure to support the arm as
mentioned previously while icing.
= Keep the ice on for 15-20 minutes and then off for
an hour.
= You may ice more than once per day if desired based on pain.
= I usually suggest icing before bed to improve sleep.
= I know you are asking yourself why put ice on a stiff shoulder.
=Ice really is helpful because it reduces inflammation.
= Heat feels good, but does not dramatically affect
the inflammation.
= Ice should be used after periods of increased activity (e.g. work or
play).
= So, if you have not been icing, begin using it daily to reduce pain and aid
healing.
Tip #3 -
= Avoid forcing the arm to move in painful ranges of motion unless
absolutely necessary.
= With a stiff frozen shoulder, the rotator cuff gets compressed when the arm is
elevated, rotated or extended beyond the point of joint mobility due to abnormal
joint mechanics and this often further aggravates the symptoms.
= This is problematic with getting dressed, fastening the seat belt or placing carry-on baggage in a plane.
= Depending on your pain state (acute, sub-acute or chronic) you may have pain in
different parts of the range of motion.
= Any significant pain with movement is a bad
thing and you should try to minimize or avoid it altogether.
= Rest from this abusive
motion is absolutely critical to resolving your inflammation and returning to preinjury
levels.
= However, this does not mean you should stop moving the arm in those directions at
all as that can cause you to lose even more mobility.
= Use moderation as your guide
and pay attention to the pain levels day to day!
Tip #4 -
= Do not perform single arm or overhead heavy lifting during periods
of inflammation.
= This position coupled with external loads will prolong your pain and slow the recovery
process.
= It is common for people to unknowingly abuse their shoulder with daily
activities including overhead lifting, carrying laptops, hauling briefcases and even
lifting luggage (especially overhead).
= I know you are asking how to avoid these positions.
= The best answer is to switch
arms or use both arms to execute lifting maneuvers when possible.
= Believe it or not,
even small loads and movements can significantly increase pain and inflammation.
= Minimizing the number of such activities is necessary to allow the injured tissue to
heal.
= Use pain as your guide with daily tasks, but be careful to avoid pushing, pulling or
lifting heavy objects with the affected arm.
= Try to use both arms and keep them as
close to the body as possible.
= This measure alone will accelerate healing and reduce
your pain.
Tip #5 -
= Perform arm pendulums (clockwise and counterclockwise circles)
daily.
= This gentle motion stimulates receptors in the shoulder joint and helps to increase
joint space and reduce pain.
= This is also a good warm-up activity prior to shoulder
exercises.
= You can eventually add a small weight or soup can to increase the effect.
= It is important to let the motion of the body direct the shoulder and not to forcefully
move the shoulder in circles.
= The arm should hang as though it were limp and follow
the lead of the body.
= I generally recommend doing 20-30 repetitions of this exercise 1-2 times per day.
= If
it causes pain, then reduce the radius of the circles or simply wait until it can be
done pain free.
= This is even more effective if you perform it after a warm shower or
applying moist heat to the shoulder for 10-15 minutes.
Tip #6 -
= Use a pillow under the arm at night to better support the injured
arm.
= Propping the arm up as opposed to letting it hang down against the bed will actually
reduce pull and tension on the shoulder and rotator cuff itself.
= Proper positioning will
keep the shoulder in a neutral position in line with the body and should feel very
comfortable.
= I also recommend trying to sleep on the unaffected side if possible, as lying on the
sore side compresses the shoulder and will typically increase pain and wake you.
= I know you are thinking it is impossible to stay in one position at night.
= You are
probably right.
= But, I encourage you to at least try these options when you are in
significant pain, as I know for sure that compression of the shoulder will make your
symptoms worse.
= That also equals more pain and less sleep.
= So, use a small to moderate sized pillow that achieves the optimal position described
above.
= Even if you move during sleep, a little break from the bad positions should
still aid in your recovery.
Tip #7 -
= Perform daily stretching and range of motion exercises.
= What if your shoulder is really sore? How does exercise aid healing? Exercise will
increase blood flow to the tissues and doing specific exercises will not only prevent
further motion loss and stiffness, but actually help you recover lost function and
mobility in your shoulder.
= It is not acceptable to do just any exercises.
= They need to be specific to the problem
you have and target the tight tissue in your shoulder.
= They must also be done at a
certain frequency, intensity and volume to reduce your pain.
= I have determined a
clinically proven formula for doing just this.
= Lower intensity and longer duration stretches coupled with specific cane range of
motion exercises are essential to promote healing, reduce inflammation and return
you to pre-injury activity levels again.
= More importantly, effective rehab exercises
will prevent future injuries and more pain and suffering.
= While there is no magic pill
or quick fix for a frozen shoulder, these exercises are guaranteed to help you get
better.
VENTILATORS
Ventilators
Definition
A ventilator is a device used to provide assisted respiration and positive-pressure breathing.
Purpose
Ventilators are used to provide mechanical ventilation for patients with respiratory failure who cannot breathe effectively on their own. They are also used to decrease myocardial gas consumption or intracranial pressure, provide stability of the chest wall after trauma or surgery, and when a patient is sedated or pharmacologically paralyzed.
Description
Different types of ventilators can be programmed to provide several modes of mechanical ventilation. A brief overview of each type and mode follows.
Negative-pressure ventilators
The original ventilators used negative pressure to remove and replace gas from the ventilator chamber. Examples of these include the iron lung, the Drinker respirator, and the chest shell. Rather than connecting to an artificial airway, these ventilators enclosed the body from the outside. As gas was pulled out of the ventilator chamber, the resulting negative pressure caused the chest wall to expand, which pulled air into the lungs. The cessation of the negative pressure caused the chest wall to fall and exhalation to occur. While an advantage of these ventilators was that they did not require insertion of an artificial airway, they were noisy, made nursing care difficult, and the patient was not able to ambulate.
Positive-pressure ventilators
Postive-pressure ventilators require an artificial airway (endotracheal or tracheostomy tube) and use positive pressure to force gas into a patient's lungs. Inspiration can be triggered either by the patient or the machine. There are four types of positive-pressure ventilators: volume-cycled, pressure-cycled, flow-cycled, and time-cycled.
VOLUME-CYCLED VENTILATORS. This type delivers a preset tidal volume then allows passive expiration. This is ideal for patients with acute respiratory distress syndrome (ARDS) or bronchospasm, since the same tidal volume is delivered regardless of the amount of airway resistance. This type of ventilator is the most commonly used in critical care environments.
PRESSURE-CYCLED VENTILATORS. These ventilators deliver gases at a preset pressure, then allow passive expiration. The benefit of this type is a decreased risk of lung damage from high inspiratory pressures, which is particularly beneficial for neonates who have a small lung capacity. The disadvantage is that the tidal volume delivered can decrease if the patient has poor lung compliance and increased airway resistance. This type of ventilation is usually used for short-term therapy (less than 24 hours). Some ventilators have the capability to provide both volume-cycled and pressure-cycled ventilation. These combination ventilators are also commonly used in critical care environments.
FLOW-CYCLED VENTILATORS. Flow-cycled ventilators deliver oxygenation until a preset flow rate is achieved during inspiration.
TIME-CYCLED VENTILATORS. Time-cycled ventilators deliver oxygenation over a preset time period. These types of ventilators are not used as frequently as the volume-cycled and pressure-cycled ventilators.
Modes of ventilation
Mode refers to how the machine will ventilate the patient in relation to the patient's own respiratory efforts. There is a mode for nearly every patient situation; plus, many different types can be used in conjunction with each other.
CONTROL VENTILATION (CV). CV delivers the preset volume or pressure regardless of the patient's own inspiratory efforts. This mode is used for patients who are unable to initiate a breath. If it is used with spontaneously breathing patients, they must be sedated and/or pharmacologically paralyzed so they don't breathe out of synchrony with the ventilator.
ASSIST-CONTROL VENTILATION (A/C) OR CONTINUOUS MANDATORY VENTILATION (CMV). A/C or CMV delivers the preset volume or pressure in response to the patient's inspiratory effort, but will initiate the breath if the patient does not do so within a preset amount of time. This mode is used for patients who can initiate a breath but who have weakened respiratory muscles. The patient may need to be sedated to limit the number of spontaneous breaths, as hyperventilation can occur in patients with high respiratory rates.
SYNCHRONOUS INTERMITTENT MANDATORY VENTILATION (SIMV). SIMV delivers the preset volume or pressure and preset respiratory rate while allowing the patient to breathe spontaneously. The vent initiates each breath in synchrony with the patient's breaths. SIMV is used as a primary mode of ventilation as well as a weaning mode. (During weaning, the preset rate is gradually reduced, allowing the patient to slowly regain breathing on their own.) The disadvantage of this mode is that it may increase the effort of breathing and cause respiratory muscle fatigue. (Breathing spontaneously through ventilator tubing has been compared to breathing through a straw.)
POSITIVE-END EXPIRATORY PRESSURE (PEEP). PEEP is positive pressure that is applied by the ventilator at the end of expiration. This mode does not deliver breaths but is used as an adjunct to CV, A/C, and SIMV to improve oxygenation by opening collapsed alveoli at the end of expiration. Complications from the increased pressure can include decreased cardiac output, lung rupture, and increased intracranial pressure.
CONSTANT POSITIVE AIRWAY PRESSURE (CPAP). CPAP is similar to PEEP, except that it works only for patients who are breathing spontaneously. The effect of CPAP (and PEEP) is compared to inflating a balloon but not letting it completely deflate before inflating it again. The second inflation is easier to perform because resistance is decreased. CPAP can also be administered using a mask and CPAP machine for patients who do not require mechanical ventilation but who need respiratory support (for example, patients with sleep apnea).
PRESSURE SUPPORT VENTILATION (PSV). PS is preset pressure which augments the patient's spontaneous inspiration effort and decreases the work of breathing. The patient completely controls the respiratory rate and tidal volume. PS is used for patients with a stable respiratory status and is often used with SIMV during weaning.
INDEPENDENT LUNG VENTILATION (ILV). This method is used to ventilate each lung separately in patients with unilateral lung disease or a different disease process in each lung. It requires a double-lumen endotracheal tube and two ventilators. Sedation and pharmacologic paralysis are used to facilitate optimal ventilation and increase comfort for the patient on whom this method is used.
HIGH FREQUENCY VENTILATION (HFV). HFV delivers a small amount of gas at a rapid rate (as much as 60-100 breaths per minute). This is used when conventional mechanical ventilation would compromise hemodynamic stability, during short-term procedures, or for patients who are at high risk for lung rupture. Sedation and/or pharmacologic paralysis are required.
INVERSE RATIO VENTILATION (IRV). The normal inspiratory:expiratory ratio is 1:2, but this is reversed during IRV to 2:1 or greater (the maximum is 4:1). This method is used for patients who are still hypoxic, even with the use of PEEP. Longer inspiratory time increases
the amount of air in the lungs at the end of expiration (the functional residual capacity) and improves oxygenation by re-expanding collapsed alveoli. The shorter expiratory time prevents the alveoli from collapsing again. This method requires sedation and therapeutic paralysis because it is very uncomfortable for the patient.
Ventilator settings
Ventilator settings are ordered by a physician and are individualized for the patient. Ventilators are designed to monitor most components of the patient's respiratory status. Various alarms and parameters can be set to warn healthcare providers that the patient is having difficulty with the settings.
RESPIRATORY RATE. The respiratory rate is the number of breaths the ventilator will deliver to the patient over a specific time period. The respiratory rate parameters are set above and below this number, and an alarm will sound if the patient's actual rate is outside the desired range.
TIDAL VOLUME. Tidal volume is the volume of gas the ventilator will deliver to the patient with each breath. The usual setting is 5-15 cc/kg. The tidal volume parameters are set above and below this number and an alarm sounds if the patient's actual tidal volume is outside the desired range. This is especially helpful if the patient is breathing spontaneously between ventilator-delivered breaths since the patient's own tidal volume can be compared with the desired tidal volume delivered by the ventilator.
OXYGEN CONCENTRATION (FIO2). Oxygen concentration is the amount of oxygen delivered to the patient. It can range from 21% (room air) to 100%.
INSPIRATORY:EXPIRATORY (I:E) RATIO. As discussed above, the I:E ratio is normally 1:2 or 1:1.5, unless inverse ratio ventilation is desired.
PRESSURE LIMIT. Pressure limit regulates the amount of pressure the volume-cycled ventilator can generate to deliver the preset tidal volume. The usual setting is 10-20 cm H2O above the patient's peak inspiratory pressure. If this limit is reached the ventilator stops the breath and alarms. This is often an indication that the patient's airway is obstructed with mucus and is usually resolved with suctioning. It can also be caused by the patient coughing, biting on the endotracheal tube, breathing against the ventilator, or by a kink in the ventilator tubing.
FLOW RATE. Flow rate is the speed with which the tidal volume is delivered. The usual setting is 40-100 liters per minute.
SENSITIVITY/TRIGGER. Sensitivity determines the amount of effort required by the patient to initiate inspiration. It can be set to be triggered by pressure or by flow.
SIGH. The ventilator can be programmed to deliver an occasional sigh with a larger tidal volume. This prevents collapse of the alveoli (atelectasis) which can result from the patient constantly inspiring the same volume of gas.
Operation
Many ventilators are now computerized and have a user-friendly control panel. To activate the various modes, settings, and alarms, the appropriate key need only be pressed. There are windows on the face panel which show settings and the alarm values. Some ventilators have dials instead of computerized keys, e.g., the smaller, portable ventilators used for transporting patients.
The ventilator tubing simply attaches to the ventilator on one end and to the patient's artificial airway on the other. Most ventilators have clamps that prevent the tubing from draping across the patient. However, there should be enough slack so that the artificial airway isn't accidentally pulled out if the patient turns.
Ventilators are electrical equipment so they must be plugged in. They do have battery back up, but this is not designed for long-term use. It should be ensured that they are plugged into an outlet that will receive generator power if there is an electrical power outage. Ventilators are a method of life-support. If the ventilator should stop working, the patient's life will be in jeopardy. There should be a bag-valve-mask device at the bedside of every patient receiving mechanical ventilation so they can be manually ventilated if needed.
Maintenance
When mechanical ventilation is initiated, the ventilator goes through a self-test to ensure it is working properly. The ventilator tubing should be changed every 24 hours and another self-test run afterwards. The bacteria filters should be checked for occlusions or tears and the water traps and filters should be checked for condensation or contaminants. These should be emptied and cleaned every 24 hours and as needed.
Health care team roles
The respiratory therapist is generally the person who sets up the ventilator, does the daily check described above, and changes the ventilator settings based on the physician's orders. The nurse is responsible for monitoring the alarms and the patient's respiratory status. The nurse is also responsible for notifying the respiratory therapist when mechanical problems occur with the ventilator and when there are new physician orders requiring changes in the settings or the alarm parameters. The physician is responsible for keeping track of the patient's status on the current ventilator settings and changing them when necessary.
Training
Training for using and maintaining ventilators is often done via hands-on methods. Critical care nurses usually have a small amount of class time during which they learn the ventilator modes and settings. They then apply this knowledge while working with patients on the unit under the supervision of a nurse preceptor. This preceptorship usually lasts about six weeks (depending upon the nurse's prior experience) and includes all aspects of critical care. Nurses often learn the most from the respiratory therapists, since ventilator management is their specialty.
Respiratory therapists complete an educational program that specifically focuses on respiratory diseases, and equipment and treatments used to manage those diseases. During orientation to a new job, they work under the supervision of an experienced respiratory therapist to learn how to maintain and manage the ventilators used by that particular institution. Written resources from the company that produced the ventilators are usually kept in the respiratory therapy department for reference.
Physicians generally do not manage the equipment aspect of the ventilator. They do, however, manage the relation of the ventilator settings to the patient's condition. They gain this knowledge of physiology during medical school and residency.
KEY TERMS
Alveoli Saclike structures in the lungs where oxygen and carbon dioxide exchange takes place.
Bag-valve-mask device Device consisting of a manually compressible bag containing oxygen and a one-way valve and mask that fits over the mouth and nose of the patient.
Endotracheal tube Tube inserted into the trachea via either the oral or nasal cavity for the purpose of providing a secure airway.
Hemodynamic stability Stability of blood circulation, including cardiac function and peripheral vascular physiology.
Hypoxic Abnormal deficiency of oxygen in the arterial blood.
Intracranial pressure The amount of pressure exerted inside the skull by brain tissue, blood, and cerebral-spinal fluid.
Peak inspiratory pressure The pressure in the lungs at the end of inspiration.
Pharmacologically paralyzed Short-term paralysis induced by medications for a therapeutic purpose.
Tracheostomy tube Surgically created opening in the trachea for the purpose of providing a secure airway. This is used when the patient requires long-term ventilatory assistance.
Weaning The process of gradually tapering mechanical ventilation and allowing the patient to resume breathing on their own.
BOOKS
Marino, P. The ICU Book. Baltimore: Williams & Wilkins, 1998.
Thelan, Lynne, et al. Critical Care Nursing: Diagnosis and Management. St. Louis: Mosby, 1998.
OTHER
Puritan-Bennett 7200 Series Ventilator System Pocket Guide. Booklet. Mallinckrodt, 2000.
Abby Wojahn, R.N., B.S.N., C.C.R.N.
Definition
A ventilator is a device used to provide assisted respiration and positive-pressure breathing.
Purpose
Ventilators are used to provide mechanical ventilation for patients with respiratory failure who cannot breathe effectively on their own. They are also used to decrease myocardial gas consumption or intracranial pressure, provide stability of the chest wall after trauma or surgery, and when a patient is sedated or pharmacologically paralyzed.
Description
Different types of ventilators can be programmed to provide several modes of mechanical ventilation. A brief overview of each type and mode follows.
Negative-pressure ventilators
The original ventilators used negative pressure to remove and replace gas from the ventilator chamber. Examples of these include the iron lung, the Drinker respirator, and the chest shell. Rather than connecting to an artificial airway, these ventilators enclosed the body from the outside. As gas was pulled out of the ventilator chamber, the resulting negative pressure caused the chest wall to expand, which pulled air into the lungs. The cessation of the negative pressure caused the chest wall to fall and exhalation to occur. While an advantage of these ventilators was that they did not require insertion of an artificial airway, they were noisy, made nursing care difficult, and the patient was not able to ambulate.
Positive-pressure ventilators
Postive-pressure ventilators require an artificial airway (endotracheal or tracheostomy tube) and use positive pressure to force gas into a patient's lungs. Inspiration can be triggered either by the patient or the machine. There are four types of positive-pressure ventilators: volume-cycled, pressure-cycled, flow-cycled, and time-cycled.
VOLUME-CYCLED VENTILATORS. This type delivers a preset tidal volume then allows passive expiration. This is ideal for patients with acute respiratory distress syndrome (ARDS) or bronchospasm, since the same tidal volume is delivered regardless of the amount of airway resistance. This type of ventilator is the most commonly used in critical care environments.
PRESSURE-CYCLED VENTILATORS. These ventilators deliver gases at a preset pressure, then allow passive expiration. The benefit of this type is a decreased risk of lung damage from high inspiratory pressures, which is particularly beneficial for neonates who have a small lung capacity. The disadvantage is that the tidal volume delivered can decrease if the patient has poor lung compliance and increased airway resistance. This type of ventilation is usually used for short-term therapy (less than 24 hours). Some ventilators have the capability to provide both volume-cycled and pressure-cycled ventilation. These combination ventilators are also commonly used in critical care environments.
FLOW-CYCLED VENTILATORS. Flow-cycled ventilators deliver oxygenation until a preset flow rate is achieved during inspiration.
TIME-CYCLED VENTILATORS. Time-cycled ventilators deliver oxygenation over a preset time period. These types of ventilators are not used as frequently as the volume-cycled and pressure-cycled ventilators.
Modes of ventilation
Mode refers to how the machine will ventilate the patient in relation to the patient's own respiratory efforts. There is a mode for nearly every patient situation; plus, many different types can be used in conjunction with each other.
CONTROL VENTILATION (CV). CV delivers the preset volume or pressure regardless of the patient's own inspiratory efforts. This mode is used for patients who are unable to initiate a breath. If it is used with spontaneously breathing patients, they must be sedated and/or pharmacologically paralyzed so they don't breathe out of synchrony with the ventilator.
ASSIST-CONTROL VENTILATION (A/C) OR CONTINUOUS MANDATORY VENTILATION (CMV). A/C or CMV delivers the preset volume or pressure in response to the patient's inspiratory effort, but will initiate the breath if the patient does not do so within a preset amount of time. This mode is used for patients who can initiate a breath but who have weakened respiratory muscles. The patient may need to be sedated to limit the number of spontaneous breaths, as hyperventilation can occur in patients with high respiratory rates.
SYNCHRONOUS INTERMITTENT MANDATORY VENTILATION (SIMV). SIMV delivers the preset volume or pressure and preset respiratory rate while allowing the patient to breathe spontaneously. The vent initiates each breath in synchrony with the patient's breaths. SIMV is used as a primary mode of ventilation as well as a weaning mode. (During weaning, the preset rate is gradually reduced, allowing the patient to slowly regain breathing on their own.) The disadvantage of this mode is that it may increase the effort of breathing and cause respiratory muscle fatigue. (Breathing spontaneously through ventilator tubing has been compared to breathing through a straw.)
POSITIVE-END EXPIRATORY PRESSURE (PEEP). PEEP is positive pressure that is applied by the ventilator at the end of expiration. This mode does not deliver breaths but is used as an adjunct to CV, A/C, and SIMV to improve oxygenation by opening collapsed alveoli at the end of expiration. Complications from the increased pressure can include decreased cardiac output, lung rupture, and increased intracranial pressure.
CONSTANT POSITIVE AIRWAY PRESSURE (CPAP). CPAP is similar to PEEP, except that it works only for patients who are breathing spontaneously. The effect of CPAP (and PEEP) is compared to inflating a balloon but not letting it completely deflate before inflating it again. The second inflation is easier to perform because resistance is decreased. CPAP can also be administered using a mask and CPAP machine for patients who do not require mechanical ventilation but who need respiratory support (for example, patients with sleep apnea).
PRESSURE SUPPORT VENTILATION (PSV). PS is preset pressure which augments the patient's spontaneous inspiration effort and decreases the work of breathing. The patient completely controls the respiratory rate and tidal volume. PS is used for patients with a stable respiratory status and is often used with SIMV during weaning.
INDEPENDENT LUNG VENTILATION (ILV). This method is used to ventilate each lung separately in patients with unilateral lung disease or a different disease process in each lung. It requires a double-lumen endotracheal tube and two ventilators. Sedation and pharmacologic paralysis are used to facilitate optimal ventilation and increase comfort for the patient on whom this method is used.
HIGH FREQUENCY VENTILATION (HFV). HFV delivers a small amount of gas at a rapid rate (as much as 60-100 breaths per minute). This is used when conventional mechanical ventilation would compromise hemodynamic stability, during short-term procedures, or for patients who are at high risk for lung rupture. Sedation and/or pharmacologic paralysis are required.
INVERSE RATIO VENTILATION (IRV). The normal inspiratory:expiratory ratio is 1:2, but this is reversed during IRV to 2:1 or greater (the maximum is 4:1). This method is used for patients who are still hypoxic, even with the use of PEEP. Longer inspiratory time increases
the amount of air in the lungs at the end of expiration (the functional residual capacity) and improves oxygenation by re-expanding collapsed alveoli. The shorter expiratory time prevents the alveoli from collapsing again. This method requires sedation and therapeutic paralysis because it is very uncomfortable for the patient.
Ventilator settings
Ventilator settings are ordered by a physician and are individualized for the patient. Ventilators are designed to monitor most components of the patient's respiratory status. Various alarms and parameters can be set to warn healthcare providers that the patient is having difficulty with the settings.
RESPIRATORY RATE. The respiratory rate is the number of breaths the ventilator will deliver to the patient over a specific time period. The respiratory rate parameters are set above and below this number, and an alarm will sound if the patient's actual rate is outside the desired range.
TIDAL VOLUME. Tidal volume is the volume of gas the ventilator will deliver to the patient with each breath. The usual setting is 5-15 cc/kg. The tidal volume parameters are set above and below this number and an alarm sounds if the patient's actual tidal volume is outside the desired range. This is especially helpful if the patient is breathing spontaneously between ventilator-delivered breaths since the patient's own tidal volume can be compared with the desired tidal volume delivered by the ventilator.
OXYGEN CONCENTRATION (FIO2). Oxygen concentration is the amount of oxygen delivered to the patient. It can range from 21% (room air) to 100%.
INSPIRATORY:EXPIRATORY (I:E) RATIO. As discussed above, the I:E ratio is normally 1:2 or 1:1.5, unless inverse ratio ventilation is desired.
PRESSURE LIMIT. Pressure limit regulates the amount of pressure the volume-cycled ventilator can generate to deliver the preset tidal volume. The usual setting is 10-20 cm H2O above the patient's peak inspiratory pressure. If this limit is reached the ventilator stops the breath and alarms. This is often an indication that the patient's airway is obstructed with mucus and is usually resolved with suctioning. It can also be caused by the patient coughing, biting on the endotracheal tube, breathing against the ventilator, or by a kink in the ventilator tubing.
FLOW RATE. Flow rate is the speed with which the tidal volume is delivered. The usual setting is 40-100 liters per minute.
SENSITIVITY/TRIGGER. Sensitivity determines the amount of effort required by the patient to initiate inspiration. It can be set to be triggered by pressure or by flow.
SIGH. The ventilator can be programmed to deliver an occasional sigh with a larger tidal volume. This prevents collapse of the alveoli (atelectasis) which can result from the patient constantly inspiring the same volume of gas.
Operation
Many ventilators are now computerized and have a user-friendly control panel. To activate the various modes, settings, and alarms, the appropriate key need only be pressed. There are windows on the face panel which show settings and the alarm values. Some ventilators have dials instead of computerized keys, e.g., the smaller, portable ventilators used for transporting patients.
The ventilator tubing simply attaches to the ventilator on one end and to the patient's artificial airway on the other. Most ventilators have clamps that prevent the tubing from draping across the patient. However, there should be enough slack so that the artificial airway isn't accidentally pulled out if the patient turns.
Ventilators are electrical equipment so they must be plugged in. They do have battery back up, but this is not designed for long-term use. It should be ensured that they are plugged into an outlet that will receive generator power if there is an electrical power outage. Ventilators are a method of life-support. If the ventilator should stop working, the patient's life will be in jeopardy. There should be a bag-valve-mask device at the bedside of every patient receiving mechanical ventilation so they can be manually ventilated if needed.
Maintenance
When mechanical ventilation is initiated, the ventilator goes through a self-test to ensure it is working properly. The ventilator tubing should be changed every 24 hours and another self-test run afterwards. The bacteria filters should be checked for occlusions or tears and the water traps and filters should be checked for condensation or contaminants. These should be emptied and cleaned every 24 hours and as needed.
Health care team roles
The respiratory therapist is generally the person who sets up the ventilator, does the daily check described above, and changes the ventilator settings based on the physician's orders. The nurse is responsible for monitoring the alarms and the patient's respiratory status. The nurse is also responsible for notifying the respiratory therapist when mechanical problems occur with the ventilator and when there are new physician orders requiring changes in the settings or the alarm parameters. The physician is responsible for keeping track of the patient's status on the current ventilator settings and changing them when necessary.
Training
Training for using and maintaining ventilators is often done via hands-on methods. Critical care nurses usually have a small amount of class time during which they learn the ventilator modes and settings. They then apply this knowledge while working with patients on the unit under the supervision of a nurse preceptor. This preceptorship usually lasts about six weeks (depending upon the nurse's prior experience) and includes all aspects of critical care. Nurses often learn the most from the respiratory therapists, since ventilator management is their specialty.
Respiratory therapists complete an educational program that specifically focuses on respiratory diseases, and equipment and treatments used to manage those diseases. During orientation to a new job, they work under the supervision of an experienced respiratory therapist to learn how to maintain and manage the ventilators used by that particular institution. Written resources from the company that produced the ventilators are usually kept in the respiratory therapy department for reference.
Physicians generally do not manage the equipment aspect of the ventilator. They do, however, manage the relation of the ventilator settings to the patient's condition. They gain this knowledge of physiology during medical school and residency.
KEY TERMS
Alveoli Saclike structures in the lungs where oxygen and carbon dioxide exchange takes place.
Bag-valve-mask device Device consisting of a manually compressible bag containing oxygen and a one-way valve and mask that fits over the mouth and nose of the patient.
Endotracheal tube Tube inserted into the trachea via either the oral or nasal cavity for the purpose of providing a secure airway.
Hemodynamic stability Stability of blood circulation, including cardiac function and peripheral vascular physiology.
Hypoxic Abnormal deficiency of oxygen in the arterial blood.
Intracranial pressure The amount of pressure exerted inside the skull by brain tissue, blood, and cerebral-spinal fluid.
Peak inspiratory pressure The pressure in the lungs at the end of inspiration.
Pharmacologically paralyzed Short-term paralysis induced by medications for a therapeutic purpose.
Tracheostomy tube Surgically created opening in the trachea for the purpose of providing a secure airway. This is used when the patient requires long-term ventilatory assistance.
Weaning The process of gradually tapering mechanical ventilation and allowing the patient to resume breathing on their own.
BOOKS
Marino, P. The ICU Book. Baltimore: Williams & Wilkins, 1998.
Thelan, Lynne, et al. Critical Care Nursing: Diagnosis and Management. St. Louis: Mosby, 1998.
OTHER
Puritan-Bennett 7200 Series Ventilator System Pocket Guide. Booklet. Mallinckrodt, 2000.
Abby Wojahn, R.N., B.S.N., C.C.R.N.
OSTEOARTHRITIS
Osteoarthritis (AH-stee-oh-ar-THREYE-tis) is the most common type of arthritis, especially among older people. Sometimes it is called degenerative joint disease or osteoarthrosis.
Osteoarthritis is a joint disease that mostly affects the cartilage (KAR-til-uj). Cartilage is the slippery tissue that covers the ends of bones in a joint. Healthy cartilage allows bones to glide over one another. It also absorbs energy from the shock of physical movement. In osteoarthritis, the surface layer of cartilage breaks down and wears away. This allows bones under the cartilage to rub together, causing pain, swelling, and loss of motion of the joint. Over time, the joint may lose its normal shape. Also, bone spurs--small growths called osteophytes--may grow on the edges of the joint. Bits of bone or cartilage can break off and float inside the joint space. This causes more pain and damage.
People with osteoarthritis usually have joint pain and limited movement. Unlike some other forms of arthritis, osteoarthritis affects only joints and not internal organs. For example, rheumatoid arthritis--the second most common form of arthritis--affects other parts of the body besides the joints. It begins at a younger age than osteoarthritis, causes swelling and redness in joints, and may make people feel sick, tired, and (uncommonly) feverish.
How Does Osteoarthritis Affect People?
Osteoarthritis affects each person differently. In some people, it progresses quickly; in others, the symptoms are more serious. Scientists do not know yet what causes the disease, but they suspect a combination of factors, including being overweight, the aging process, joint injury, and stresses on the joints from certain jobs and sports activities.
What Areas Does Osteoarthritis Affect?Osteoarthritis most often occurs at the ends of the fingers, thumbs, neck, lower back, knees, and hips.
Osteoarthritis hurts people in more than their joints: their finances and lifestyles also are affected.
Financial effects include:
-The cost of treatment
-Wages lost because of disability.
Lifestyle effects include:
-Depression
-Anxiety
-Feelings of helplessness
-Limitations on daily activities
-Job limitations
-Trouble participating in everyday personal and family joys and responsibilities.
Despite these challenges, most people with osteoarthritis can lead active and productive lives. They succeed by using osteoarthritis treatment strategies, such as the following:
-Pain relief medications
-Rest and exercise
-Patient education and support programs
-Learning self-care and having a "good-health attitude."
Fighting Osteoarthritis With Exercise
You can use exercises to keep strong and limber, extend your range of movement, and reduce your weight.Some different types of exercise include the following:
Strength exercises:
These can be performed with exercise bands, inexpensive devices that add resistance.Aerobic activities: These keep your lungs and circulation systems in shape.Range of motion activities: These keep your joints limber.Agility exercises: These can help you maintain daily living skills.Neck and back strength exercises: These can help you keep your spine strong and limber.
Ask your doctor or physical therapist what exercises are best for you. Ask for guidelines on exercising when a joint is sore or if swelling is present. Also, check if you should (1) use pain-relieving drugs, such as analgesics or anti-inflammatories (also called NSAIDs), to make exercising easier, or (2) use ice afterwards.
Rest and joint care:
Treatment plans include regularly scheduled rest. Patients must learn to recognize the body's signals, and know when to stop or slow down, which prevents pain caused by overexertion. Some patients find that relaxation techniques, stress reduction, and biofeedback help. Some use canes and splints to protect joints and take pressure off them. Splints or braces provide extra support for weakened joints. They also keep the joint in proper position during sleep or activity. Splints should be used only for limited periods because joints and muscles need to be exercised to prevent stiffness and weakness. An occupational therapist or a doctor can help the patient get a properly fitting splint.
Nondrug pain relief:
People with osteoarthritis may find nondrug ways to relieve pain. Warm towels, hot packs, or a warm bath or shower to apply moist heat to the joint can relieve pain and stiffness. In some cases, cold packs (a bag of ice or frozen vegetables wrapped in a towel can relieve pain or numb the sore area. (Check with a doctor or physical therapist to find out if heat or cold is the best treatment.) Water therapy in a heated pool or whirlpool also may relieve pain and stiffness. For osteoarthritis in the knee, patients may wear insoles or cushioned shoes to redistribute weight and reduce joint stress.
Weight control:
Osteoarthritis patients who are overweight or obese need to lose weight. Weight loss can reduce stress on weight-bearing joints and limit further injury. A dietitian can help patients develop healthy eating habits. A healthy diet and regular exercise help reduce weight.
Osteoarthritis is a joint disease that mostly affects the cartilage (KAR-til-uj). Cartilage is the slippery tissue that covers the ends of bones in a joint. Healthy cartilage allows bones to glide over one another. It also absorbs energy from the shock of physical movement. In osteoarthritis, the surface layer of cartilage breaks down and wears away. This allows bones under the cartilage to rub together, causing pain, swelling, and loss of motion of the joint. Over time, the joint may lose its normal shape. Also, bone spurs--small growths called osteophytes--may grow on the edges of the joint. Bits of bone or cartilage can break off and float inside the joint space. This causes more pain and damage.
People with osteoarthritis usually have joint pain and limited movement. Unlike some other forms of arthritis, osteoarthritis affects only joints and not internal organs. For example, rheumatoid arthritis--the second most common form of arthritis--affects other parts of the body besides the joints. It begins at a younger age than osteoarthritis, causes swelling and redness in joints, and may make people feel sick, tired, and (uncommonly) feverish.
How Does Osteoarthritis Affect People?
Osteoarthritis affects each person differently. In some people, it progresses quickly; in others, the symptoms are more serious. Scientists do not know yet what causes the disease, but they suspect a combination of factors, including being overweight, the aging process, joint injury, and stresses on the joints from certain jobs and sports activities.
What Areas Does Osteoarthritis Affect?Osteoarthritis most often occurs at the ends of the fingers, thumbs, neck, lower back, knees, and hips.
Osteoarthritis hurts people in more than their joints: their finances and lifestyles also are affected.
Financial effects include:
-The cost of treatment
-Wages lost because of disability.
Lifestyle effects include:
-Depression
-Anxiety
-Feelings of helplessness
-Limitations on daily activities
-Job limitations
-Trouble participating in everyday personal and family joys and responsibilities.
Despite these challenges, most people with osteoarthritis can lead active and productive lives. They succeed by using osteoarthritis treatment strategies, such as the following:
-Pain relief medications
-Rest and exercise
-Patient education and support programs
-Learning self-care and having a "good-health attitude."
Fighting Osteoarthritis With Exercise
You can use exercises to keep strong and limber, extend your range of movement, and reduce your weight.Some different types of exercise include the following:
Strength exercises:
These can be performed with exercise bands, inexpensive devices that add resistance.Aerobic activities: These keep your lungs and circulation systems in shape.Range of motion activities: These keep your joints limber.Agility exercises: These can help you maintain daily living skills.Neck and back strength exercises: These can help you keep your spine strong and limber.
Ask your doctor or physical therapist what exercises are best for you. Ask for guidelines on exercising when a joint is sore or if swelling is present. Also, check if you should (1) use pain-relieving drugs, such as analgesics or anti-inflammatories (also called NSAIDs), to make exercising easier, or (2) use ice afterwards.
Rest and joint care:
Treatment plans include regularly scheduled rest. Patients must learn to recognize the body's signals, and know when to stop or slow down, which prevents pain caused by overexertion. Some patients find that relaxation techniques, stress reduction, and biofeedback help. Some use canes and splints to protect joints and take pressure off them. Splints or braces provide extra support for weakened joints. They also keep the joint in proper position during sleep or activity. Splints should be used only for limited periods because joints and muscles need to be exercised to prevent stiffness and weakness. An occupational therapist or a doctor can help the patient get a properly fitting splint.
Nondrug pain relief:
People with osteoarthritis may find nondrug ways to relieve pain. Warm towels, hot packs, or a warm bath or shower to apply moist heat to the joint can relieve pain and stiffness. In some cases, cold packs (a bag of ice or frozen vegetables wrapped in a towel can relieve pain or numb the sore area. (Check with a doctor or physical therapist to find out if heat or cold is the best treatment.) Water therapy in a heated pool or whirlpool also may relieve pain and stiffness. For osteoarthritis in the knee, patients may wear insoles or cushioned shoes to redistribute weight and reduce joint stress.
Weight control:
Osteoarthritis patients who are overweight or obese need to lose weight. Weight loss can reduce stress on weight-bearing joints and limit further injury. A dietitian can help patients develop healthy eating habits. A healthy diet and regular exercise help reduce weight.
Monday, June 25, 2007
Cardiopulmonary resuscitation (CPR): First aid
Cardiopulmonary resuscitation (CPR) is a lifesaving technique useful in many emergencies, including heart attack or near drowning, in which someone's breathing or heartbeat has stopped. CPR involves a combination of mouth-to-mouth rescue breathing and chest compression that keeps oxygenated blood flowing to the brain and other vital organs until more definitive medical treatment can restore a normal heart rhythm.
When the heart stops, the absence of oxygenated blood can cause irreparable brain damage in only a few minutes. Death will occur within eight to 10 minutes. Time is critical when you're helping an unconscious person who isn't breathing.
Remember the ABCs
Airway, Breathing and Circulation — to remember the steps explained below.
AIRWAY: Clear the airway
1. Put the person on his or her back on a firm surface.
2. Kneel next to the person's neck and shoulders.
3. Open the person's airway using the head tilt-chin lift. Put your palm on the person's forehead and gently push down. Then with the other hand, gently lift the chin forward to open the airway.
4. Check for normal breathing, taking no more than 10 seconds: Look for chest motion, listen for breath sounds, and feel for the person's breath on your cheek and ear. Do not consider gasping to be normal breathing. If the person isn't breathing normally or you aren't sure, begin mouth-to-mouth breathing.
BREATHING: Breathe for the person
Rescue breathing can be mouth-to-mouth breathing or mouth-to-nose breathing if the mouth is seriously injured or can't be opened.
1. With the airway open (using the head tilt-chin lift), pinch the nostrils shut for mouth-to-mouth breathing and cover the person's mouth with yours, making a seal.
2. Prepare to give two rescue breaths. Give the first rescue breath — lasting one second — and watch to see if the chest rises. If it does rise, give the second breath. If the chest doesn't rise, repeat the head tilt-chin lift and then give the second breath.
3. Begin chest compressions — go to "CIRCULATION" below.
CIRCULATION: Restore blood circulation
1. Place the heel of one hand over the center of the person's chest, between the nipples. Place your other hand on top of the first hand. Keep your elbows straight and position your shoulders directly above your hands.
2. Use your upper body weight (not just your arms) as you push straight down on (compress) the chest 1 1/2 to 2 inches. Push hard and push fast — give two compressions per second, or about 100 compressions per minute.
3. After 30 compressions, tilt the head back and lift the chin up to open the airway. Prepare to give two rescue breaths. Pinch the nose shut and breathe into the mouth for one second. If the chest rises, give a second rescue breath. If the chest doesn’t rise, repeat the head tilt-chin lift and then give the second rescue breath. That's one cycle. If someone else is available, ask that person to give two breaths after you do 30 compressions.
4. If the person has not begun moving after five cycles (about two minutes) and an automated external defibrillator (AED) is available, open the kit and follow the prompts. If you're not trained to use an AED, a 911 operator may be able to guide you in its use. Trained staff at many public places are also able to provide and use an AED. Use pediatric pads, if available, for children ages 1 to 8. If pediatric pads aren't available, use adult pads. Do not use an AED for infants younger than age 1. If an AED isn't available, go to Number 5 below.
5. Continue CPR until there are signs of movement or until emergency medical personnel take over.
To perform CPR on a child:
The procedure for giving CPR to a child age 1 through 8 is essentially the same as that for an adult. The differences are as follows:
Perform five cycles of compressions and breaths on the child — this should take about two minutes — before calling 911 or the local emergency number, unless someone else can call while you attend to the child.
Use only one hand to perform heart compressions.
Breathe more gently.
Use the same compression/breath rate as is used for adults: 30 compressions followed by two breaths. This is one cycle. Following the two breaths, immediately begin the next cycle of compressions and breaths. Continue until the victim moves or help arrives.
To perform CPR on a baby:
Most cardiac arrests in infants occur from lack of oxygen, such as from drowning or choking. If you know the infant has an airway obstruction, perform first aid for choking. If you don't know why the infant isn't breathing, perform CPR.
To begin, assess the situation. Stroke the baby and watch for a response, such as movement, but don't shake the child.
If there's no response, follow the ABC procedures below and time the call for help as follows:
If you're the only rescuer and CPR is needed, do CPR for two minutes — about five cycles — before calling 911 or your local emergency number.
If another person is available, have that person call for help immediately while you attend to the baby.
AIRWAY: Clear the airway
1. Place the baby on his or her back on firm, flat surface, such as a table. The floor or ground also will do.
2. Gently tip the head back by lifting the chin with one hand and pushing down on the forehead with the other hand.
3. In no more than 10 seconds, put your ear near the baby's mouth and check for breathing: Look for chest motion, listen for breath sounds, and feel for breath on your cheek and ear.
If the infant isn't breathing, begin mouth-to-mouth breathing immediately.
BREATHING: Breathe for the infant
1. Cover the baby's mouth and nose with your mouth.
2. Prepare to give two rescue breaths. Use the strength of your cheeks to deliver gentle puffs of air (instead of deep breaths from your lungs) to slowly breathe into the baby's mouth one time, taking one second for the breath. Watch to see if the baby's chest rises. If it does, give a second rescue breath. If the chest does not rise, repeat the head tilt-chin lift and then give the second breath.
3. If the chest still doesn't rise, examine the mouth to make sure no foreign material is inside. If the object is seen, sweep it out with your finger. If the airway seems blocked, perform first aid for a choking infant.
4. Begin chest compressions — go to "CIRCULATION" below.
CIRCULATION: Restore blood circulation
1. Imagine a horizontal line drawn between the baby's nipples. Place two fingers of one hand just below this line, in the center of the chest.
2. Gently compress the chest to about one-third to one-half the depth of the chest.
3. Count aloud as you pump in a fairly rapid rhythm. You should pump at a rate of about 100 times a minute.
4. Give two breaths after every 30 chest compressions.
5. Perform CPR for about two minutes before calling for help unless someone else can make the call while you attend to the baby.
6. Continue CPR until you see signs of life or until a professional relieves you.
When the heart stops, the absence of oxygenated blood can cause irreparable brain damage in only a few minutes. Death will occur within eight to 10 minutes. Time is critical when you're helping an unconscious person who isn't breathing.
Remember the ABCs
Airway, Breathing and Circulation — to remember the steps explained below.
AIRWAY: Clear the airway
1. Put the person on his or her back on a firm surface.
2. Kneel next to the person's neck and shoulders.
3. Open the person's airway using the head tilt-chin lift. Put your palm on the person's forehead and gently push down. Then with the other hand, gently lift the chin forward to open the airway.
4. Check for normal breathing, taking no more than 10 seconds: Look for chest motion, listen for breath sounds, and feel for the person's breath on your cheek and ear. Do not consider gasping to be normal breathing. If the person isn't breathing normally or you aren't sure, begin mouth-to-mouth breathing.
BREATHING: Breathe for the person
Rescue breathing can be mouth-to-mouth breathing or mouth-to-nose breathing if the mouth is seriously injured or can't be opened.
1. With the airway open (using the head tilt-chin lift), pinch the nostrils shut for mouth-to-mouth breathing and cover the person's mouth with yours, making a seal.
2. Prepare to give two rescue breaths. Give the first rescue breath — lasting one second — and watch to see if the chest rises. If it does rise, give the second breath. If the chest doesn't rise, repeat the head tilt-chin lift and then give the second breath.
3. Begin chest compressions — go to "CIRCULATION" below.
CIRCULATION: Restore blood circulation
1. Place the heel of one hand over the center of the person's chest, between the nipples. Place your other hand on top of the first hand. Keep your elbows straight and position your shoulders directly above your hands.
2. Use your upper body weight (not just your arms) as you push straight down on (compress) the chest 1 1/2 to 2 inches. Push hard and push fast — give two compressions per second, or about 100 compressions per minute.
3. After 30 compressions, tilt the head back and lift the chin up to open the airway. Prepare to give two rescue breaths. Pinch the nose shut and breathe into the mouth for one second. If the chest rises, give a second rescue breath. If the chest doesn’t rise, repeat the head tilt-chin lift and then give the second rescue breath. That's one cycle. If someone else is available, ask that person to give two breaths after you do 30 compressions.
4. If the person has not begun moving after five cycles (about two minutes) and an automated external defibrillator (AED) is available, open the kit and follow the prompts. If you're not trained to use an AED, a 911 operator may be able to guide you in its use. Trained staff at many public places are also able to provide and use an AED. Use pediatric pads, if available, for children ages 1 to 8. If pediatric pads aren't available, use adult pads. Do not use an AED for infants younger than age 1. If an AED isn't available, go to Number 5 below.
5. Continue CPR until there are signs of movement or until emergency medical personnel take over.
To perform CPR on a child:
The procedure for giving CPR to a child age 1 through 8 is essentially the same as that for an adult. The differences are as follows:
Perform five cycles of compressions and breaths on the child — this should take about two minutes — before calling 911 or the local emergency number, unless someone else can call while you attend to the child.
Use only one hand to perform heart compressions.
Breathe more gently.
Use the same compression/breath rate as is used for adults: 30 compressions followed by two breaths. This is one cycle. Following the two breaths, immediately begin the next cycle of compressions and breaths. Continue until the victim moves or help arrives.
To perform CPR on a baby:
Most cardiac arrests in infants occur from lack of oxygen, such as from drowning or choking. If you know the infant has an airway obstruction, perform first aid for choking. If you don't know why the infant isn't breathing, perform CPR.
To begin, assess the situation. Stroke the baby and watch for a response, such as movement, but don't shake the child.
If there's no response, follow the ABC procedures below and time the call for help as follows:
If you're the only rescuer and CPR is needed, do CPR for two minutes — about five cycles — before calling 911 or your local emergency number.
If another person is available, have that person call for help immediately while you attend to the baby.
AIRWAY: Clear the airway
1. Place the baby on his or her back on firm, flat surface, such as a table. The floor or ground also will do.
2. Gently tip the head back by lifting the chin with one hand and pushing down on the forehead with the other hand.
3. In no more than 10 seconds, put your ear near the baby's mouth and check for breathing: Look for chest motion, listen for breath sounds, and feel for breath on your cheek and ear.
If the infant isn't breathing, begin mouth-to-mouth breathing immediately.
BREATHING: Breathe for the infant
1. Cover the baby's mouth and nose with your mouth.
2. Prepare to give two rescue breaths. Use the strength of your cheeks to deliver gentle puffs of air (instead of deep breaths from your lungs) to slowly breathe into the baby's mouth one time, taking one second for the breath. Watch to see if the baby's chest rises. If it does, give a second rescue breath. If the chest does not rise, repeat the head tilt-chin lift and then give the second breath.
3. If the chest still doesn't rise, examine the mouth to make sure no foreign material is inside. If the object is seen, sweep it out with your finger. If the airway seems blocked, perform first aid for a choking infant.
4. Begin chest compressions — go to "CIRCULATION" below.
CIRCULATION: Restore blood circulation
1. Imagine a horizontal line drawn between the baby's nipples. Place two fingers of one hand just below this line, in the center of the chest.
2. Gently compress the chest to about one-third to one-half the depth of the chest.
3. Count aloud as you pump in a fairly rapid rhythm. You should pump at a rate of about 100 times a minute.
4. Give two breaths after every 30 chest compressions.
5. Perform CPR for about two minutes before calling for help unless someone else can make the call while you attend to the baby.
6. Continue CPR until you see signs of life or until a professional relieves you.
Sunday, June 24, 2007
The Gallbladder or Cholecyst
Anatomy
The gallbladder is about 7-10 cm long in humans and appears dark green because of its contents (bile), rather than its tissue. It is connected to the liver and the duodenum by the biliary tract.
The cystic duct connects the gallbladder to the common hepatic duct to form the common bile duct.
The common bile duct then joins the pancreatic duct, and enters through the hepatopancreatic ampulla at the major duodenal papilla.
Microscopic anatomy
The different layers of the gallbladder are as follows:
The gallbladder has a simple columnar epithelial lining characterized by recesses called Aschoff's recesses, which are pouches inside the lining.
Under the epithelium there is a layer of connective tissue (lamina propria).
Beneath the connective tissue is a wall of smooth muscle (muscularis muscosa) that contracts in response to cholecystokinin, a peptide hormone secreted by the duodenum.
There is essentially no submucosa separating the connective tissue from serosa and adventitia.
Stained section of a gall bladder showing the highly convoluted mucosal folds
Function
The gallbladder stores about 50ml of bile (1.7 US fluid ounces / 1.8 Imperial fluid ounces), which is released when food containing fat enters the digestive tract, stimulating the secretion of cholecystokinin (CCK). The bile, produced in the liver, emulsifies fats and neutralizes acids in partly digested food.
After being stored in the gallbladder, the bile becomes more concentrated than when it left the liver, increasing its potency and intensifying its effect on fats. Most digestion occurs in the duodenum.
Role in disease
Cholestasis is the blockage in the supply of bile into the digestive tract. It can be "intrahepatic" (the obstruction is in the liver) or "extrahepatic" (outside the liver). It can lead to jaundice, and is identified by the presence of elevated bilirubin level that is mainly conjugated.
Biliary colic is when a gallstone blocks either the common bile duct or the duct leading into it from the gallbladder.
Up to 25% of all people have gallstones (cholelithiasis), composed of lecithin and bile acids. These can cause abdominal pain, usually in relation with the meal, as the gallbladder contracts and gallstones pass through the bile duct.
Acute or chronic inflammation of the gallbladder (cholecystitis) causes abdominal pain. 90% of cases of acute cholecystitis are caused by the presence of gallstones. The actual inflammation is due to secondary infection with bacteria of an obstructed gallbladder, with the obstruction caused by the gallstone.
When gallstones obstruct the common bile duct (choledocholithiasis), the patient develops jaundice and liver cell damage. It is a medical emergency, requiring endoscopic or surgical treatment such as a cholecystectomy.
A rare clinical entity is ileus (bowel) obstruction by a large gallstone, or gallstone ileus. This condition develops in patients with longstanding gallstone disease, in which the gallbladder forms a fistula with the digestive tract. Large stones pass into the bowel, and generally block the gut at the level of Treitz' ligament or the ileocecal valve, two narrow points in the digestive tract. The treatment is surgical.
Cancer of the gallbladder is a rare but highly fatal disease. It has been associated with gallstone disease, estrogens, cigarette smoking, alcohol consumption and obesity. Despite aggressive modern surgical approaches, advanced imaging techniques, and endoscopy, nearly 90% of patients die from advanced stages of the disease and experience pain, jaundice, weight loss, and ascites.
Polyps (growths) are sometimes detected during diagnostic tests for gallbladder disease. Small gallbladder polyps (up to 10 mm) pose little or no risk, but large ones (greater than 15 mm) pose some risk for cancer, so the gallbladder should be removed. Patients with polyps 10 mm to 15 mm have a lower risk but they should still discuss removal of their gallbladder with their physician. Of special note is a condition called primary sclerosing cholangitis, which causes inflammation and scarring in the bile duct. It is associated with a lifetime risk of 7% to 12% for gallbladder cancer. The cause is unknown, although primary sclerosing cholangitis tends to strike younger men who have ulcerative colitis. Polyps are often detected in this condition and have a very high likelihood of malignancy.
References
^ Physiology at MCG 6/6ch2/s6ch2_30
The gallbladder is about 7-10 cm long in humans and appears dark green because of its contents (bile), rather than its tissue. It is connected to the liver and the duodenum by the biliary tract.
The cystic duct connects the gallbladder to the common hepatic duct to form the common bile duct.
The common bile duct then joins the pancreatic duct, and enters through the hepatopancreatic ampulla at the major duodenal papilla.
Microscopic anatomy
The different layers of the gallbladder are as follows:
The gallbladder has a simple columnar epithelial lining characterized by recesses called Aschoff's recesses, which are pouches inside the lining.
Under the epithelium there is a layer of connective tissue (lamina propria).
Beneath the connective tissue is a wall of smooth muscle (muscularis muscosa) that contracts in response to cholecystokinin, a peptide hormone secreted by the duodenum.
There is essentially no submucosa separating the connective tissue from serosa and adventitia.
Stained section of a gall bladder showing the highly convoluted mucosal folds
Function
The gallbladder stores about 50ml of bile (1.7 US fluid ounces / 1.8 Imperial fluid ounces), which is released when food containing fat enters the digestive tract, stimulating the secretion of cholecystokinin (CCK). The bile, produced in the liver, emulsifies fats and neutralizes acids in partly digested food.
After being stored in the gallbladder, the bile becomes more concentrated than when it left the liver, increasing its potency and intensifying its effect on fats. Most digestion occurs in the duodenum.
Role in disease
Cholestasis is the blockage in the supply of bile into the digestive tract. It can be "intrahepatic" (the obstruction is in the liver) or "extrahepatic" (outside the liver). It can lead to jaundice, and is identified by the presence of elevated bilirubin level that is mainly conjugated.
Biliary colic is when a gallstone blocks either the common bile duct or the duct leading into it from the gallbladder.
Up to 25% of all people have gallstones (cholelithiasis), composed of lecithin and bile acids. These can cause abdominal pain, usually in relation with the meal, as the gallbladder contracts and gallstones pass through the bile duct.
Acute or chronic inflammation of the gallbladder (cholecystitis) causes abdominal pain. 90% of cases of acute cholecystitis are caused by the presence of gallstones. The actual inflammation is due to secondary infection with bacteria of an obstructed gallbladder, with the obstruction caused by the gallstone.
When gallstones obstruct the common bile duct (choledocholithiasis), the patient develops jaundice and liver cell damage. It is a medical emergency, requiring endoscopic or surgical treatment such as a cholecystectomy.
A rare clinical entity is ileus (bowel) obstruction by a large gallstone, or gallstone ileus. This condition develops in patients with longstanding gallstone disease, in which the gallbladder forms a fistula with the digestive tract. Large stones pass into the bowel, and generally block the gut at the level of Treitz' ligament or the ileocecal valve, two narrow points in the digestive tract. The treatment is surgical.
Cancer of the gallbladder is a rare but highly fatal disease. It has been associated with gallstone disease, estrogens, cigarette smoking, alcohol consumption and obesity. Despite aggressive modern surgical approaches, advanced imaging techniques, and endoscopy, nearly 90% of patients die from advanced stages of the disease and experience pain, jaundice, weight loss, and ascites.
Polyps (growths) are sometimes detected during diagnostic tests for gallbladder disease. Small gallbladder polyps (up to 10 mm) pose little or no risk, but large ones (greater than 15 mm) pose some risk for cancer, so the gallbladder should be removed. Patients with polyps 10 mm to 15 mm have a lower risk but they should still discuss removal of their gallbladder with their physician. Of special note is a condition called primary sclerosing cholangitis, which causes inflammation and scarring in the bile duct. It is associated with a lifetime risk of 7% to 12% for gallbladder cancer. The cause is unknown, although primary sclerosing cholangitis tends to strike younger men who have ulcerative colitis. Polyps are often detected in this condition and have a very high likelihood of malignancy.
References
^ Physiology at MCG 6/6ch2/s6ch2_30
Friday, June 22, 2007
The VISA Score for Grading Patellar Tendinosis (Jumper's Knee)
Overview :
The VISA (Victorian Institute of Sport Assessment) score can be used to grade the severity of symptoms in patients with patellar tendinosis (jumper's knee). It can be used to monitor patient's over time and to assess the impact of various interventions.
The Victorian Institute of Sport is in South Melbourne, Victoria, Australia.
Questionnaire
(1) How many minutes can you sit pain free?
• points = INTEGER (MINIMUM (100, (minutes/10))
(2) Do you have pain walking downstairs with a normal gait cycle?
• points from 0 to 10
• severe strong pain: 0 points
• no pain: 10 points
(3) Do you have pain at the knee with full active non-weight bearing knee extension?
• points from 0 to 10
• severe strong pain: 0 points
• no pain: 10 points
(4) Do you have pain when doing a full-weight bearing lung?
• points from 0 to 10
• severe strong pain: 0 points
• no pain: 10 points
(5) Do you have problems squatting?
• points from 0 to 10
• unable: 0 points
• no problems: 10 points
(6) Do you have pain during immediately after doing 10 single leg hops?
• points from 0 to 10
• strong severe pain/unable: 0 points
• no pain: 10 points
(7) Are you currently undertaking sport or other physical activity?
• not at all: 0 points
• modified training +/- modified competition: 4 points
• full training +/- competition but not at same level as when symptoms began: 7 points
• competing at the same or higher level as when symptoms began: 10 points
(8) Complete EITHER 8a, 8b, OR 8c, selecting as follows:
• If you have no pain while undertaking sport, please complete 8A only.
(8a) If you have no while undertaking sport, for how long can you train/practice?
• If you have pain while undertaking sport but it does not stop you from completing the activity, please complete 8b only.
(8b) If you have some pain while undertaking sport, but it does not stop you from completing your training/practice, for how long can you train/practice?
• If you have pain that stops you from completing sporting activities, please complete 8c only.
(8c) If you have pain that stops you from completing your training/practice, for how long can you train/practice?
Question nil 0-5 mts 6-10 mts 11-15 mts > 15 minutes
8a 0 7 14 21 30
8b 0 4 10 14 20
8c 0 2 5 7 10
total VISA score =
= SUM(points for responses to all 8 questions)
Interpretation:
• minimum score: 0
• maximum score: 100
• The higher the score, the better the patient's condition.
• Patients may be categorized into groups based on 81-100, 61-80, and < name="ref">References:
Visentini PJ, Khan KM, et al. The VISA Score: An index of severity of symptoms in patients with jumper's knee (patellar tendinosis). J Science and Medicine in Sport. 1998; 1: 22-28.
The VISA (Victorian Institute of Sport Assessment) score can be used to grade the severity of symptoms in patients with patellar tendinosis (jumper's knee). It can be used to monitor patient's over time and to assess the impact of various interventions.
The Victorian Institute of Sport is in South Melbourne, Victoria, Australia.
Questionnaire
(1) How many minutes can you sit pain free?
• points = INTEGER (MINIMUM (100, (minutes/10))
(2) Do you have pain walking downstairs with a normal gait cycle?
• points from 0 to 10
• severe strong pain: 0 points
• no pain: 10 points
(3) Do you have pain at the knee with full active non-weight bearing knee extension?
• points from 0 to 10
• severe strong pain: 0 points
• no pain: 10 points
(4) Do you have pain when doing a full-weight bearing lung?
• points from 0 to 10
• severe strong pain: 0 points
• no pain: 10 points
(5) Do you have problems squatting?
• points from 0 to 10
• unable: 0 points
• no problems: 10 points
(6) Do you have pain during immediately after doing 10 single leg hops?
• points from 0 to 10
• strong severe pain/unable: 0 points
• no pain: 10 points
(7) Are you currently undertaking sport or other physical activity?
• not at all: 0 points
• modified training +/- modified competition: 4 points
• full training +/- competition but not at same level as when symptoms began: 7 points
• competing at the same or higher level as when symptoms began: 10 points
(8) Complete EITHER 8a, 8b, OR 8c, selecting as follows:
• If you have no pain while undertaking sport, please complete 8A only.
(8a) If you have no while undertaking sport, for how long can you train/practice?
• If you have pain while undertaking sport but it does not stop you from completing the activity, please complete 8b only.
(8b) If you have some pain while undertaking sport, but it does not stop you from completing your training/practice, for how long can you train/practice?
• If you have pain that stops you from completing sporting activities, please complete 8c only.
(8c) If you have pain that stops you from completing your training/practice, for how long can you train/practice?
Question nil 0-5 mts 6-10 mts 11-15 mts > 15 minutes
8a 0 7 14 21 30
8b 0 4 10 14 20
8c 0 2 5 7 10
total VISA score =
= SUM(points for responses to all 8 questions)
Interpretation:
• minimum score: 0
• maximum score: 100
• The higher the score, the better the patient's condition.
• Patients may be categorized into groups based on 81-100, 61-80, and < name="ref">References:
Visentini PJ, Khan KM, et al. The VISA Score: An index of severity of symptoms in patients with jumper's knee (patellar tendinosis). J Science and Medicine in Sport. 1998; 1: 22-28.
Carpal Tunnel Syndrome
Definition
Carpal tunnel syndrome is a disorder caused by compression at the wrist of the median nerve supplying the hand, causing numbness and tingling.
Description
The carpal tunnel is an area in the wrist where the bones and ligaments create a small passageway for the median nerve. The median nerve is responsible for both sensation and movement in the hand, in particular the thumb and first three fingers. When the median nerve is compressed, an individual's hand will feel as if it has "gone to sleep."
Women between the ages of 30 and 60 have the highest rates of carpal tunnel syndrome. Research has demonstrated that carpal tunnel syndrome is a significant cause of missed work days due to pain. In 1995, about $270 million was spent on sick days taken for pain from repetitive motion injuries.
Causes & symptoms
Compression of the median nerve in the wrist can occur during a number of different conditions, particularly those conditions which lead to changes in fluid accumulation throughout the body. Because the area of the wrist through which the median nerve passes is very narrow, any swelling in the area will lead to pressure on the median nerve. This pressure will ultimately interfere with the nerve's ability to function normally. Pregnancy, obesity, arthritis, certain thyroid conditions, diabetes, and certain pituitary abnormalities all predispose to carpal tunnel syndrome. Other conditions that increase the risk for carpal tunnel syndrome include some forms of arthritis and various injuries to the arm and wrist (including fractures, sprains, and dislocations). Furthermore, activities which cause a person to repeatedly bend the wrist inward toward the forearm can predispose to carpal tunnel syndrome. Certain jobs that require repeated strong wrist motions carry a relatively high risk of carpal tunnel syndrome. Injuries of this type are referred to as "repetitive motion" injuries, and are more frequent among secretaries who do a lot of typing, people working at computer keyboards or cash registers, factory workers, and some musicians.
Symptoms of carpal tunnel syndrome include numbness, burning, tingling, and a prickly pin-like sensation over the palm surface of the hand, and into the thumb, forefinger, middle finger, and half of the ring finger. Some individuals notice a shooting pain which goes from the wrist up the arm, or down into the hand and fingers. With continued median nerve compression, an individual may begin to experience muscle weakness, making it difficult to open jars and hold objects with the affected hand. Eventually, the muscles of the hand served by the median nerve may begin to grow noticeably smaller (atrophy), especially the fleshy part of the thumb. Untreated, carpal tunnel syndrome may eventually result in permanent
weakness, loss of sensation, or even paralysis of the thumb and fingers of the affected hand.
Diagnosis
The diagnosis of carpal tunnel syndrome is made in part by checking to see whether the patient's symptoms can be brought on by holding his or her hand with the wrist bent for about a minute. Wrist x rays are often taken to rule out the possibility of a tumor causing pressure on the median nerve. A physician examining a patient suspected of having carpal tunnel syndrome will perform a variety of simple tests to measure muscle strength and sensation in the affected hand and arm. Further testing might include electromyographic or nerve conduction velocity testing to determine the exact severity of nerve damage. These tests involve stimulating the median nerve with electricity and measuring the resulting speed and strength of the muscle response, as well as recording the speed of nerve transmission across the carpal tunnel. In 2002, a report stated that three medical organizations had concluded that electrodiagnostic studies were the preferred methods of diagnosing carpal tunnel syndrome, offering the highest degrees of sensitivity and specificity.
Treatment
Carpal tunnel syndrome is initially treated with splints, which support the wrist and prevent it from flexing inward into the position that exacerbates median nerve compression. Some people get significant relief by wearing such splints to sleep at night, while others will need to wear the splints all day, especially if they are performing jobs that stress the wrist.
The activity which caused the condition should be avoided whenever possible. Also, the actions of making a fist, holding objects, and typing should be reduced. The patient's work area should be modified to reduce stress on the body. This may be achieved by correct positioning and with ergonomically designed furniture. Performing hand and wrist exercises periodically throughout the day can be beneficial.
Researchers found that the carpal ligament can be lengthened or released without surgery through osteopathic manipulation and weight loading. Combining the two gives additional benefit because manipulation lengthens the ligament at one end and weight loading increases the length at the other end. Patients can be taught a stretching exercise for self-manipulation of the ligament.
A National Institute of Health (NIH) panel concluded that traditional acupuncture may be a useful alternative or complementary treatment for carpal tunnel syndrome. Studies have shown that both laser acupuncture and microamp transcutaneous electrical nerve stimulation (TENS) can significantly reduce the pain associated with carpal tunnel syndrome. Both of these therapies are painless. Greater than 90% of the patients treated reported no pain or pain that had been reduced by more than half. Patients in this study were also using Chinese herbal medicines, deep acupuncture (including needle acupuncture), moxibustion, and omega-3 fish oil capsules. All patients were able to return to work and the pain of most patients remained stable for up to two years. Persons over the age of 60 years had a poorer response.
Some studies have shown that persons with carpal tunnel syndrome are deficient in vitamin B6 (pyridoxine) and that supplementation with this vitamin is beneficial. Carpal tunnel syndrome should improve within two to three months by taking 100 mg three times daily. The patient should consult with his or her physician when taking high doses of this vitamin.
Chinese and homeopathic remedies include:
arnica; 30c dose
astra essence
Rhus toxicodendron; 6c dose
Ruta graveolens; 6c dose
Allopathic treatment
Ibuprofen or other nonsteroidal anti-inflammatory drugs may be prescribed to decrease pain and swelling. Diuretics may be used if the syndrome is related to the menstrual cycle. When carpal tunnel syndrome is more advanced, steroids may be injected into the wrist to decrease inflammation.
The most severe cases of carpal tunnel syndrome may require surgery to decrease the compression of the median nerve and restore its normal function. Such a repair involves cutting that ligament that crosses the wrist, thus allowing the median nerve more room and decreasing compression. This surgery is done almost exclusively on an outpatient basis and is often performed without the patient having to be made unconscious. Careful injection of numbing medicines (local anesthesia) or nerve blocks (the injection of anesthetics directly into the nerve) create sufficient numbness to allow the surgery to be performed painlessly, without the risks associated with general anesthesia. Recovery from this type of surgery is usually quick and without complications.
In 2002, researchers in the Netherlands reported that after studying about 80 patients over two years, surgery proved more successful than nighttime splints in freeing up compressed nerves of patients with carpal tunnel syndrome. Many patients in the splint group ended up choosing the surgery option after several months of wearing splints.
Expected results
Without treatment, continued pressure on the median nerve puts the patient at risk for permanent disability in the affected hand. Alternative medicines have been shown to reduce pain. Most people are able to control the symptoms of carpal tunnel syndrome with splinting and anti-inflammatory agents. For those who go on to require surgery, about 95% will have complete cessation of symptoms.
Prevention
Avoiding or reducing the repetitive motions that put the wrist into a bent position may help to prevent carpal tunnel syndrome. People who must work long hours at a computer keyboard, for example, may need to take advantage of recent advances in ergonomics and position the keyboard and computer components in a way that increases efficiency and decreases stress. Early use of a splint may also be helpful for persons whose jobs put them at risk of carpal tunnel syndrome.
Carpal tunnel syndrome is a disorder caused by compression at the wrist of the median nerve supplying the hand, causing numbness and tingling.
Description
The carpal tunnel is an area in the wrist where the bones and ligaments create a small passageway for the median nerve. The median nerve is responsible for both sensation and movement in the hand, in particular the thumb and first three fingers. When the median nerve is compressed, an individual's hand will feel as if it has "gone to sleep."
Women between the ages of 30 and 60 have the highest rates of carpal tunnel syndrome. Research has demonstrated that carpal tunnel syndrome is a significant cause of missed work days due to pain. In 1995, about $270 million was spent on sick days taken for pain from repetitive motion injuries.
Causes & symptoms
Compression of the median nerve in the wrist can occur during a number of different conditions, particularly those conditions which lead to changes in fluid accumulation throughout the body. Because the area of the wrist through which the median nerve passes is very narrow, any swelling in the area will lead to pressure on the median nerve. This pressure will ultimately interfere with the nerve's ability to function normally. Pregnancy, obesity, arthritis, certain thyroid conditions, diabetes, and certain pituitary abnormalities all predispose to carpal tunnel syndrome. Other conditions that increase the risk for carpal tunnel syndrome include some forms of arthritis and various injuries to the arm and wrist (including fractures, sprains, and dislocations). Furthermore, activities which cause a person to repeatedly bend the wrist inward toward the forearm can predispose to carpal tunnel syndrome. Certain jobs that require repeated strong wrist motions carry a relatively high risk of carpal tunnel syndrome. Injuries of this type are referred to as "repetitive motion" injuries, and are more frequent among secretaries who do a lot of typing, people working at computer keyboards or cash registers, factory workers, and some musicians.
Symptoms of carpal tunnel syndrome include numbness, burning, tingling, and a prickly pin-like sensation over the palm surface of the hand, and into the thumb, forefinger, middle finger, and half of the ring finger. Some individuals notice a shooting pain which goes from the wrist up the arm, or down into the hand and fingers. With continued median nerve compression, an individual may begin to experience muscle weakness, making it difficult to open jars and hold objects with the affected hand. Eventually, the muscles of the hand served by the median nerve may begin to grow noticeably smaller (atrophy), especially the fleshy part of the thumb. Untreated, carpal tunnel syndrome may eventually result in permanent
weakness, loss of sensation, or even paralysis of the thumb and fingers of the affected hand.
Diagnosis
The diagnosis of carpal tunnel syndrome is made in part by checking to see whether the patient's symptoms can be brought on by holding his or her hand with the wrist bent for about a minute. Wrist x rays are often taken to rule out the possibility of a tumor causing pressure on the median nerve. A physician examining a patient suspected of having carpal tunnel syndrome will perform a variety of simple tests to measure muscle strength and sensation in the affected hand and arm. Further testing might include electromyographic or nerve conduction velocity testing to determine the exact severity of nerve damage. These tests involve stimulating the median nerve with electricity and measuring the resulting speed and strength of the muscle response, as well as recording the speed of nerve transmission across the carpal tunnel. In 2002, a report stated that three medical organizations had concluded that electrodiagnostic studies were the preferred methods of diagnosing carpal tunnel syndrome, offering the highest degrees of sensitivity and specificity.
Treatment
Carpal tunnel syndrome is initially treated with splints, which support the wrist and prevent it from flexing inward into the position that exacerbates median nerve compression. Some people get significant relief by wearing such splints to sleep at night, while others will need to wear the splints all day, especially if they are performing jobs that stress the wrist.
The activity which caused the condition should be avoided whenever possible. Also, the actions of making a fist, holding objects, and typing should be reduced. The patient's work area should be modified to reduce stress on the body. This may be achieved by correct positioning and with ergonomically designed furniture. Performing hand and wrist exercises periodically throughout the day can be beneficial.
Researchers found that the carpal ligament can be lengthened or released without surgery through osteopathic manipulation and weight loading. Combining the two gives additional benefit because manipulation lengthens the ligament at one end and weight loading increases the length at the other end. Patients can be taught a stretching exercise for self-manipulation of the ligament.
A National Institute of Health (NIH) panel concluded that traditional acupuncture may be a useful alternative or complementary treatment for carpal tunnel syndrome. Studies have shown that both laser acupuncture and microamp transcutaneous electrical nerve stimulation (TENS) can significantly reduce the pain associated with carpal tunnel syndrome. Both of these therapies are painless. Greater than 90% of the patients treated reported no pain or pain that had been reduced by more than half. Patients in this study were also using Chinese herbal medicines, deep acupuncture (including needle acupuncture), moxibustion, and omega-3 fish oil capsules. All patients were able to return to work and the pain of most patients remained stable for up to two years. Persons over the age of 60 years had a poorer response.
Some studies have shown that persons with carpal tunnel syndrome are deficient in vitamin B6 (pyridoxine) and that supplementation with this vitamin is beneficial. Carpal tunnel syndrome should improve within two to three months by taking 100 mg three times daily. The patient should consult with his or her physician when taking high doses of this vitamin.
Chinese and homeopathic remedies include:
arnica; 30c dose
astra essence
Rhus toxicodendron; 6c dose
Ruta graveolens; 6c dose
Allopathic treatment
Ibuprofen or other nonsteroidal anti-inflammatory drugs may be prescribed to decrease pain and swelling. Diuretics may be used if the syndrome is related to the menstrual cycle. When carpal tunnel syndrome is more advanced, steroids may be injected into the wrist to decrease inflammation.
The most severe cases of carpal tunnel syndrome may require surgery to decrease the compression of the median nerve and restore its normal function. Such a repair involves cutting that ligament that crosses the wrist, thus allowing the median nerve more room and decreasing compression. This surgery is done almost exclusively on an outpatient basis and is often performed without the patient having to be made unconscious. Careful injection of numbing medicines (local anesthesia) or nerve blocks (the injection of anesthetics directly into the nerve) create sufficient numbness to allow the surgery to be performed painlessly, without the risks associated with general anesthesia. Recovery from this type of surgery is usually quick and without complications.
In 2002, researchers in the Netherlands reported that after studying about 80 patients over two years, surgery proved more successful than nighttime splints in freeing up compressed nerves of patients with carpal tunnel syndrome. Many patients in the splint group ended up choosing the surgery option after several months of wearing splints.
Expected results
Without treatment, continued pressure on the median nerve puts the patient at risk for permanent disability in the affected hand. Alternative medicines have been shown to reduce pain. Most people are able to control the symptoms of carpal tunnel syndrome with splinting and anti-inflammatory agents. For those who go on to require surgery, about 95% will have complete cessation of symptoms.
Prevention
Avoiding or reducing the repetitive motions that put the wrist into a bent position may help to prevent carpal tunnel syndrome. People who must work long hours at a computer keyboard, for example, may need to take advantage of recent advances in ergonomics and position the keyboard and computer components in a way that increases efficiency and decreases stress. Early use of a splint may also be helpful for persons whose jobs put them at risk of carpal tunnel syndrome.
Thursday, June 21, 2007
How to Lift and Carry Safely
Lifting and carrying are power jobs—when you lift and carry the wrong way, you can damage your back. Back injuries are the most common type of injury in the workplace, causing approximately 900,000 disabling injuries in 1995. Over half of these injuries are from lifting.
Back injuries may be difficult to treat and may have lengthy and expensive rehabilitation times.
Whether you are lifting at home or at work, make an effort to take care of your back. The National Safety Council recommends a number of tips to prevent unintentional injuries and keep your back strong and healthy.
Power warm-ups
You will work better if you start each day with slow stretches. These warm-ups let you ease comfortably into your workday and help you avoid injuries.
Leg and back warm-up
Prop one foot on a chair or a stool for support
Take a deep breath
Ease forward slowly—keep your back slightly curved
Blow slowly outward as you ease forward to a seven count
Repeat seven times
Switch and do the same with the other foot
Backbend
Stand with your feet about 12 inches apart
Support the small of your back with your hands
Hold your stomach in firmly and take a deep breath
Arch backward—bend your head and neck as you go, blowing air slowly out for seven counts
Repeat seven times
Power lifting tips
Protect your hands and feet by wearing safety gear
Size up the load—tip it on its side to see if you can carry it comfortably. Get help if the load is too big or bulky for one person. Check for nails, splinters, rough strapping and sharp edges
Lift it right—make sure your footing is solid. Keep your back straight, with no curving or slouching. Center your body over your feet, get a good grip on the object and pull it close to you. Pull your stomach in firmly. Lift with your legs, not your back; if you need to turn, move your feet and don't twist your back
Tough lifting jobs
Oversized loads: do not try to carry a big load alone; ask for help. Work as a team by lifting, walking and lowering the load together. Let one person call the shots and direct the lift. Use proper mechanical devices for heavy loads.
High loads: use a step stool or a sturdy ladder to reach loads that are above your shoulders. Get as close to the load as you can and slide the load toward you. Do all the work with your arms and legs, not your back.
Low loads: loads that are under racks and cabinets need extra care. Pull the load toward you, then try to support it on one knee before you lift. Use your legs to power the lift.
Always use your stomach as a low back support by pulling it in during lifting.
Remember, a strong, healthy, powerful back is vital to your job. It also helps you enjoy life. Take pains to avoid injuries by making it a full-time job to take care of your back!
Back injuries may be difficult to treat and may have lengthy and expensive rehabilitation times.
Whether you are lifting at home or at work, make an effort to take care of your back. The National Safety Council recommends a number of tips to prevent unintentional injuries and keep your back strong and healthy.
Power warm-ups
You will work better if you start each day with slow stretches. These warm-ups let you ease comfortably into your workday and help you avoid injuries.
Leg and back warm-up
Prop one foot on a chair or a stool for support
Take a deep breath
Ease forward slowly—keep your back slightly curved
Blow slowly outward as you ease forward to a seven count
Repeat seven times
Switch and do the same with the other foot
Backbend
Stand with your feet about 12 inches apart
Support the small of your back with your hands
Hold your stomach in firmly and take a deep breath
Arch backward—bend your head and neck as you go, blowing air slowly out for seven counts
Repeat seven times
Power lifting tips
Protect your hands and feet by wearing safety gear
Size up the load—tip it on its side to see if you can carry it comfortably. Get help if the load is too big or bulky for one person. Check for nails, splinters, rough strapping and sharp edges
Lift it right—make sure your footing is solid. Keep your back straight, with no curving or slouching. Center your body over your feet, get a good grip on the object and pull it close to you. Pull your stomach in firmly. Lift with your legs, not your back; if you need to turn, move your feet and don't twist your back
Tough lifting jobs
Oversized loads: do not try to carry a big load alone; ask for help. Work as a team by lifting, walking and lowering the load together. Let one person call the shots and direct the lift. Use proper mechanical devices for heavy loads.
High loads: use a step stool or a sturdy ladder to reach loads that are above your shoulders. Get as close to the load as you can and slide the load toward you. Do all the work with your arms and legs, not your back.
Low loads: loads that are under racks and cabinets need extra care. Pull the load toward you, then try to support it on one knee before you lift. Use your legs to power the lift.
Always use your stomach as a low back support by pulling it in during lifting.
Remember, a strong, healthy, powerful back is vital to your job. It also helps you enjoy life. Take pains to avoid injuries by making it a full-time job to take care of your back!
BACK CARE FOR SITTING WORK
Professor Alan Hedge, PhD Director Human Factors and Ergonomics Laboratory Cornell UniversityDepartment of Design and Environmental Analysis Ithaca, NY http://ergo.human.cornell.edu
Sitting has become a way of life for many Americans. We sit in cars, buses, trains or planes when we travel, we sit to eat meals, we sit and watch TV, we sit in classrooms, and for many of us, we sit most of the day at work, often in front of a computer all day. Studies of sedentary workers show that low back problems are associated with poor chair design and inappropriate sitting posture.
Although for many activities we could stand just as easily as sit, for example, we could stand to watch TV, stand to eat, and stand in front of a computer all day. There are at least three good reasons why we prefer sitting.
Sitting uses about 20% less energy compared with standing to do the same work, so comfortable sitting helps to relieve fatigue.
Sitting helps to reduce the strain on our back muscles and on the intervertebral discs of the lumbar spine, providing that we sit back in a supported, reclined posture.
Sitting gives us greater postural stability for performing fine manipulative tasks, such as eating with a knife and fork, sewing, writing, etc.
(Image reproduced courtesy of Humanscale)
Anatomical Changes During Sitting
When we change from a standing posture to a sitting posture anatomical changes occur. The lumbar spine changes shape depending on what we sit on and how we sit. If we sit on a flat surface, such as a bench, bleachers or stool, without any back support we tend to hunch the body forwards for support, often resting our arms on our legs to reduce fatigue. As we hunch forwards, the lower back curves outwards into a kyphotic shape. This is generally regarded as an unhealthy posture if sustained for a prolonged period. With nothing to lean back on, the upper body becomes fatigued and we typically regard this as an uncomfortable way to sit. However, this is the way that many people end up sitting over the course of each workday, so it isn't surprising that studies of sedentary workers, such as office workers, have frequently reported high levels of postural discomfort. [2] What we want is to be able to sit and maintain the lumbar spine in a posture called lordosis.
Ergonomic Chair Design
If we sit on a good ergonomic chair, the seat pan is curved from back to front to encourage the pelvis to rotate forwards, and this helps the lumbar spine to maintain lordosis. As we sit back the lower back should be well supported by a contoured lumbar support. The average preferred height for a good lumbar support is abut 7.5 -inches above the compressed seat surface (19 cm), and the mean preferred seat depth (horizontal distance from front of seat to lumbar support point) is about 15.25-inches (38.7 cm). Ideally, the chair should have a backrest that is sufficient high to provide support to the thoracic region as well. [3] Also, make sure that the seat is height adjustable (15" - 22"), the backrest angle is adjustable (100° - 120°), the armrests have a minimum 16.1” width and have adjustable height (7.1”-10.6” above compressed seat height). [4] Studies of office chairs show that users often cannot correctly identify or operate chair controls [5], so make sure that the chair has user-friendly controls.
(Image reproduced courtesy of Humanscale)
Safe Sitting
Keeping the spine healthy requires periodic changes in posture, and dynamic movement helps to promote circulation and reduce muscle fatigue. Sitting in any static posture for a prolonged period eventually will become uncomfortable. This means that there isn't a fixed posture that's best for everyone, all of the time, whatever the task at hand. Rather, there is a desirable range of movement that works well for most people doing most of the kinds of tasks performed when sitting.
The preferred way of sitting involves the following:
Make sure that the seat height is correctly adjusted so that your feet are on the ground or on a solid surface like a good footrest.
Recline back in the chair, with the chair backrest angled between 100-110-degrees, so that the chair back can help support the weight of the torso.
Make sure that the chair has good lumbar support in the right area for your shape and size of back. If there is an adjustable support, use this to get the best position. If not, use a rolled towel or a cushion to improve your lower back support.
Make sure that the seat pan is the right size for you and doesn't press behind your knees.
Look for a chair that doesn't tip up the seat pan when you recline because this can put pressure under the thighs and behind the knees.
If the chair has arms, make sure that these are correctly adjusted for height so that your shoulders are relaxed, not hunched or raised when you rest on the armrests.
If the chair has a high neck/headrest make sure that this can be used in different sitting positions.
Now that your body is in a good, supported posture you should be ready to work without any discomfort, but remember to take periodic breaks, and to change posture, get up and move around.
(Image reproduced courtesy of Humanscale)
Tips for Choosing the Best Ergonomic Chair
When choosing a chair ask yourself the following questions:
1. Is the chair comfortable to sit in for the way that you work?
a) Does the shape of the seat fit you and let your legs move freely?
b) Is the cushioning comfortable and made of a breathable material?
c) Do you have at least one-inch free space on either side of your hips and thighs?
d) Do you have at least one-inch free space between the edge of the seat and the back of your knees?
e) Can you sit comfortably with your feet on the floor or a footrest?
2. Can you easily adjust the important features of the chair?
a) Can you adjust seat height while you are sitting in the chair?
b) Is the range of height adjustment of the chair adequate?
c) Can you adjust the position of the lumbar support and is this comfortable?
d) Can you recline the chair back to a comfortable position?
e) Are the controls easy to understand and use?
3. Is the chair stable when you sit on it?
a) Does it have a 5+ pedestal base so it won't easily tip over?
b) Does the chair move easily when you need to?
c) Can you swivel easily so that you don't have to twist your back to turn?
4. Does the chair have comfortable armrests?
a) Are the armrests broad, contoured, and adequately cushioned?
b) While sitting can you adjust the height of the armrests?
c) Can you easily move the arms out of the way if you need to do this?
If you answered "No" to any of the questions then the chair you are considering might not be right for you. If you answered "Yes" to all of the questions, then this chair will work for you. Remember, you will probably sit for a large part of your life, so make sure that your chair is a source of comfort and pleasure, not discomfort and pain.
Professor Alan Hedge, PhD Director Human Factors and Ergonomics Laboratory Cornell UniversityDepartment of Design and Environmental Analysis Ithaca, NY http://ergo.human.cornell.edu
Sitting has become a way of life for many Americans. We sit in cars, buses, trains or planes when we travel, we sit to eat meals, we sit and watch TV, we sit in classrooms, and for many of us, we sit most of the day at work, often in front of a computer all day. Studies of sedentary workers show that low back problems are associated with poor chair design and inappropriate sitting posture.
Although for many activities we could stand just as easily as sit, for example, we could stand to watch TV, stand to eat, and stand in front of a computer all day. There are at least three good reasons why we prefer sitting.
Sitting uses about 20% less energy compared with standing to do the same work, so comfortable sitting helps to relieve fatigue.
Sitting helps to reduce the strain on our back muscles and on the intervertebral discs of the lumbar spine, providing that we sit back in a supported, reclined posture.
Sitting gives us greater postural stability for performing fine manipulative tasks, such as eating with a knife and fork, sewing, writing, etc.
(Image reproduced courtesy of Humanscale)
Anatomical Changes During Sitting
When we change from a standing posture to a sitting posture anatomical changes occur. The lumbar spine changes shape depending on what we sit on and how we sit. If we sit on a flat surface, such as a bench, bleachers or stool, without any back support we tend to hunch the body forwards for support, often resting our arms on our legs to reduce fatigue. As we hunch forwards, the lower back curves outwards into a kyphotic shape. This is generally regarded as an unhealthy posture if sustained for a prolonged period. With nothing to lean back on, the upper body becomes fatigued and we typically regard this as an uncomfortable way to sit. However, this is the way that many people end up sitting over the course of each workday, so it isn't surprising that studies of sedentary workers, such as office workers, have frequently reported high levels of postural discomfort. [2] What we want is to be able to sit and maintain the lumbar spine in a posture called lordosis.
Ergonomic Chair Design
If we sit on a good ergonomic chair, the seat pan is curved from back to front to encourage the pelvis to rotate forwards, and this helps the lumbar spine to maintain lordosis. As we sit back the lower back should be well supported by a contoured lumbar support. The average preferred height for a good lumbar support is abut 7.5 -inches above the compressed seat surface (19 cm), and the mean preferred seat depth (horizontal distance from front of seat to lumbar support point) is about 15.25-inches (38.7 cm). Ideally, the chair should have a backrest that is sufficient high to provide support to the thoracic region as well. [3] Also, make sure that the seat is height adjustable (15" - 22"), the backrest angle is adjustable (100° - 120°), the armrests have a minimum 16.1” width and have adjustable height (7.1”-10.6” above compressed seat height). [4] Studies of office chairs show that users often cannot correctly identify or operate chair controls [5], so make sure that the chair has user-friendly controls.
(Image reproduced courtesy of Humanscale)
Safe Sitting
Keeping the spine healthy requires periodic changes in posture, and dynamic movement helps to promote circulation and reduce muscle fatigue. Sitting in any static posture for a prolonged period eventually will become uncomfortable. This means that there isn't a fixed posture that's best for everyone, all of the time, whatever the task at hand. Rather, there is a desirable range of movement that works well for most people doing most of the kinds of tasks performed when sitting.
The preferred way of sitting involves the following:
Make sure that the seat height is correctly adjusted so that your feet are on the ground or on a solid surface like a good footrest.
Recline back in the chair, with the chair backrest angled between 100-110-degrees, so that the chair back can help support the weight of the torso.
Make sure that the chair has good lumbar support in the right area for your shape and size of back. If there is an adjustable support, use this to get the best position. If not, use a rolled towel or a cushion to improve your lower back support.
Make sure that the seat pan is the right size for you and doesn't press behind your knees.
Look for a chair that doesn't tip up the seat pan when you recline because this can put pressure under the thighs and behind the knees.
If the chair has arms, make sure that these are correctly adjusted for height so that your shoulders are relaxed, not hunched or raised when you rest on the armrests.
If the chair has a high neck/headrest make sure that this can be used in different sitting positions.
Now that your body is in a good, supported posture you should be ready to work without any discomfort, but remember to take periodic breaks, and to change posture, get up and move around.
(Image reproduced courtesy of Humanscale)
Tips for Choosing the Best Ergonomic Chair
When choosing a chair ask yourself the following questions:
1. Is the chair comfortable to sit in for the way that you work?
a) Does the shape of the seat fit you and let your legs move freely?
b) Is the cushioning comfortable and made of a breathable material?
c) Do you have at least one-inch free space on either side of your hips and thighs?
d) Do you have at least one-inch free space between the edge of the seat and the back of your knees?
e) Can you sit comfortably with your feet on the floor or a footrest?
2. Can you easily adjust the important features of the chair?
a) Can you adjust seat height while you are sitting in the chair?
b) Is the range of height adjustment of the chair adequate?
c) Can you adjust the position of the lumbar support and is this comfortable?
d) Can you recline the chair back to a comfortable position?
e) Are the controls easy to understand and use?
3. Is the chair stable when you sit on it?
a) Does it have a 5+ pedestal base so it won't easily tip over?
b) Does the chair move easily when you need to?
c) Can you swivel easily so that you don't have to twist your back to turn?
4. Does the chair have comfortable armrests?
a) Are the armrests broad, contoured, and adequately cushioned?
b) While sitting can you adjust the height of the armrests?
c) Can you easily move the arms out of the way if you need to do this?
If you answered "No" to any of the questions then the chair you are considering might not be right for you. If you answered "Yes" to all of the questions, then this chair will work for you. Remember, you will probably sit for a large part of your life, so make sure that your chair is a source of comfort and pleasure, not discomfort and pain.
Sunday, June 17, 2007
Pain
Exercises for pain relief
It is essential that you consult your health professional before commencing these exercises. Robin Mckenzie has written an easy to follow guide called "Treat your own back" and invented the following exercises. Exercise One Lying Face Down Lie face down with your arms beside your body and your head turned to one side Stay in this position, take a few deep breaths and then relax completely for four to five minutes. You must make a conscious effort to remove all tension from the muscles in your lower back; without COMPLETE RELAXATION there is NO CHANCE of ELIMINATING any DISTORTION that may be present in the joint. This exercise is used mainly in the treatment of acute back pain that is pain that is short-lived and is one of the First Aid exercises. It should be done once at the BEGINNING of EACH exercise session, and the sessions are to be spread evenly six to eight times throughout the day. This means that you should repeat the sessions about every two hours. In addition, you must lie face down whenever you are resting. When in acute pain you should avoid sitting, at least during the first few days. Exercise Two Lying Face Down in Extension Remain face down. Place your elbows under your shoulders so that you lean on your forearms. During this exercise you should commence taking in a few deep breaths and allow the muscles in the lower back to relax completely. Again you should stay in this position for about five minutes. You must make a conscious effort to remove all tension from the muscles in your lower back; without COMPLETE RELAXATION there is NO CHANCE of ELIMINATING any DISTORTION that may be present in the joint. This exercise is used mainly in the treatment of severe low back pain and is one of the First Aid exercises it should always follow exercise one and is to be performed once per session. Should you experience severe and increasing pain on attempting this exercise, there are certain measures to be taken before you can continue exercising, these are discussed in the section 'No response or benefit' Exercise Three Extension in Lying Remain face down. Place your elbows under your shoulders in the press-up position. Now you are ready to start exercise 3. Straighten your elbows and push the top half of your body up as far as the pain permits. It is important that you completely relax the pelvis, hips and legs as you do this. Keep your pelvis, hips and legs hanging limp and allow your back to sag. Once you have maintained this position for a second or two, you should lower yourself to the starting position. Each time you repeat this movement cycle you must try to raise your upper body a little higher, so that in the end your back is extended as much as possible with your arms as straight as possible. Once your arms are straight, remember to hold the sag for a second or two as this is a most important part of the exercise. The sag may be maintained for longer than one or two seconds if you feel the pain reducing or centralizing. This is the most useful and effective first aid procedure in the treatment of acute low back pain. The exercise can also be used to treat stiffness of the low back, and to PREVENT low back pain RECURRING once you are fully recovered. When used in the treatment of either pain or stiffness, the exercise should be performed ten times per session and the sessions are to be spread evenly six to eight times throughout the day. Should you not respond or have increasing pain on attempting this exercise, there are certain measures to be taken before you can continue exercising, these are discussed in the section 'No response or benefit' read it now. Exercise Four Extension in Standing Stand upright with your feet slightly apart. Place your hands in the small of your back with your fingers pointing backwards and your thumbs pointing forwards. You are now ready to start Exercise Four Bend your trunk backwards at the waist as far as you can, using your hands as a fulcrum. It is important that you keep your knees straight as you do this. Once you have maintained this position for a second or two you should return to the starting position. Each time you repeat this movement cycle, you should try to bend backwards a little further so that in the end you have reached the maximum possible degree of extension. When you are in acute pain, this exercise may replace exercise 3 should circumstances prevent you from exercising in the lying position. This exercise however is not as effective as exercise 3. Once you have fully recovered and no longer have low back pain, this exercise is your MAIN TOOL in the PREVENTION of further BACK PROBLEMS As a preventive measure, repeat the exercise every once in a while whenever you find yourself working in a forward bent position. Perform the exercise BEFORE the pain appears. Exercise Five Flexion in Lying Lie on your back with your knees bent and you feet flat on the floor or bed. You are now ready to start Exercise Five Bring both knees up towards the chest. Place both hands around your knees and gently but firmly pull the knees as close to the chest as the pain permits. Once you have maintained this position for a second or two you should lower the legs and return to the starting position. It is important that you DO NOT RAISE YOUR HEAD as you perform this exercise, or STRAIGHTEN YOUR LEGS AS YOU LOWER THEM. Each time you repeat this movement cycle, you should try to pull your knees a little further so that in the end you have reached the maximum possible degree of flexion. At this stage your knees may touch the chest. This exercise is used in the treatment of stiffness in the low back which may have developed since your injury or pain began. While damaged tissues may have now healed, they may have also shortened and become less flexible; it is now necessary to restore their elasticity and full function by performing flexion exercises. These exercises should be commenced with caution. In the beginning you must only do five or six per session, and the sessions are to be repeated three or four times per day. As you have probably realized, this exercise eliminates the lordosis once the knees are bent to the chest, so in order to rectify any distortion that may result, FLEXION EXERCISES MUST ALWAYS BE FOLLOWED BY A SESSION OF EXERCISE 3 - EXTENSION IN LYING. You may stop performing Exercise 4 when you can readily pull the knees to the chest without producing tightness or pain. You may then progress to Exercise 6 Exercise Six Flexion in Sitting Sit on the edge of a steady chair with your knees and feet well apart and let your hands rest between your legs. You are now ready to start Exercise 6 Bend your trunk forwards and touch the floor with your hands. Return immediately to the starting position. Each time you repeat this movement cycle you must bend down a little further so that end you have reached the maximum possible degree of flexion. At this reached the maximum possible degree of flexion and your head is as close as possible to the floor. The exercise can be made more effective by holding on to your ankles with your hands and pulling yourself down further. Exercise 6 SHOULD ONLY BE COMMENCED AFTER THE COMPLETION OF ONE WEEK OF EXERCISE 5, WHETHER EXERCISE 5 HAS BEEN SUCCESSFUL OR NOT IN REDUCING YOUR STIFFNESS OR PAIN. In the beginning you must only do five or six repetitions per session and the sessions are to be repeated three or four times per day. FLEXION EXERCISES MUST ALWAYS BE FOLLOWED BY A SESSION OF EXERCISE 3 - EXTENSION IN LYING. No Response or Benefit after exercising without any relief or benefit for three or four days, you may conclude that the exercises as performed are ineffectual. There are two main causes for lack of response or benefit from these exercises. A lack of response to these exercises is possible in some people when their pain is felt only to one side of the spine, or is felt much more to one side than the other. If your pain during the course of the day is felt only to one side, more to one side as you perform Exercises 1, 2, 3 you may need to modify your body position before commencing them. To achieve this modification, you should: 1. Adopt a position to perform Exercise 1 and allow yourself to relax for a few minutes. 2. Remain face down and now shift your hips AWAY from the PAINFUL side; that is if your pain is usually more on the right side you must move your hips three or four inches to the left, and once more completely relax for a few minutes. 3. While allowing the hips to remain off-centre, lean on the elbows as described in exercise two and relax for a further three or four minutes. You are now ready to commence Exercise 3. With the hips still off-centre, complete one session of Exercise 3 and relax once more. You may need to repeat the exercise several times but before commencing each session of ten you should ensure that the hips are still off centre; remember, away from the painful side. Even with your hips in the off-centre position, you should try with each repetition to move higher and higher. You should reach the maximum amount of extension possible at which time the arms should be completely straight. For the next three or four days you should continue to perform Exercises 1, 2, 3 from the modified starting position. After a few days of practice you may notice that the pain is distributed more evenly across the back or may have centralized. Once this occurs you may stop shifting the hips before exercising and continue exercising as described earlier. Occasionally shifting the hips away from the painful side is sufficient to stop the pain completely. The second cause for lack of response to the exercise arises when Exercise 3 is performed without adequate fixation. Exercise 3 occasionally gives benefit for a few hours only and then the pain returns. The effectiveness of Exercise 3 can be improved by holding the pelvis down using the hands of another person, or by constructing a simple device which can be improvised at home using an ironing board with a seat belt or strong leather strap placed firmly around the waistline. This added fixation frequently makes the difference between the success and failure of the exercise. RECURRENCE Irrespective of what you are doing or where you are, at the first sign of recurrence of low back pain you should immediately start the exercises which previously led to recovery and follow the instructions to relieve acute pain. You should at once commence Exercise 4 - Extension in Standing. If this does not abolish your pain within minutes, you must quickly introduce Exercise 3 - Extension in Lying. The immediate performance of Exercise 3 can so often prevent the onset of a disabling attack. If your pain is already too severe to tolerate these exercises, you should commence Exercises 1 and 2 - Lying face down and lying down in extension. Finally, if you have on sided symptoms which do not centralize with the exercises recommended so far, you should shift your hips away from the painful side before commencing the exercises and hold your hips in the off-centre position while you exercise. In addition to the exercises, you must pay extra attention to your posture and maintain the Lordosis as much as possible. If this episode of low back pain seems to be different from previous occasions and if your pain persists despite the fact that you closely follow the instructions, you should seek advice.
It is essential that you consult your health professional before commencing these exercises. Robin Mckenzie has written an easy to follow guide called "Treat your own back" and invented the following exercises. Exercise One Lying Face Down Lie face down with your arms beside your body and your head turned to one side Stay in this position, take a few deep breaths and then relax completely for four to five minutes. You must make a conscious effort to remove all tension from the muscles in your lower back; without COMPLETE RELAXATION there is NO CHANCE of ELIMINATING any DISTORTION that may be present in the joint. This exercise is used mainly in the treatment of acute back pain that is pain that is short-lived and is one of the First Aid exercises. It should be done once at the BEGINNING of EACH exercise session, and the sessions are to be spread evenly six to eight times throughout the day. This means that you should repeat the sessions about every two hours. In addition, you must lie face down whenever you are resting. When in acute pain you should avoid sitting, at least during the first few days. Exercise Two Lying Face Down in Extension Remain face down. Place your elbows under your shoulders so that you lean on your forearms. During this exercise you should commence taking in a few deep breaths and allow the muscles in the lower back to relax completely. Again you should stay in this position for about five minutes. You must make a conscious effort to remove all tension from the muscles in your lower back; without COMPLETE RELAXATION there is NO CHANCE of ELIMINATING any DISTORTION that may be present in the joint. This exercise is used mainly in the treatment of severe low back pain and is one of the First Aid exercises it should always follow exercise one and is to be performed once per session. Should you experience severe and increasing pain on attempting this exercise, there are certain measures to be taken before you can continue exercising, these are discussed in the section 'No response or benefit' Exercise Three Extension in Lying Remain face down. Place your elbows under your shoulders in the press-up position. Now you are ready to start exercise 3. Straighten your elbows and push the top half of your body up as far as the pain permits. It is important that you completely relax the pelvis, hips and legs as you do this. Keep your pelvis, hips and legs hanging limp and allow your back to sag. Once you have maintained this position for a second or two, you should lower yourself to the starting position. Each time you repeat this movement cycle you must try to raise your upper body a little higher, so that in the end your back is extended as much as possible with your arms as straight as possible. Once your arms are straight, remember to hold the sag for a second or two as this is a most important part of the exercise. The sag may be maintained for longer than one or two seconds if you feel the pain reducing or centralizing. This is the most useful and effective first aid procedure in the treatment of acute low back pain. The exercise can also be used to treat stiffness of the low back, and to PREVENT low back pain RECURRING once you are fully recovered. When used in the treatment of either pain or stiffness, the exercise should be performed ten times per session and the sessions are to be spread evenly six to eight times throughout the day. Should you not respond or have increasing pain on attempting this exercise, there are certain measures to be taken before you can continue exercising, these are discussed in the section 'No response or benefit' read it now. Exercise Four Extension in Standing Stand upright with your feet slightly apart. Place your hands in the small of your back with your fingers pointing backwards and your thumbs pointing forwards. You are now ready to start Exercise Four Bend your trunk backwards at the waist as far as you can, using your hands as a fulcrum. It is important that you keep your knees straight as you do this. Once you have maintained this position for a second or two you should return to the starting position. Each time you repeat this movement cycle, you should try to bend backwards a little further so that in the end you have reached the maximum possible degree of extension. When you are in acute pain, this exercise may replace exercise 3 should circumstances prevent you from exercising in the lying position. This exercise however is not as effective as exercise 3. Once you have fully recovered and no longer have low back pain, this exercise is your MAIN TOOL in the PREVENTION of further BACK PROBLEMS As a preventive measure, repeat the exercise every once in a while whenever you find yourself working in a forward bent position. Perform the exercise BEFORE the pain appears. Exercise Five Flexion in Lying Lie on your back with your knees bent and you feet flat on the floor or bed. You are now ready to start Exercise Five Bring both knees up towards the chest. Place both hands around your knees and gently but firmly pull the knees as close to the chest as the pain permits. Once you have maintained this position for a second or two you should lower the legs and return to the starting position. It is important that you DO NOT RAISE YOUR HEAD as you perform this exercise, or STRAIGHTEN YOUR LEGS AS YOU LOWER THEM. Each time you repeat this movement cycle, you should try to pull your knees a little further so that in the end you have reached the maximum possible degree of flexion. At this stage your knees may touch the chest. This exercise is used in the treatment of stiffness in the low back which may have developed since your injury or pain began. While damaged tissues may have now healed, they may have also shortened and become less flexible; it is now necessary to restore their elasticity and full function by performing flexion exercises. These exercises should be commenced with caution. In the beginning you must only do five or six per session, and the sessions are to be repeated three or four times per day. As you have probably realized, this exercise eliminates the lordosis once the knees are bent to the chest, so in order to rectify any distortion that may result, FLEXION EXERCISES MUST ALWAYS BE FOLLOWED BY A SESSION OF EXERCISE 3 - EXTENSION IN LYING. You may stop performing Exercise 4 when you can readily pull the knees to the chest without producing tightness or pain. You may then progress to Exercise 6 Exercise Six Flexion in Sitting Sit on the edge of a steady chair with your knees and feet well apart and let your hands rest between your legs. You are now ready to start Exercise 6 Bend your trunk forwards and touch the floor with your hands. Return immediately to the starting position. Each time you repeat this movement cycle you must bend down a little further so that end you have reached the maximum possible degree of flexion. At this reached the maximum possible degree of flexion and your head is as close as possible to the floor. The exercise can be made more effective by holding on to your ankles with your hands and pulling yourself down further. Exercise 6 SHOULD ONLY BE COMMENCED AFTER THE COMPLETION OF ONE WEEK OF EXERCISE 5, WHETHER EXERCISE 5 HAS BEEN SUCCESSFUL OR NOT IN REDUCING YOUR STIFFNESS OR PAIN. In the beginning you must only do five or six repetitions per session and the sessions are to be repeated three or four times per day. FLEXION EXERCISES MUST ALWAYS BE FOLLOWED BY A SESSION OF EXERCISE 3 - EXTENSION IN LYING. No Response or Benefit after exercising without any relief or benefit for three or four days, you may conclude that the exercises as performed are ineffectual. There are two main causes for lack of response or benefit from these exercises. A lack of response to these exercises is possible in some people when their pain is felt only to one side of the spine, or is felt much more to one side than the other. If your pain during the course of the day is felt only to one side, more to one side as you perform Exercises 1, 2, 3 you may need to modify your body position before commencing them. To achieve this modification, you should: 1. Adopt a position to perform Exercise 1 and allow yourself to relax for a few minutes. 2. Remain face down and now shift your hips AWAY from the PAINFUL side; that is if your pain is usually more on the right side you must move your hips three or four inches to the left, and once more completely relax for a few minutes. 3. While allowing the hips to remain off-centre, lean on the elbows as described in exercise two and relax for a further three or four minutes. You are now ready to commence Exercise 3. With the hips still off-centre, complete one session of Exercise 3 and relax once more. You may need to repeat the exercise several times but before commencing each session of ten you should ensure that the hips are still off centre; remember, away from the painful side. Even with your hips in the off-centre position, you should try with each repetition to move higher and higher. You should reach the maximum amount of extension possible at which time the arms should be completely straight. For the next three or four days you should continue to perform Exercises 1, 2, 3 from the modified starting position. After a few days of practice you may notice that the pain is distributed more evenly across the back or may have centralized. Once this occurs you may stop shifting the hips before exercising and continue exercising as described earlier. Occasionally shifting the hips away from the painful side is sufficient to stop the pain completely. The second cause for lack of response to the exercise arises when Exercise 3 is performed without adequate fixation. Exercise 3 occasionally gives benefit for a few hours only and then the pain returns. The effectiveness of Exercise 3 can be improved by holding the pelvis down using the hands of another person, or by constructing a simple device which can be improvised at home using an ironing board with a seat belt or strong leather strap placed firmly around the waistline. This added fixation frequently makes the difference between the success and failure of the exercise. RECURRENCE Irrespective of what you are doing or where you are, at the first sign of recurrence of low back pain you should immediately start the exercises which previously led to recovery and follow the instructions to relieve acute pain. You should at once commence Exercise 4 - Extension in Standing. If this does not abolish your pain within minutes, you must quickly introduce Exercise 3 - Extension in Lying. The immediate performance of Exercise 3 can so often prevent the onset of a disabling attack. If your pain is already too severe to tolerate these exercises, you should commence Exercises 1 and 2 - Lying face down and lying down in extension. Finally, if you have on sided symptoms which do not centralize with the exercises recommended so far, you should shift your hips away from the painful side before commencing the exercises and hold your hips in the off-centre position while you exercise. In addition to the exercises, you must pay extra attention to your posture and maintain the Lordosis as much as possible. If this episode of low back pain seems to be different from previous occasions and if your pain persists despite the fact that you closely follow the instructions, you should seek advice.
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