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A pharmacist shall note the details of the consultation and agreement required under this subsection on the prescription or, if the drug is dispensed at a remote pharmacy, on the digital image of the prescription described in subsection (1), and shall maintain that documentation with the prescription as required in section 17752. If all other requirements of this part are met, a pharmacist shall dispense a drug or device under a prescription described in this subsection. A pharmacist may dispense a drug or device under a prescription described in this subsection even if the prescription does not contain the quantity ordered. The pharmacist shall record the quantity dispensed on the prescription and shall maintain that documentation with the prescription as required in section 17752. Except for a controlled substance included in schedule 5 that does not contain an opioid, this subsection does not apply to a prescription for a controlled substance. The record of cancellation must include the date the copy was issued, to whom issued, and the identification of the pharmacist who issued the copy. The electronically transmitted prescription must include all of the following information: (a) the name, address, and telephone number of the prescriber. The electronic transmission of a prescription must be communicated in a retrievable, recognizable form acceptable to the intended recipient. The electronic transmission of a prescription under this section must be communicated in a retrievable, recognizable form acceptable to the intended recipient. The electronic form utilized in the transmission of a prescription must not include "dispense as written" or "d. As used in this subdivision, "health care facility" includes, but is not limited to, any of the following: (i) A hospital. The department shall establish by rule the requirements for obtaining a waiver under this subsection. The rules must not establish requirements that are more stringent than any requirements used by the federal Centers for Medicare and Medicaid Services for waiving the Medicare requirement for the electronic transmission of controlled substance prescriptions. If a prescriber provides evidence satisfactory to the department that the prescriber has received a waiver of the Medicare requirement for the electronic transmission of controlled substances prescriptions from the federal Centers for Medicare and Medicaid Services, the department shall grant a waiver to the prescriber under this subsection. A waiver that is granted by the department under this subsection is valid for a period not to exceed 2 years and is renewable. If a drug or biological drug product is dispensed that is not the prescribed brand, the purchaser must be notified and the prescription label must indicate both the name of the brand prescribed and the name of the brand dispensed and designate each respectively. Except as otherwise provided in section 17756, if the dispensed drug or biological drug product does not have a brand name, the prescription label must indicate the generic name of the drug dispensed or the proprietary name of the biological drug product dispensed. The communication required under this subsection must be made as follows: (a) By making an entry that is electronically accessible to the prescriber through an interoperable electronic medical records system, an electronic prescribing technology, a pharmacy benefit management system, a health information exchange, or a pharmacy record. An entry made as described in this subdivision is presumed to provide notice to the prescriber. The prescription shall also bear upon the label the following statement: "Discard this medication 1 year after the date it is dispensed. If the medication expires on another date, the pharmacist dispensing the prescription shall strike or omit the statement required under this subsection and shall specify on the label the actual expiration date of the medication. The label shall also include the statement required under subsection (1) or the actual expiration date of the medication in the container in the same manner required under subsection (1) for a prescription dispensed by a pharmacist. The information must be provided to the person making the request before a drug is dispensed to the person. A person that makes a request for price information under this subsection is not obligated to purchase the drug for which the price or comparative prices are requested. You are under no obligation to have the prescription filled here and may use this price information to shop around at other pharmacies. Every pharmacy has the current selling prices of both generic and brand name drugs dispensed by the pharmacy. Ask your pharmacist if a lower-cost generic drug is available to fill your prescription. A generic drug contains the same medicine as a brand name drug and is a suitable substitute in most instances. A generic drug may not be dispensed by your pharmacist if your doctor has written "dispense as written" or the initials "d. If you have questions about the drugs that have been prescribed for you, ask your doctor or pharmacist for more information. To avoid dangerous drug interactions, let your doctor and pharmacist know about any other medications you are taking. This is especially important if you have more than 1 doctor or have prescriptions filled at more than 1 pharmacy. The text of the notice must be in at least 32-point bold type and must be printed on paper at least 11 inches by 17 inches in size. The pharmacist shall retain a copy of each receipt furnished under subsection (6) for 90 days. The inclusion of the items required under subsection (6) on the prescription container label is a valid receipt to the purchaser. Including the items required under subsection (6) on the written prescription form and retaining the form constitutes retention of a copy of the receipt. The information shall be provided to the person making the request before a prescription drug is dispensed to the person. A person who makes a request for price information under this subsection is not obligated to purchase the prescription drug for which the price or comparative prices are requested. You are under no obligation to have the prescription filled here and may use this price information to shop around. You may choose to have the prescription filled by your doctor or the pharmacy of your choice. A generic drug contains the same medicine as a brand name drug and is a suitable substitute in most cases. If you have questions about the drugs which have been prescribed for you, ask your doctor or pharmacist for more information. This is especially important if you have more than 1 doctor or have prescriptions filled at more than 1 location. The text of the notice shall be in at least 32-point bold type and shall be printed on paper at least 11 inches by 17 inches in size. A person may duplicate or reproduce the notice if the duplication or reproduction is a true copy of the notice as produced by the department, without any additions or deletions. The operation of the automated device is limited to licensed health professionals. In addition to the grounds set forth in part 161, the disciplinary subcommittee may fine, reprimand, or place a pharmacist licensee on probation, or deny, limit, suspend, or revoke the license of a pharmacist or order restitution or community service for a violation or abetting in a violation of this part or rules promulgated under this part, or for 1 or more of the following grounds: (a) Permitting the dispensing of prescriptions by an individual who is not a pharmacist, pharmacist intern, or dispensing prescriber. In determining whether a label is misleading, consideration shall be given to the representations made or suggested by the statement, word, design, device, sound, or any combination thereof, and the extent to which the label fails to reveal facts material in view of the representations made or material as to consequences that may result from use of the drug or device to which the label relates under conditions of use prescribed in the label or under customary or usual conditions of use. It is not a defense to a charge under this subsection that the person did not intend to kill a specific individual, or did not intend to cause serious impairment of a body function of 2 or more specific individuals. A person is not subject to penalties for a violation of this part dealing with adulteration or misbranding, if the person establishes that a guaranty or undertaking was made in accordance with the federal act, or that a guaranty was signed by and contains the name and address of the person residing in this state from whom the former person received in good faith the drug or device, to the effect that the drug or device is not adulterated or misbranded within the meaning of this part. The guaranty does not protect the seller if the product is adulterated or misbranded under this part and the board has previously given written notice to the seller of that fact. The board shall not serve notice on the seller until the board has notified the manufacturer or wholesale distributor of the findings of the state analyst with reference to the product. The notice to the manufacturer or wholesale distributor shall be written and shall be mailed at least 10 days before a notice is given to a seller under this section. Except as provided in sections 17766d, 17780, and 21418, a person that does any of the following is guilty of a misdemeanor: (a) Obtains or attempts to obtain a prescription drug by giving a false name to a pharmacist or other authorized seller, prescriber, or dispenser. This subdivision does not prohibit the person from being charged with, convicted of, and sentenced for any other violation of law arising out of the violation of subsection (1)(d). The written protocols shall be maintained on the premises and shall be readily accessible to each pharmacist on duty. The written protocols shall include, at a minimum, each of the following: (a) Methods to ensure that damage, deterioration, or contamination has not occurred during the delivery, handling, storage, and return of the prescription drugs which would adversely affect the identity, strength, quality, purity, stability, integrity, or effectiveness of those prescription drugs or otherwise render those drugs unfit for distribution. A unit dose package or unit of issue package prepared by the pharmacist and returned to stock shall only be redispensed in that same unit dose package or unit of issue package and shall only be redispensed once. A pharmacist shall not add unit dose package drugs to a partially used unit of issue package. The log or other means of recording the sale as required under this subdivision shall be maintained for a minimum of 6 months and made available to only a law enforcement agency upon request.

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As a result common changes include:- - Cellular swelling 3 Pathophysiology Lipid accumulation (Fatty change process in the cytoplasm of cells). It is complete loss of normal architectural orientation of one cell with the next both in shape and size. Types of Hyperplasia 5 Pathophysiology a) Physiologic Hyperplasia: occurs when there hormonal stimulation - Occurs in puberty and pregnancy b) Compensatory-Hyperplasia - Occurs in organs that are capable of regenerating lost tissues. Causes of cell injury:Causes of cell injury are the same causes of cellular adaptive changes as mentioned above. Classification of cell injury:Cellular injury can be reversible or it may progress to irreversible change (Lethal change). Reversible cell injury:Is cell injury which can be reversed when the stimulus or the cause of injury is removed. Example -Ischemia: o o Ischemia refers to a critical lack of blood supply to a localized area. It is reversible in that tissues are restored to normal function when oxygen is again supplied to them, but if late progress to ischemic infraction 9 Pathophysiology o o It usually occurs in the presence of atherosclerosis in the major arteries. Necrosis:- 10 Pathophysiology o the term necrosis refers to cell or tissue death characterized by structural evidence of this death. Benign tumor: - Is characterized by abnormal cell division but no metastasis or invasion of the surrounding tissues. Malignant tumor: - Abnormal cell division characterized by ability to invade locally, metastasize and reoccur. Benign and Malignant Neoplasia the capacity of undergoing mitosis is inherent in all cells. Every time a normal cell passes through a cycle of division, the opportunity exists for it to become Neoplastic. Seldom Recur after removal by surgery N e c r o s i s a n dulceration is uncommon S y s t e m i c e f f e c t i suncommon 15 Pathophysiology 1. Nomenclature of Neoplasms Naming of Neoplasia based on two main important features of the tumor. Genetic Instability:The theory of somatic cell mutation supports the concept that mutational carcinogenic agents and heredity susceptibility can induce genetic abnormalities. Carcinogens Carcinogens are those substances that are capable of inducing neoplastic growth. Some substances induce neoplastic growth at higher doses and exposure rates while others can be carcinogenic at lower doses and exposure rate. Chemical carcinogens Many chemical agents are capable of causing Neoplasms in either humans or animals. A long latent period often exists between exposure and development of clinical disease. Example:-leukemia and skin cancers became very common long years later in Hiroshima and Nagasaki,Japan;after atomic bomb detonation. Viral carcinogens (oncogenic viruses) Viruses are thought to cause some human and Animals malignant neoplasms. Current evidence shows that viruses alter the genome of the 19 Pathophysiology infected cells, which then alter the offspring of the host cells. Some of these factors are dietary habits, sexuality, and other personal habits like smoking, alcohol consumption etc. List local and systemic manifestations of inflammations Describe the pathophysiology of resolution (healing) process of Inflammations. The skin and mucous membranes the skin and mucous membranes are the first line of defense mechanisms. They serve as a mechanical barrier for protection of the body against different injurious agents. Rather, it consists of phagocytic cells located in various tissues and organs (see Table 2. The macrophages of the liver, spleen, bone marrow, lungs, lymph nodes, and nervous system (microglial cells) are fixed phagocytes. Monocyts spend a few days in the blood and then enter tissues and change into macrophages. The term inflammation is often but incorrectly used as a synonym for the term infection. However, a person who is neutropenic may not be able to mount an inflammatory response. An infection involves invasion of tissues or cells by microorganisms such as bacteria, fungi, and viruses. The mechanism of inflammation is basically the same regardless of the injuring agent. The inflammatory response can be divided in to:1) Vascular response, 2) Cellular response, 3) Formation of exudates 4) Healing. After release of histamine and other chemicals by the injured cells, the vessels dilate. Vasodilatation and chemical mediators cause endothelial cell retraction, which 26 Pathophysiology increases capillary permeability. Extravasations involve the following sequence of events: a) Margination b) Transmigration across the endothelium to interstitical tissue (also called diapedesis). Phagocytic cells include polymorphonuclear leukocytes (particularly neutrophils), monocytes and tissue macrophages. Recognition and attachment of the particle to be ingested by the leukocytes: Phagocytosis is enhanced if the material to be phagocyted is coated with certain plasma proteins called opsonins. Engulfment As a result of fusion between the phagosome and lysosome, a phagolysosome is formed and the engulfed particle is exposed to the degradative lysosomal enzymes 3. Killing or degradation the ultimate step in phagocytosis of bacteria (any foreign body) is killing and degradation. Oxygen independent mechanism: 30 Pathophysiology It is mediated by lysosomal enzymes (the primary and secondary granules) of polymorphonuclear leukocytes. Some of the chemical mediators of inflammation include histamine, serotonin, lysosomal enzymes, prostaglandins, leukotriens, activated oxygen species, nitric oxide, cytokines, Mediators of the inflammatory response are presented in (see table2. Clinical Manifestations of inflammations 34 Pathophysiology the clinical manifestations of inflammation can be classified as i. Local response to inflammation includes the manifestations of redeness, heat, pain, swelling, and loss of function (see table 2. An increase in pulse and respiration follows the rise in metabolism as a result of an increase in body temperature. Fever 36 Pathophysiology o the onset of fever is triggered by the release of cytokines. The hypothalamus then activates the sympathetic branch of the autonomic nervous system to stimulate increased muscle tone and shivering and decreased perspiration and blood flow to the periphery. This seeming paradox is dramatic: the body is hot yet an individual piles on blankets and may go to bed to go warm. When the circulating body temperature reaches the set point of the core body temperature, the chills and warmth- seeking behavior cease. The classifications of febrile response the febrile response is classified into four stages: Prodromal, chill, flush and defervescence. Beneficial aspects of fever include increased killing of microorganisms, increased phagocytes by neutrohils, and increased proliferation of T cells. Types of Inflammation 39 Pathophysiology the basic types of inflammation are acute, sub- acute, and chronic. In acute inflammation the healing occurs in 3 to 3 weeks and usually leaves no residual damage. For example, infective endocarditic is a smoldering infection with acute inflammation, but it persists throughout weeks or months.

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The dose is additive; a 50% toxic dose of two separate drugs may become 100% toxic if they share similar properties. Accordingly, vigilant perioperative patient monitoring with blood pressure, pulse oximetry, and electrocardiography for quick intervention is necessary when using any of these anesthetic medications. Treatment initially includes oxygen, intravenous fluids, and removal of the cocaine-soaked pledgets. If cardiovascular alterations are noted, appropriate anesthesia care is necessary. They may be seen at the start of surgery and extend well beyond the completion of the healing phase. Hemorrhage: Early Bleeding or hemorrhage is one of the more common complications of septoplasty, usually occurring during surgery or immediately after surgery. When performing septoplasty surgery, it is important to tell all patients to expect 1 to 2 days of mild oozing after surgery. True hemorrhage as a result of septoplasty has been reported at a rate of 6% to 13. To prevent bleeding from inadequate injection of local anesthesia, initial topical decongestion with oxymetazoline or cocaine for 5 to 10 minutes before making an incision not only improves visibility but offers the surgeon an opportunity to discern inflammatory mucosal disease from true anatomic septal irregularities. It is beneficial to inject the area in which the incisions are to be made and the important areas of vessel origins (dorsal septum, posterior bony septum, along the nasal floor, and at the anterior nasal spine) adequately. A total of 5 to 6 mL of local anesthesia is typically required for an adequate septal injection when adequate time for vasoconstriction is provided. Proper injections hydrodissect the mucoperichondrium off of the septal cartilage, aiding in flap elevation. In cases of ``traumatic' noses or nasal septal fractures, hydrodissection may not work as well and multiple injection sites may help to minimize bleeding. In terms of traumatic causes of bleeding with septoplasty, in addition to poor technique and accidental mucosal trauma with the septal needle during closure, concomitant intraoperative treatment of turbinate disease is suspected to be the most common cause of postoperative bleeding. The most common source of postoperative 466 Bloom et al bleeding seems to be from the turbinate incision site for inferior turbinectomies. Given their vascularity, it is important to inject the head of each inferior turbinate with approximately 1 mL of local anesthesia 5 to 10 minutes before turbinectomy. Additionally, submucosal resection of the inferior turbinates with a microdebrider is a nice technique that not only allows for a quicker recovery but minimizes mucosal trauma compared with standard turbinate resection followed by cauterization. After the turbinectomy, oxymetazoline-soaked pledgets can be packed against the head of the turbinate for compression to limit bleeding further. It is always important to secure the pledget strings to avoid accidental aspiration. There are many methods to prevent significant hemorrhage from occurring after a septoplasty. Fibrin sealant is a formulation based on a concentrate of human clottable proteins and a highly purified human thrombin. Vaiman and colleagues11 have shown that fibrin sealant, administered by aerosol spray in endonasal surgery, is more effective and convenient than nasal packing. The sealant facilitates hemostasis and prevents or reduces postoperative bleeding and oozing during surgical procedures. Also, as a human blood product, it stimulates normal wound healing of the operated area. No special treatment is required with the use of fibrin sealant, there is no danger of aspiration, and no antibiotics are necessary because there is no foreign object inserted into the nasal cavity. In fact, Vaiman and colleagues12 have shown that when using a fibrin sealant during septoplasties, their patients achieved complete resolution of major symptoms; good tissue approximation; and no hematomas, swelling, synechiae, atrophic changes, or adhesions. For example, if heavy intraoperative bleeding occurs, it could be secondary to rare occurrences, such as an internal carotid artery-cavernous sinus fistula causing a hyperemic and reactive nose. Be aware of additional signs and symptoms of this complication, including a developing orbital proptosis, deterioration of visual acuity, and pulsating tinnitus. This complication is caused by a tear of the dura mater surrounding the brain and its supporting structures of the skull base, which therefore produces a leak of fluid through the formed connection between the subarachnoid space and the nasal cavity. This problem is extremely unusual after septoplasty, but it can be a serious and life-threatening complication if not managed quickly and appropriately. When performing a septoplasty and a high bony septal deviation needs to be addressed, a controlled break of the perpendicular plate with a 4-mm chisel or Caplan scissors provides safe separation of the perpendicular plate from the skull base (Fig. This is particularly important to remember when repairing a nasal septal fracture, especially in the case of a ``twisted' nasal septum when the dorsal septum is already malpositioned, likely requiring manipulation. In some cases, if a proper diagnosis is not made, there can be enlargement and remodeling of the bone over time and a dural defect, leading to herniation of the meninges and brain tissue through the defect by pulsation of the brain. This type of skull base defect after septoplasty would subsequently put the patient at risk for an ascending infection. It is also imperative to prevent this complication with good realization and preoperative awareness of anatomic variations and a less aggressive septoplasty method, especially when manipulating the perpendicular plate attached to the ethmoid roof. A controlled cut through the perpendicular plate of the ethmoid reduces torque on the skull base. It is important to maintain a 10-mm dorsal strut at the bony cartilaginous junction (seen here). Aiming the chisel or scissors toward the sphenoid sinus should also prevent inadvertent anterior skull base penetration. The defect may be approached endoscopically or transcranially to allow for a multilayer repair. If this complication occurs during surgery, it can be repaired endoscopically at that time once informed consent for the additional procedure is obtained. The mucous membranes act as a protective barrier and aid in processing foreign bodies. During septoplasty, those mucous membranes are traumatized and can put the patient at risk for infection and bacteremia by the vascular route within the nasal mucous membranes. Transient bacteremia is usually harmless in healthy subjects and usually resolves spontaneously without complications; however, the possibility of bacteremia during septoplasty surgery must be kept in mind, and the necessary precautions should be taken before surgery in patients with high risk for cardiovascular infection because this can lead to a dramatic result. Septoplasty surgery to fix a deviated septum can significantly improve mucociliary transport; however, the procedure does impair mucociliary transport in the intermediate postoperative stages. Complete recovery of this transport system is established 5 days after surgery if the basal cells and basement membrane of the mucosa remain intact. Eviatar and colleagues20 have found that although there is not a major difference in bacterial cultures before and after surgery, as implied by the dominance of Staphylococcus aureus, a change in nasal culture results does exist. So, although surgery does not completely disrupt the balance among nasal bacteria, changes in the cultures in the first postoperative month might indicate that the procedure caused mucosal abnormalities secondary to Septoplasty Complications 469 secretions, stasis, crusting, and packing after surgery. These events and circumstances suggest the importance of local environmental factors, aside from growth of bacteria in blood-absorbent packing matrix, in promoting the growth of S aureus. The mechanism is compared with toxic shock syndrome secondary to tampon use on a large mucosal surface. Given this potential risk and patient discomfort, it may be beneficial to avoid nasal packing unless it is required for uncontrolled bleeding, which is rare. Septoplasties are considered potentially contaminated operations, but the proportion of patients developing a postoperative infection is small; therefore, perioperative systemic or postoperative antimicrobial prophylaxis is unnecessary. In addition, the downside to the indiscriminant use of antibiotics includes severe complications, such as toxic reactions and reduction of the antibody formation stimuli, in addition to representing high costs and encouraging less strict compliance with good surgical practice. Postoperative antibiotics are given only to those patients who have structural grafting or some type of splint or packing placed. Again, as with any surgical procedure, there are some circumstances in which antibiotics are necessary. Patients with significant comorbid immune-related conditions, such as diabetes or compromised immunity, may receive prophylactic antibiotics. After surgery, in cases of acute or chronic infection of the operative site, use of cartilage grafts, implantation of allogenic materials, presence of a hematoma, mechanical blockage attributable to nasal packing, or postoperative nasal obstruction producing rhinosinusitis, antibiotics should be administered. A septal hematoma may arise in the dead space created between the mucoperichondrial flaps when the cartilage or bony septum is removed during septoplasty. This space is susceptible to accumulation of blood products and the formation of a septal hematoma. A septal hematoma may also subsequently lead to the formation of a septal abscess, with Staphylococcus, Haemophilus influenza, and, rarely, Pseudomonas being the most common pathogens (Fig.

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So too, the McGill Pain Questionnaire, which taps into subjective experience-one of the functions of the brain-is the most widely used to instrument to measure pain. Yet, as historians of science have pointed out, good theories are instrumental in producing facts that eventually require a new theory to incorporate them. It is possible to make adjustments to the gate theory so that, for example, it includes long-lasting activity of the sort Wall has described (see Ref 4). But there is a set of observations on pain in paraplegic patients that just does not fit the theory. But the data on painful phantoms below the level of total spinal cord section18,19 indicate that we need to go above the spinal cord and into the brain. Note that we mean more than the spinal projection areas in the thalamus and cortex. These areas are important, of course, but they are only part of the neural processes that underlie perception. The cortex, Gybels and Tasker made amply clear, is not the pain center and neither is the thalamus. Furthermore, cognitive processes are known to involve widespread areas of the brain. Despite this increased knowledge, we do not have yet an adequate theory of how the brain works. First, because the phantom limb feels so real, it is reasonable to conclude that the body we normally feel is subserved by the same neural processes in the brain as the phantom; these brain processes are normally activated and modulated by inputs from the body but they can act in the absence of any inputs. Second, all the qualities of experience we normally feel from the body, including pain, are also felt in the absence of inputs from the body; from this we may conclude that the origins of the patterns of experience lie in neural networks in the brain; stimuli may trigger the patterns but do not produce them. The experience of a unity of such diverse feelings, including the self as the point of orientation in the surrounding environment, is produced by central neural processes and cannot derive from the peripheral nervous system or spinal cord. These conclusions provide the basis of the conceptual model18,19,21 depicted in Figure 3. The loops diverge to permit parallel processing in different components of the neuromatrix and converge repeatedly to permit interactions between the output products of processing. The repeated cyclical processing and synthesis of nerve impulses through the neuromatrix imparts a characteristic pattern: the neurosignature. The neurosignature of the neuromatrix is imparted on all nerve impulse patterns that flow through it; the neurosignature is produced by the patterns of synaptic connections in the entire neuromatrix. All inputs from the body undergo cyclical processing and synthesis so that characteristic patterns are impressed on them in the neuromatrix. Portions of the neuromatrix are specialized to process information related to major sensory events (such as injury, temperature change and stimulation of erogenous tissue) and may be labeled as neuromodules which impress sub signatures on the larger neurosignature. The neurosignature, which is a continuous output from the body-self neuromatrix, is projected to areas in the brain-the sentient neural hub-in which the stream of nerve impulses (the neurosignature modulated by ongoing inputs) is converted into a continually changing stream of awareness. Furthermore, the neurosignature patterns may also activate a second neuromatrix to produce movement, the action-neuromatrix. That is, the signature patterns bifurcate so that a pattern proceeds to the sentient neural hub (where the pattern is transformed into the experience of movement) and a similar pattern proceeds through a neuromatrix that eventually activates spinal cord neurons to produce muscle patterns for complex actions. The Body-Self Neuromatrix the body is felt as a unity, with different qualities at different times. The brain mechanism that underlies the experience also comprises a unified system that acts as a whole and produces a neurosignature pattern of a whole body. Finally, the array of neurons in a neuromatrix is genetically programmed to perform the Volume 4, January/February 2013 Outline of the Theory the anatomical substrate of the body-self is a large, widespread network of neurons that consists of loops between the thalamus and cortex as well as between the cortex and limbic system. The output patterns from the neuromatrix produce the multiple dimensions of pain experience, as well as concurrent homeostatic and behavioral responses. Copyright 2001 Sage Publications) specific function of producing the signature pattern. The final, integrated neurosignature pattern for the body-self ultimately produces awareness and action. The neuromatrix, distributed throughout many areas of the brain, comprises a widespread network of neurons which generates patterns, processes information that flows through it, and ultimately produces the pattern that is felt as a whole body. The stream of neurosignature output with constantly varying patterns riding on the main signature pattern produces the feelings of the whole body with constantly changing qualities. Conceptual Reasons for a Neuromatrix It is difficult to comprehend how individual bits of information from skin, joints, or muscles can all come together to produce the experience of a coherent, articulated body. Melzack18,19,21 conceptualized a genetically built-in neuromatrix for the whole body, producing a characteristic neurosignature for the body which carries with it patterns for the myriad qualities we feel. The neuromatrix produces a continuous message that represents the whole body in which details are differentiated within the whole as inputs come into it. We start from the top, with the experience of a unity of the body, and look for differentiation of detail within the whole. These views are in sharp contrast to the classical specificity theory in which the qualities of experience are presumed to be inherent in peripheral nerve fibers. Pain is not injury; the quality of pain experiences must not be confused with the physical event of breaking skin or bone. There are no external equivalents to stinging, smarting, tickling, itch; the qualities are produced by built-in neuromodules whose neurosignatures innately produce the qualities. We do not learn to feel qualities of experience: our brains are built to produce them. The inadequacy of the traditional peripheralist view becomes especially evident when we consider paraplegic patients with high-level complete spinal cord transections. In spite of the absence of inputs from the body, virtually every quality of sensation and affect is experienced. It is known that the absence of input produces hyperactivity and abnormal firing patterns in spinal cells above the level of the break. This must occur in the brain, in which neurosignatures are produced by neuromatrixes that are triggered by the output of hyperactive cells. When all sensory systems are intact, inputs modulate the continuous neuromatrix output to produce the wide variety of experiences we feel. It is a single unitary feeling just as an orchestra produces a single unitary sound at any moment even though the sound comprises violins, cellos, horns, and so forth. Similarly, at a particular moment in time we feel complex qualities from all of the body. It is hard to imagine of all of these bits and pieces coming together to produce a unitary body-self, but we can conceive of a neuromatrix which impresses a characteristic signature on all the inputs that converge on it and thereby produces the never-ending stream of feeling from the body. The experience of the body-self involves multiple dimensions-sensory, affective, evaluative, postural and many others. The sensory dimensions are subserved, in part at least, by portions of the neuromatrix that lie in the sensory projection areas of the brain; the affective dimensions are subserved by areas in the brainstem and limbic system. Each major psychological dimension (or quality) of experience is subserved by a particular portion of the neuromatrix which contributes a distinct portion of the total neurosignature. However, the neural networks proposed by Hebb22 and Bindra23 developed by gradual sensory learning, whereas Melzack, instead, conceived the structure of the neuromatrix to be predominantly determined by genetic factors, although its eventual synaptic architecture is influenced by sensory inputs. This emphasis on the genetic contribution to the brain does not diminish the importance of sensory inputs. The neuromatrix is a psychologically meaningful unit, developed by both heredity and learning, that represents an entire unified entity. Action Patterns: the Action-Neuromatrix the output of the body neuromatrix is directed at two systems: (1) the neuromatrix that produces awareness of the output, and (2) a neuromatrix involved in overt action patterns. Just as there is a steady stream of awareness, there is also a steady output of behavior (including movements during sleep). It is important to recognize that behavior occurs only after the input 6 has been at least partially synthesized and recognized. For example, when we respond to the experience of pain or itch, it is evident that the experience has been synthesized by the body-self neuromatrix (or relevant neuromodules) sufficiently for the neuromatrix to have imparted the neurosignature patterns that underlie the quality of experience, affect and meaning. Most behavior occurs only after inputs have been analyzed and synthesized sufficiently to produce meaningful experience. When we respond to pain (by withdrawal or even by telephoning for an ambulance), we respond to an experience that has sensory qualities, affect and meaning as a dangerous (or potentially dangerous) event to the body.

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Failure to establish accurate baseline levels of strength limits the adequacy of the strength training dosage and progression, and thus limits the benefits of the training. A carefully developed and individualized strength training program may have significant health benefits for older adults. Given the clinical benefits and lack of evidence indicating harmful effects of ambulation and activity both are recommended following achievement of anticoagulation goals unless there are overriding medical indications. Utilizing whirlpools to treat wounds predisposes the patient to risks of bacterial cross-contamination, damage to fragile tissue from high turbine forces and complications in extremity edema when arms and legs are treated in a dependent position in warm water. Other more selective forms of hydrotherapy should be utilized, such as directed wound irrigation or a pulsed lavage with suction. Communication of this request was distributed to members via website posting, e-mail blast and social media. A modified Delphi technique was used to rank and prioritize the recommendations based upon the Choosing Wisely criteria. The expert panel reviewed the literature and provided a ranking of recommendations based upon the established criteria. Therapeutic ultrasound versus sham ultrasound for the management of patients with knee osteoarthritis: a randomized double-blind controlled clinical study. Interventions associated with an increased or decreased likelihood of pain reduction and improved function in patients with adhesive capsulitis: a retrospective cohort study. Subacromial impingement syndrome-effectiveness of physiotherapy and manual therapy. Influence of strength training variables on strength gains in adults over 55 years old: A meta-analysis of dose-response relationships. Systematic review of high-intensity progressive resistance strength training of the lower limb compared with other intensities of strength training in older adults. Efficacy of progressive resistance training interventions in older adults in nursing homes: a systematic review. Dose-response relationship of resistance training in older adults: a meta-analysis. A meta-analysis of bed rest versus early ambulation in the management of pulmonary embolism, deep vein thrombosis, or both. Influence of bedrest or ambulation in the clinical treatment of acute deep vein thrombosis on patient outcomes: a review and synthesis of the literature. Efficacy of continuous passive motion following total knee arthroplasty: a metaanalysis. Continuous passive motion following total knee arthroplasty: a useful adjunct to early mobilisation? Continuous passive motion following total knee arthroplasty in people with arthritis. Effect of continuous passive motion after total knee arthroplasty: a systematic review. Effect of continuous passive motion following total knee arthroplasty on knee range of motion and function: a systematic review. Outbreak of severe pseudomonas aeruginosa infections caused by a contaminated drain in a whirlpool bathtub. Physical therapists apply research and proven treatment to help people reduce pain and restore movement after injury, illness or surgery; prevent injury; and achieve fitness, health and wellness. No matter what area of the body, physical therapists have an established history of helping individuals improve their quality of life. The final decision regarding use of pharmacologic prophylaxis should be agreed upon by the physician and patient after a discussion of the potential benefits and harms as they relate to the individual. Uninfected wounds are contaminated with surface flora and will yield false positive culture results. Furthermore, wounds that are not clinically infected do not require antibiotics and the unnecessary prescription of antibiotics may have harmful side effects and lead to further antibiotic resistance. History and physical exam findings can establish the diagnosis of acute Achilles tendon ruptures in nearly all instances. The standard of care includes treating any infection present, ensuring there is adequate circulation for healing, taking pressure off the wound (offloading) and regular debridement. Synthetic or donated grafts are expensive and are ineffective without first performing the standard of care. If a wound being treated with standard care has not healed by at least 50 percent in four weeks, synthetic or donated grafts may then be necessary. The Committee worked with podiatric colleagues to create an initial list of recommendations, which was reviewed and narrowed down to eight recommendations. The list of eight recommendations was further developed and distributed to the Committee for ranking in numerical order. Committee members were asked to rank the recommendations based on their relevance, timeliness, strength of supporting evidence and appropriateness for inclusion in the Choosing Wisely Campaign. The rankings and deliberation enabled the Committee to come to the final five recommendations, which were again reviewed to ensure appropriate evidence was used to support each recommendation. Routine use of low-molecular-weight heparin for deep venous thrombosis prophylaxis after foot and ankle surgery: A cost-effectiveness analysis. The non-operative functional management of patients with a rupture of the tendo Achillis leads to low rates of re-rupture. The management of diabetic foot ulcers through optimal off-loading: Building consensus guidelines and practical recommendations to improve outcomes. Consensus recommendation on advancing the standard of care for treating neuropathic foot ulcers in patients with diabetes. Percent change in wound area of diabetic foot ulcers over a 4-week period is a robust predictor of complete healing in a 12-week prospective trial. Pitfalls and limitations of magnetic resonance imaging in chronic posttraumatic osteomyelitis. However, evidence for the efficacy and safety of using multiple antipsychotic medications is limited, and risk for drug interactions, noncompliance and medication errors is increased. Generally, the use of two or more antipsychotic medications concurrently should be avoided except in cases of three failed trials of monotherapy, which included one failed trial of Clozapine where possible, or where a second antipsychotic medication is added with a plan to cross-taper to monotherapy. There is inadequate evidence for the efficacy of antipsychotic medications to treat insomnia (primary or due to another psychiatric or medical condition), with the few studies that do exist showing mixed results. Efforts should be made to combine both evidence-based pharmacological and psychosocial interventions and support. Limited availability of evidence based psychosocial interventions may make it difficult for every child to receive this ideal combination. Discussion of potential risks and benefits of medication treatment with the child and their guardian is critical. A short and long term treatment and monitoring plan to assess outcome, side effects, metabolic status and discontinuation, if appropriate, is also critical. The evidence base for use of atypical antipsychotics in preschool and younger children is limited and therefore further caution is warranted in prescribing in this population. Guideline watch (September 2009): practice guideline for the treatment of patients with schizophrenia [Internet]. Practice guideline for the treatment of patients with schizophrenia, second edition. Effectiveness of clozapine versus olanzapine, quetiapine, and risperidone in patients with chronic schizophrenia who did not respond to prior atypical antipsychotic treatment. A critical review of atypical antipsychotic utilization: comparing monotherapy with polypharmacy and augmentation. Atypical antipsychotic-induced metabolic side effects: insights from receptor-binding profiles. Psychosocial interventions for reducing antipsychotic medication in care home residents. American Diabetes Association; American Psychiatric Association; American Association of Clinical Endocrinologists; North American Association for the Study of Obesity. Monitoring and management of antipsychotic-related metabolic and endocrine adverse events in pediatric patients.

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Relationship of urinary sodium/potassium excretion and calcium intake to blood pressure and prevalence of hypertension among older Chinese vegetarians. Relationship between lactose digestion, gastrointestinal transit time and symptoms in lactose malabsorbers after dairy consumption. Poor predictability of lactose malabsorption from clinical symptoms for Chilean populations. Lactose malabsorption in Greek adults: correlation of small bowel transit time with the severity of lactose intolerance. Low-dose lactose, fructose and sorbitol malabsorption and intolerance does not often coexist in normal adults [abstract]. Coincidental malabsorption of lactose, fructose, and sorbitol ingested at low doses is not common in normal adults. Honey may have a laxative effect on normal subjects because of incomplete fructose absorption. Evaluation of pharmacological aids on physical 240 performance after a transmeridian flight. Low serum 25-hydroxyvitamin D concentrations and secondary hyperparathyroidism in middle-aged white strict vegetarians. Gastrointestinal dysfunction in a community sample of subjects with symptoms of irritable bowel syndrome. Milk, milk products and lactose intake and ovarian cancer risk: a meta-analysis of epidemiological studies. Disaccharidases and histology of duodenal mucosa in congenital lactose malabsorption. Impact of digestion and absorption in the weaning period on infant feeding practices. Correlation of lactase activity, lactose tolerance and milk consumption in different age groups. Characterization of human intestinal lactase and hetero-beta-galactosidases of infants and adults. Lactose malabsorption is associated with early signs of mental depression in females: a preliminary report. Chronic diarrhoea in infants and young children: causes, clinical features and outcome. Absence of increased fecal blood loss in adult volunteers after oral administration of conventional tablets and osmotic tablets of albuterol. Adult-type hypolactasia is not a predisposing factor for the early functional and structural changes of atherosclerosis: the Cardiovascular Risk in Young Finns Study. Alleviation of symptoms of lactase-deficient patients during lactose challenge after administration of enteric coated lactobacilli- preparation. Comparison of whole milk and skim milk with aqueous lactose solution in lactose tolerance testing. Evaluation of hard gelatin capsules as a rectal dosage form for a freely water-soluble model drug, metoclopramide hydrochloride. Blood glucose, gastric emptying and oro-coecal transit time after a conventional breakfast vs. Influence of metronidazole on the breath hydrogen response and symptoms in acarbose-induced malabsorption of sucrose. Is the assay of disaccharidase activity in small bowel mucosal biopsy relevant for clinical gastroenterologists? Concordance of indirect methods for the detection of lactose malabsorption in diabetic and nondiabetic subjects. Effect of an episode of severe malnutrition and age on lactose absorption by recovered infants and children. Controlled study of the effects of a homoeopathic dilution of influenza vaccine on antibody titres in man. Recurrent abdominal pain in children: lactose and sucrose intolerance, a prospective study. The response to dietary treatment of patients with chronic post-infectious diarrhea and lactose intolerance. Evaluating routine diuretics after coronary surgery: a prospective randomized controlled trial. Breath hydrogen test for assessment of lactose malabsorption following rotavirus gastroenteritis. Influence of nonfermented dairy products containing bacterial starter cultures on lactose maldigestion in humans. Effect of buccal administration of a lactose-containing nitroglycerin tablet (Suscard) on plaque pH. Probiotics: a critical review of their potential role as antihypertensives, immune modulators, hypocholesterolemics, and perimenopausal treatments. Double blind study of milk lactose intolerance in a group of rural and urban children. Correlation in the diagnosis of intestinal lactase deficiency between the radiological method and the lactose tolerance test. Bovine milk protein-induced intestinal malabsorption of lactose and fat in infants. Urinary hormonal concentrations and spinal bone densities of premenopausal vegetarian and nonvegetarian women. Simultaneous assessment of intestinal permeability and lactose tolerance with orally administered raffinose, lactose and Larabinose. Suitability of the azocoupling reaction with 1-naphthyl-beta-D-glucoside for the histochemical demonstration of lactase (lactase-beta-glucosidase complex) in human enterobiopsies. Metabolism of lactose by intestinal mucosa from normal and lactase-deficient subjects. Comparison of the effects of binodaline and amitriptyline on peripheral autonomic functions in healthy volunteers. Sulpiride and melatonin decrease tinnitus perception modulating the auditolimbic dopaminergic pathway. A second enzyme defect in acquired lactase deficiency: lack of small-intestinal phlorizin-hydrolase. The effects of nicotinic acid and xanthinol nicotinate on human memory in different categories of age. Influence of caffeine on information processing stages in well rested and fatigued subjects. Diagnosis, symptoms, and calcium intakes of individuals with selfreported lactose intolerance. Effectiveness and safety of T3 (Triiodothyronine) therapy for euthyroid fibromyalgia: A double-blind placebo-controlled response-driven crossover study. The process of change during T3 treatment for euthyroid fibromyalgia: A double-blind placebo-controlled crossover study. European Journal of Clinical Microbiology & Infectious Diseases 2001 Dec; 20(12):843-9. A quantitative cytochemical assay of betagalactosidase in single cultured human skin fibroblasts. Food consumption and nutrient intakes with a special focus on milk product consumption in early pubertal girls in Central Finland. The European respiratory journal : official journal of the European Society for Clinical Respiratory Physiology Vol 8; 1995: 1506-13. Carbohydrate malabsorption in infants with diarrhea: diagnostic and evolutive aspects. Lactose intolerance, detected by the hydrogen breath test, in infants and children with chronic diarrhoea. Intestinal nitrogen and electrolyte movements following fermented milk ingestion in man. Effect of pancreatic insufficiency and intestinal lactase deficiency on the gastric emptying of starch and lactose.

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Laxity of the elbow with hyperextension defect equals 10 to 15% loss of use of the arm. Dislocation of the shoulder: Do not give a schedule award until no recurrence has occurred for one year. Pre-existent recurrent dislocation of the shoulder calls for an overall schedule and apportionment. Acromio-clavicular or sterno-clavicular separation equals 7 1/2 to 10% loss of use of the arm. Winged scapula due to Serratus Anterior Palsy and/or Trapezius Palsy may be given 15-20% loss of use of the arm depending on degree of functional impairment. For such cases do not give a schedule until two years post surgical repair of a major nerve. Resection of the clavicle, either end, equals 10% for bone loss; entire clavicle equals 15% loss of use of the arm. Resection of the head of the humerus with prosthesis equals 50% loss of use of the arm for anatomical bone loss. Add for mobility defects to a final schedule of 60 to 66 2/3% loss of use of the arm. Rupture of the long head of the biceps muscle is equal to 10-15% loss of use of the arm. Rupture at distal point of insertion of the biceps is equal to 20% loss of use of the arm. Taking into consideration mobility and muscle weakness, the schedule can vary up to 33 1/3% loss of use of the arm depending on degree of impairment found. Marked defects of both internal and external rotation equals 20-25% loss of use of the arm. Moderate defects of internal and external rotation equals 15% loss of use of the arm. Rotator cuff tear with or without surgery is given for 10-15% loss of use of the arm and add for mobility defects. Frozen shoulder and adhesive capsulitis (with or without surgery): if the condition is asymptomatic give a schedule loss of use of the arm. If extremely painful and all modalities of treatment exhausted, consider classification after two years. In case of a high schedule for one given part of the extremity calculate first for the major loss in part involved. For example, amputation at the wrist equals 100% loss of use of the hand or equals 80% loss of use of the arm. If there are additional defects of the elbow and/or shoulder add 10% to the 8% loss of use of the arm and the final schedule would be 90% loss of use of the arm. Total joint replacement of the shoulder should be evaluated as other joint replacements taking into consideration anatomical bone loss, mobility defects and muscle atrophy. Excision of the humeral head as with excision of the head of the femur is equal to 50% for anatomical bone loss. Percent Loss of Use of the Leg: Anterior Flexion Defects of the Hip Anterior Flexion of the Hip to 90 degrees 45 degrees 25 degrees % Loss of Use of the Leg 10% 33 1/3% 66 2/3% Posterior extension equals 7 1/2% to 10% loss of use of the leg. Normal abduction is 45 degrees and normal adduction is 35 degrees and loss of both equals 33 1/3% loss of use of the leg. Marked defects of both equals 25% loss of use of the leg; moderate defects of both equals 17 1/2%; mild defects of both equals 10%. Marked defect of both equals 25%; moderate defect of both equals 15%; mild defect of both equals 10%. Shortening or lengthening of the leg equals 5% schedule loss of use of the leg for 1/2 inch, 7 1/2% for 3/4 inch and 10% for 1 inch. Quadriceps atrophy with weakness of extension of the knee equals 10% schedule loss of use of the leg. Excision of the head and neck of the femur with or without prosthetic replacement equals 50% schedule loss of use of the leg for anatomical loss. Total hip replacement has an average schedule of 60-66-2/3% schedule loss of use of the leg. Amputee with 100% loss of use of the leg can receive an additional schedule award for a second accident or consequential injury (e. Hip fracture with or without surgery requires two years before final evaluation for schedule award. Request for up to date X-ray to rule out aseptic necrosis of the femoral head, loosening and displacement/malalignment of hardware. Synovitis of the hip, bursitis (Iliopsoas bursa, trochanteric bursa, ischiogluteal bursa): defer final evaluation for two years and usual schedule award is 0 to 7 1/2% loss of use of the leg. Fractured pelvis could be given a schedule award at end of two years if there is residual impairment to the hip, such as restriction defects of mobility of the hip joint and atrophy of muscles of the thigh. In case of subsequent injury an amputee who has received a 100% schedule loss of use of leg may receive an additional schedule award. Patella: total excision equals 15% loss of use of the leg; partial excision equals 7 1/2-10%; Add for mobility defects and atrophy of muscles. Mild defect of extension of the knee equals 7 1/2-10% schedule loss of use of the leg. Mild defect of flexion and extension equals 10-15% schedule loss of use of the leg; moderate defects of flexion and extension equals 40-45%; marked defects of flexion and extension equals 66 2/3%. Flexion limited to 25 degrees 30 degrees 45 degrees 60 degrees 90 degrees 110 degrees 120 degrees % Loss of Use of the Leg 65% 60% 55% 50% 40% 20% 7 1/2% - 10% 2. Recurrent dislocation of the patella with or without surgery equals 10-15% loss of use of the leg if residual impairment is present. Chondromalacia patella, mild to marked degree, equals 7 1/2%-10% loss of use of the leg, depending on the defects of motion and atrophy of muscles found. Rupture of the quadriceps tendon and patella ligament equals 10%- 15% loss of use of the leg. Osteochondritis desiccans with or without surgery equals 7 1/2 - 10% loss of use of the leg. Medial or lateral meniscus excision, for one or both, equals 7 1/2-10% loss of use of the leg. Partial excision of the meniscus without defects equals 7 1/2% loss of use of the leg. Excision of the meniscus should be documented by operative report or pathological report. Instability of the knee cannot be scheduled unless corrected by surgical reconstruction. If surgery fails and instability persists which will require the use of a brace, consider classification. Laxity of the ligaments (anteroposterior or lateral medial) is given a schedule loss of use of the leg. Revision surgery tends to be less successful and have more complications than initial replacements. For these reasons, one may consider classifications rather than a schedule loss of the leg. In non-functional prosthesis of an amputee with residual symptoms and complications, such as neuroma, phantom pain and chronic ulcers, consider classification. Recurrent locking of the knee may not be amenable for schedule and should be disposed as a classification. Tibial shaft fracture healed and no malalignment equal 0 - 10% loss of use of the leg. Rupture of the Achilles tendon equals an average schedule of 20-25% schedule loss of use of the foot. Malleolar fractures (bimalleolar or trimalleolar) equals an average 20-30% schedule loss of use of the foot. Schedule losses must be substantiated by determination of residual permanent defects; consider tissue loss, mobility defects, sensory and motor loss, and impaired function. Os calcis fracture equals an average schedule of 33 1/3% to 40% loss of use of the foot depending on residual mobility defects.

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Keep handgrip loose during motion to allow for the compromising positions of the glenohumeral joint as it goes through the motions. Seat patient to isolate the muscular surrounding the shoulder responsible for Glenohumeral stabilization. For neuromuscular re-education, vary torque limits and have patient apply the "correct" force to ensure proper attachment movement (to challenge the patient, make various changes to torque limits without patient knowledge - but ensure that correct movement occurs. Quick Reference Dynamometer Orientation: Dynamometer Tilt: Positioning Chair Orientation: Seatback Tilt: Axis of Rotation: Ready Position: Parts Needed Dynamometer: Positioning Chair: Figure 3. Any bony malalignment (such as a fracture) interferes with the critical angles of these articulations making normal movement impossible. The flexor/pronator muscles of the wrist originate at the medial epicondyle of the humerus and wrist extensor group at the lateral epicondyle. Setup and Positioning (Starting Movement: Away/Extension) Seat patient on chair Place Elbow/Shoulder attachment onto shaft (remove cuff). Install limb support (angled toward patient) in chair side receiving tube for side to be tested or exercised. Limb support pad should be angled back with pad angled slightly downward, allowing full extension. In this way job specific tasks, functional tasks, or sports activities may be simulated. Many times when rest is recommended it does not mean total immobilization but the elimination of activities that cause pain. It has been recommended by some clinicians that the dominant arm should be 5% stronger than the non-dominant arm in recreational athletes and 10% stronger in competitive athletes. Ice may be applied to the site of the lesion while the patient is in the passive mode for approximately fifteen minutes. Red range of motion limit set buttons may be set to encompass a slightly greater range of motion than the patient currently is capable of moving. The percent range dials should be turned down to 55% and the patient should be placed on the unit. Throwing injuries commonly occur secondary to throwing too frequently and throwing repeatedly at maximum force. These injuries may be treated by working either passively, isokinetically, or eccentrically at submaximal levels. During pronation/supination, the radial head articulates with the capitellum of the humerus and the radial notch of the ulna. Distally the radius and articular disc of the distal radioulnar joint articulates with the scaphoid, lunate and triquetrum. Pronation/supination may be a particularly difficult motion to fully achieve after injury secondary to the complex nature of the movement. Install limb support (angled away from patient) in chair side receiving tube for side to be tested or exercised. The isokinetic mode may be used at bi-directional velocities in order to simulate functional or sports activities. The passive mode may be used to initiate treatment of reflex sympathetic dystrophy. The passive mode may be used to work a specific muscle group both concentrically and eccentrically, e. The supinators may be worked both concentrically and eccentrically to gain motion and increase strength. The isometric mode may be used to strengthen musculature when pain, instability or surgery is a factor. This may be important since the wrist is frequently used eccentrically during functional activities. If edema is a concern, the dynamometer and multi-support fixture may be raised during rehabilitation. This allows for adduction/abduction, flexion/extension and circumduction to occur. The isokinetic mode may be used bi-directionally to emphasize one particular muscle group, e. The passive mode may be used in cases of reflex sympathetic dystrophy which frequently develops in conjunction with a colles fracture. These patients may receive sympathetic blocks followed by mobilization and range of motion. The patient may move passively at first and, as tolerated, begin to assist the motion in each direction. In this way the wrist, both muscle groups or one muscle group may be exercised concentrically/eccentrically or vice versa, e. Isometrics may be used to strengthen musculature after very delicate surgical procedures, e. Whenever there is wrist involvement, it is important to examine shoulder and elbow movements. Wrist flexion and extension exercises are frequently performed with the forearm pronated because tests have demonstrated that a greater mean torque can be produced than when in supination. Radial deviation is limited by bony contact of the scaphoid tubercle against the radial styloid. The isokinetic mode may be used at bi-directional velocities to simulate function or to emphasize one particular muscle group. After surgery to correct a scapholunate advanced collapse, place the patient in the passive mode at the range available and gradually increase as warranted. The passive mode may be used to perform concentric/concentric, concentric/eccentric, eccentric/concentric, and eccentric/eccentric contraction types. It is important to perform multiple contraction types when rehabilitating the wrist since the hand performs such a wide variety of functional tasks. Isometrics may be used after delicate surgical procedures or when instability is a concern. To simulate a functional activity, set the isotonic force accordingly to a patient task. The eccentric mode may be used to perform submaximal eccentrics or to simulate functional activities. If so, the multi-support fixture and dynamometer may be raised to keep the hand above the level of the heart. In a colles fracture, secondary to malalignment during healing, there may be a permanent loss in ulnar deviation. In this case, it is important to work on motions that may have been limited during immobilization such as ulnar deviation. Whenever the wrist is involved, it is important to evaluate the entire upper extremity for lack of mobility and then treat accordingly. Essentially, this device converts rotational motion at the dynamometer into linear motion, allowing closed kinematic chain exercises to be performed on the ankle, knee, hip, shoulder, elbow, wrist and back without eliciting the increased shear forces inherent in open chain exercise. Interchangeable upper and lower extremity attachments afford a wide range of exercise possibilities. These four screws are located on the side of the Closed Chain attachment that faces the dynamometer. In addition to horizontal left and right positions, the Closed-Chain Attachment can be used in the vertical up and vertical down positions. For upper extremity exercise, insert handgrip into attachment receiving tube with neutral handle facing up or down, based on the pattern to be performed. The degree of elbow and shoulder flexion is easily adjusted by raising or lowering the dynamometer or adjusting seatback or dynamometer positioning fore/aft. Be sure to note the height, position and tilt settings of the dynamometer and chair to ensure reproducibility in future exercise sessions. The handgrip can be inserted with the neutral handle facing up or down based on patient protocol.