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Fortunately for all of us, magnetism is a very fugitive force, and although it may be potent when fresh, it soon fades unless it has been deliberately created by means of ritual. The terrible atmosphere that surrounds the victim of an occult attack and permeates all his belongings is not difficult to get rid of, though it will rapidly reform unless the conditions which gave rise to it are cleared up. If it be in any way possible, let the victim of an occult attack move temporarily to another environment, taking with him as few of his belongings as possible, and let him make the move in new clothes, or in clothes that are just back from the cleaner. I was about to take part in an important piece of occult work to which I knew there would be opposition. A friend who was concerned in the matter asked me to dine with her on the night before the day fixed for the proceeding. We were both conscious of tension in the atmosphere, and she suggested that I should remain the night at her flat instead of returning to my own, informing no one of my whereabouts in order to throw the attack off the trail. I decided therefore to walk to the appointed place across Hyde Park in order to refresh myself. When part of the way across, I suddenly felt that the tension relaxed, and I was able to go through the work in hand without interference. We looked up the spot on a map, and found that I had just crossed the underground conduit which takes the overflow from the Serpentine. Nevertheless, the sense of relief was sufficiently marked to cause me to mention it when I saw my friend again, and to be able to indicate the spot where it had occurred. In other words, if we act as if thought possessed the combined qualities of electricity and bacteria we shall have a sufficiently accurate method of steering by dead reckoning in the absence of certain knowledge and actual sight. If we consider the various methods used in folk-magic of all ages and races, we shall observe that they are in agreement with these hypotheses. Running water, we know, has peculiar electrical qualities, as is witnessed by its effect on the divining-rod in the hands of a sensitive person. Whatever it may be that affects the diviner is probably the same thing that affects the occult attack. It is used in the rite of baptism by the Church and in the Preparation of the Place by the occultist about to perform a ceremony. Strictly speaking, there should be a trace of salt in the water thus employed, and both salt and water are blessed with powerful invocations when the priest is preparing holy water, whether for a baptism, or for placing in the holy water stoup for the use of the congregation. As far as the occultist is concerned, salt to him is the emblem of the element of earth. It is also a crystalline substance, and crystalline substances, in their different forms, receive and hold etheric magnetism better than anything else.
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During the clinical examination, the most tender area can be demonstrated, as can any areas with contusion marks and swelling. This information may be important in helping the radiologist determine what views to take for a fracture to be demonstrated. If this occurs, the patient will have maximum soreness on the dorsal and ulnar side of the wrist. A golfer or another athlete (baseball batter) who hits hard with a racket or club may injure the hook of the hamate (which projects into the palm of the hand). If a carpal bone fracture is demonstrated, the patient should be referred to a specialist for further diagnostics and treatment. Symptoms and signs: Symptoms are pain, soreness, and swelling, possibly combined with reduced function. Diagnosis: Fractures should be suspected when the clinical examination reveals localized tenderness, swelling, and possibly bruising. Treatment: An isolated, nondisplaced fracture through the triquetrum, the hamate, or the pisiform may be treated with a cast or splint for 4? weeks. Some fractures are part of a serious fracture-dislocation injury, and the treatment alternatives include open reposition of displaced bones, repair of ligaments, osteosynthesis using pins or screws, and a cast for 8?2 weeks. If there are late symptoms from a hamate or pisiform fracture, the hook of the hamate or the pisiform can be surgically removed without any noticeable loss of function. Prognosis: the prognosis depends completely on the type of fracture, when the injury is diagnosed and treated, and especially on the type of treatment that is given. Most patients recover fully; however, some end up with persistent pain and should be investigated for treatable nonunions or post-traumatic arthritis from displaced carpal bones that may eventually make some type of arthrodesis necessary. The patient, the physical therapist, and the physician will need to discuss every case individually as to when the athlete may resume sport activity. Ligament Injury in the Wrist A number of ligaments stabilize the various carpal bones to each other and to the radius, ulna, and metacarpal bones. Some of the interosseous ligament connections have the strongest part on the palmar side, whereas others have greater dorsal strength. If there is a strong blow to the hand, usually caused by a fall on a hyperextended, ulnar-deviated, and somewhat rotated hand, then a fracture, a ligament injury, or a combination of the two may occur. Ligament injuries, with or without dislocation of the carpal bones, may be difficult to diagnose. When both ligaments are injured, the lunate bone becomes unstable and may become dislocated. If an athlete falls on an extended hand, the ligaments in the carpus may rupture (as seen from the palmar side) (b). Diagnosis: Diagnosis is based on radial or ulnar (depending on what ligament is injured) instability and tenderness in the wrist. During the acute phase it is difficult to do a clinical test of the various carpal ligaments ("everything hurts"), but this is often possible later on.
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More superiorly, the posterior aspect of the calcaneal tuberosity is almost subcutaneous; therefore, its outlines are usually clearly visible. This deformity is manifested by a large visible bump, especially over the supralatcral corner of the calcaneal tuberosity (Fig. Thickened skin and subcutaneous bursal enlargement may further increase the prominence of this deformity. Because it is thought to be caused, or at least exacerbated, by shoe pressure over the calcaneal tuberosity, this deformity is often popularly described as a pump bump. The retrocalcaneal bursa lies between the distal Achilles tendon and the superior portion of the calcaneal tuberosity. In the presence of retrocalcaneal bursitis, chronic thickening of this bursa also adds to the apparent prominence of the calcaneal tuberosity. More proximally, the Achilles tendon can be seen coursing between the medial and the lateral malleoli to its insertion on the calcaneal tuberosity. A, medial malleolus; B, lateral malleolus; C, tibialis anterior tendon; D, extensor hallucis longus; E, extensor digitorum longus; F, anterior inferior tibiofibular ligament; G, peroneus tertius. In the case of a rupture, the examiner notes more diffuse swelling throughout the visible length of the tendon owing to the accumulation of hemorrhage and edema. More proximally, the Achilles tendon fans out into a flat aponeurosis over the posterior aspect of the soleus muscle belly (Fig. Still higher on the leg, the two distinct heads of the gastrocnemius insert into this common aponeurosis. The outlines of the medial and the lateral heads of the gastrocnemius are visible in many individuals, especially if the patient is asked to perform a toe raise (Fig. Because the normal bulk of the calf muscles can vary tremendously from one individual to another, a lack of symmetry is the key finding that should suggest abnormality. Calf atrophy may be the residuum of an otherwise corrected clubfoot deformity (Fig. Bony contours that are visible from the medial perspective include the head of the first metatarsal, the calcaneal tuberosity, and the medial malleolus. Distal and anterior to the medial malleolus, the examiner often can see the much smaller prominence created by the navicular tuberosity. When an accessory navicular or cornuate navicular is present, the prominence of the navicular tuberosity may be increased until it rivals that of the medial malleolus in size. The saphenous vein is usually large and superficial at the ankle and can often be seen as it passes anterior to the medial malleolus. Proceeding immediately posteriorly from the medial malleolus one encounters, in order, the tibialis posterior (posterior tibial) and flexor digitorum longus tendons, the posterior tibial artery and nerve, and the flexor hallucis longus tendon. Of all these structures, only the tibialis posterior is normally visible, and resisted inversion and plantar flexion are usually necessary to make it stand out distinctly (Fig. When this resistance is applied, the tibialis posterior tendon is most easily seen between the posterior edge of the lateral malleolus and its insertion on the navicular tuberosity. The medial viewpoint gives the examiner a direct view of the arch and the vicinity of the major neurovascular bundle (Fig.
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The duration of seizure activity to meet the definition has traditionally been 15?0 min. Both disorders are associated with absolute or relative insulin deficiency, volume depletion, and altered mental status. Despite a total-body potassium deficit, the serum potassium at presentation may be normal or mildly high as a result of acidosis. Hyperamylasemia is usually of salivary origin but may suggest a diagnosis of pancreatitis. The prototypical pt is an elderly individual with a several week history of polyuria, weight loss, and diminished oral intake. Though the measured serum sodium may be normal or slightly low, the corrected serum sodium is usually increased [add 1. Hyperglycemic Hyperosmolar State the precipitating problem should be sought and treated. The calculated free water deficit (usually 9?0 L) should be reversed over the next 1? days, using 0. Admit to hospital; intensive-care setting may be necessary for frequent monitoring or if pH < 7. Measure capillary glucose every 1? h; measure electrolytes (especially K+, bicarbonate, phosphate) and anion gap every 4 h for first 24 h. Monitor blood pressure, pulse, respirations, mental status, fluid intake and output every 1? h. Continue above until patient is stable, glucose goal is 150?50 mg/dL, and acidosis is resolved. The insulin infusion should be continued until the patient has resumed eating and can be transitioned to a subcutaneous insulin regimen. Counterregulatory responses to hypoglycemia include insulin suppression and the release of catecholamines, glucagon, growth hormone, and cortisol. The laboratory diagnosis of hypoglycemia is usually defined as a plasma glucose level <2. Tachycardia, elevated systolic blood pressure, pallor, and diaphoresis may be present on physical examination. Under these circumstances, the first manifestation of hypoglycemia is neuroglycopenia, placing patients at risk of being unable to treat themselves. Nevertheless, blood should be drawn at the time of symptoms, whenever possible before the administration of glucose, to allow documentation of the glucose level. In the absence of documented spontaneous hypoglycemia, overnight fasting or food deprivation during observation in the outpatient setting will sometimes elicit hypoglycemia and allow diagnostic evaluation. Treatment of other forms of hypoglycemia is dietary, with avoidance of fasting and ingestion of frequent small meals.
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Pennate muscles are generally stronger than fusiform muscles, because several muscle fibers can work parallel to each other. However, because they contain shorter fibers, the maximum contraction speed is lower. The striated muscle cell is a fiber with a diameter of 10?00 m and a length up to 20 cm. The primary elements in the muscle fibers are myofibrils, which are composed of protein filaments (mainly actin and myosin). Capillaries surround the muscle fibers, so that the ability to supply the fibers with oxygen and nutrients is very good. The generation of force without changes in the joint angle is called an "isometric" or "static" muscle action (the length of the muscle is constant, but the tension changes), whereas the muscle contraction where the length changes but tension remains constant is called "isotonic. For concentric muscle action, maximal muscle force is reduced when the speed of contraction increases, whereas in eccentric muscle activity, muscle force increases with increasing speed. This means that the risk of muscle injuries is greater with eccentric than with concentric muscle action. That working conditions play a decisive role in the generation of force can be illustrated by comparing various types of jumps. The greater force generated from a drop jump significantly increases the risk of acute strains, and the risk of overuse injuries is high in sports characterized by this type of muscle action. Muscle volume and strength increase significantly after a short period of specific strength training (Figure 1. Two factors contribute to increasing strength: (1) the ability to recruit several muscle fibers at the same time for the contraction (neural factors) and (2) muscle volume (muscular factors). Muscle volume primarily increases as a result of individual muscle fibers increasing their cross-sectional area (hypertrophy), and also by forming new muscle cells (hyperplasia) from stem cells (satellite cells) in the musculature. Neural factors contribute most to the initial strength increase, whereas hypertrophy is primarily responsible for the subsequent strength increase. Strength increase Anabolic steroids Strength Neural adaptation Hypertrophy Weeks Months Years Time the enhancement of endurance capacity of muscles, in turn, involves traininginduced increases in the oxidative capacity of the muscles. Both main types of training, endurance (low-intensity, high volume) and strength (high-intensity, short duration) training, are known to improve the energy status of working muscle, subsequently resulting in the ability to maintain higher muscle force output for longer periods of time. Recent experimental data demonstrate that strength training can also lead to enhanced long-term (>30 min) and short-term (<15 min) endurance capacity in well-trained individuals and elite endurance athletes when high-volume, heavy-resistance strength training protocols are applied. Because strength increases after a few weeks but tendons, cartilage, and bone require months to adjust, there is a danger that overuse injuries will occur in these structures in connection with the beginning of systematic strength and jump training. The patellar tendons and the Achilles tendons are examples of structures that are especially vulnerable in adult athletes. This is particularly true when the patient uses anabolic steroids, where there seems to be an increased risk for a total rupture of muscle or tendons. In addition, the musculature is sometimes injured as a result of unusual and hard training, especially eccentric training.
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Despite this peak load tolerance, tendon overuse injury (tendinopathy) is one of the most frequent injuries among elite and recreational athletes. Such overuse injuries most often affect tendons such as the Achilles, patellar, or supraspinatus tendon (Table 12. In sports characterized by forceful and explosive muscle contractions, the prevalence of patellar tendinopathy can reach 45?5% in populations of jumping athletes such as elite volleyball and basketball players. The prevalence of Achilles tendinopathy is also considerable in a variety of different sports such as running (about 10% of all athletes) and different ball games. Overuse injuries in the upper limb occur in athletes (throwing and racquet sports), but are also prevalent in an older population, particularly manual workers. Sport Anatomical region of tendon Achilles/iliotibial band/fascia plantaris Achilles Patella Patella Patella/Achilles Achilles/patella Supraspinatus/other rotator cuff Supraspinatus/other rotator cuff Prevalence Running Football Volleyball Basketball Track and fields Badminton Handball Baseball 10% of runners 5?0% of all elite players 55% of elite-players 45% of elite players 10% of elite athletes 5% of all players 5% of elite players 20% of all players the numbers reported are estimates based on the studies available. Tendons that rupture are often painfree, but have an extensive pathology and the force imposed on them is greater than the tendon integrity (Kannus & Jozsa, 1991). The mechanisms of tendon injury have not been identified and this greatly limits the ability of coaches and clinicians to prevent and treat tendon injuries. In tendinopathy, where so little is known about the basics of the condition, prevention strategies are limited and not supported by evidence. To fully comprehend tendon injury mechanisms and the prevention of tendon injuries, it is important to understand tendon structure and function. Thus, we briefly introduce the structure, function 187 188 Chapter 12 and mechanics of normal tendon. Then we review the etiology of tendinopathy and propose opportunities for injury prevention. Macroscopic tendinosis Normal tendon Increased cellularity (myofibroblasts) Basic tendon structure All muscles basically have two tendons, a short one at their proximal end (origin of muscle) and a somewhat longer one at their distal end (insertion of muscle) underlining that the mechanical properties of the tendons will have a great impact upon the function of the entire muscle?endon?one complex. Tendons and muscles join, and integrate, at the myotendinous junction-the site where the tendon infiltrates or interdigitates the muscle body to provide a large contact surface between the two structures. Distally, the tendon joins bone in the osteotendinous junction, a complex transition from soft to hard tissue. Because the muscle?endon junction is primarily affected in a muscle strain injury, we will not consider the structure and function of the myotendinous junction in this chapter. The structural design of different tendons varies substantially; some are short and thick, and others long and thin. Long tendons, such as the Achilles tendon, provide the body with energy-returning springs so that movement is energy efficient. Short, broad tendons, such as the quadriceps tendon, serve as pure force-transducers for their attached muscles. Normal tightly bundled type I collagen fibrils Neovessels Increased matrix protein Collagen fibrils in disarray Figure 12.
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For example, in adults there is no statistical relationship between radiographic spondylolysis or spondylolisthesis and pain. Spondylolysis or spondylolisthesis should be excluded in young athletes who have back pain. If the patient has chronic sciatica caused by disk herniation or recess stenosis, a decision must be made about whether or not to perform surgery on the patient and what consequences surgery would have for sport activity in the long and short terms. In the elderly, pain and walking difficulties that improve when the patient bends forward may be caused by spinal stenosis (spinal claudication). In downhill and cross-country skiing, in weightlifting, and in sports that involve throwing (including ball sports), the tendon insertions may become inflamed or may rupture because of sudden or repeated loading. Repeated loading during martial arts, such as judo and karate, may cause muscle and ligament damage. Diagnostic Thinking If the patient has chronic pain, the diagnosis should include a functional evaluation relating to the individual sport. In addition to the examination based on pathological anatomy, psychological, and social factors should be evaluated. First, the practitioner should determine whether the pain derives from the back or from some other area or cause. The practitioner should then determine whether the condition requires immediate attention or referral (spinal cord affection or cauda equina lesion); whether symptoms and signs indicate serious back disease (red flags are noted in Table 5. Most patients with acute back pain become asymptomatic within 1? weeks without treatment. A patient seeks medical assistance because she wants pain relief and advice about what to do. Because it is difficult to make a specific diagnosis during the acute stage, the patient should be given an opportunity to return for a complete new examination within 2 weeks. Surgery is indicated during the acute stage if the patient has lost control of urination or defecation or has increasing leg paralysis. In the latter case, the patient should be referred for appropriate orthopedic or neurosurgical care immediately. The prognosis for acute bladder or rectal paresis is worse if it lasts more than 11 hours. Patients with kyphosis or structural scoliosis should be referred for orthopedic evaluation. If Bekhterev disease or another inflammatory disease is present, a rheumatologist should evaluate the patient. If the condition lasts less than 2 weeks, the patient is usually examined and treated by a primary physician.
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The ring apophysis starts to ossify at about 13 years of age and begins to fuse with the vertebral body at about 17 years of age. At completed growth, each vertebra has an elevated rim and a central depression of the endplates. The etiology and development of intervertebral disc degeneration and abnormalities affecting the vertebral endplates and ring apophyses are not fully known. As evidenced by the high frequency of abnormalities in the spine of adolescent athletes, mechanical trauma at a young age appears to be a factor of importance especially in sports with great demands on the back (Jackson, 1979; Sw? et al. In an experimental study, a degenerative disc was created by drilling a hole through the cranial endplate of a lumbar vertebra into the disc. The results in this study were that twice the axial load was required to create failure of the degenerated discs as compared to non-degenerated discs. Muscles of the lumbar spine For descriptive purposes, the spine muscles may be divided into three groups: superficial, intermediate, and deep. The superficial (trapezius, latissimus dorsi, levator scapulae, and rhomboid muscles) and intermediate (serratus posterior superior and inferior muscles) groups are extrinsic back muscles that are concerned with movements of the limbs. The deep group (semispinalis, multifidus, rotators, interspinales, and intertransversarii muscles) constitute the intrinsic back muscles that are concerned with control of the vertebral column. The muscles quadratus lumborum, iliopsoas and the abdominal muscles are also important lumbar spine muscles. Core stability/neuromuscular control the term stability is a mechanical concept that most be relate to, but which can be difficult to explain when applied to the body in motion. The term is borrowed from traditional mechanics and describes the ability of a body to remain in the same position while forces are being exerted on it. However, when performing in sports, body configuration is rarely static; in fact, it constantly and rapidly changes. Thus, the athlete must be sufficiently stable and at the same time mobile in order to adapt to the demands placed on them during various movement patterns. The stability and mobility of a joint is primarily dependent on three factors: passive structures (bones, ligaments, joint capsules), active structures (muscles), and the ability to successfully coordinate information and activate the muscles (the central and peripheral nervous system) (Figure 8. Thus, Control system (nervous system) Passive subsystem (ligaments, bone, joint capsule) Active subsystem (muscles) Figure 8. In training terminology this is often referred to as stability, and when referring to the low back pelvis and hip region, "core stability. More simply put, the deep paraspinal muscles, with high endurance and fine motor skills, stabilize the joint systems (here the lower back, pelvis, and hip), whereas the superficial muscles, with less endurance, produce propulsion.
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Upon achieving the criteria that have been outlined, a formal interval sport program should be initiated. The athlete may perform the program three times per week with a day off in between each step. If the athlete experiences symptoms at a particular step within the program, he or she is instructed to regress to the prior step until symptoms subside. Typically, the athlete should warm-up, stretch, and perform one set of their exercise program before throwing, followed by two additional sets of exercises after throwing. The injury panorama ranges from "innocent" sprains to complicated fracture dislocations. An injury causing stiffness of the wrist and eventually a fusion as a result of a missed diagnosis and treatment, results in a higher medical disability as compared to loss of the anterior cruciate ligament in the knee. Therefore, the physician must strive for good and accurate diagnostics and treatment of hand injuries. The athlete falls and puts her hands out for protection resulting in twisting, stretching, or hyperextension. This may cause pressure, contusion, and partial overstretching of the skin, the musculature, and/or the capsule apparatus. A partial rupture of a ligament causes pain, swelling, and discoloration of the skin, but no signs of instability or fracture. A fracture is more common in elderly people than in youths, the quality of the bone being better in younger people. Depending on the force at the time of the injury, a fracture in the distal forearm or a ligament injury within the carpus with or without a fracture in the carpal bones may be the result. However, if overlooked and untreated, these fractures may cause changes in the wrist and carpus that might require future surgery. These injuries are often overlooked as an arthroscopic examination, considered the gold standard for diagnosing intra-articular injuries of the radiocarpal joint, is rarely performed in acute injuries. If a patient is suffering from wrist pain after healing of a fracture of the distal radius, these structures are generally the ones that are affected. Tendon injuries at the wrist level without a simultaneous open wound are very rare. Diagnostic Thinking Some injuries in the hand and wrist present with obvious abnormalities such as: laceration, bruising and swelling, skeletal deformity, and postural abnormalities. Other injuries, particularly those involving the wrist, may have very subtle features making them difficult to diagnose. Upon initial inspection of the hand and the wrist, the physician should look for a deformity. Swelling or discoloration should be looked for, indicating bleeding from a fracture hematoma or a ligament rupture. If there is deformity and/or swelling, the patient should be referred for a radiographic examination. Generally, however, deformity, major swelling, or definite signs of instability are uncommon-quite unlike tenderness from direct palpation.
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Distal weakness is usually due to neuropathy (any), but also some muscle diseases (Emery?reifuss, myotonic dystrophy, dysferlinopathy, Miyoshi myopathy). Difficulties bending forward, lifting head off the bed, respiratory involvement, nocturnal hypoventilation, and diaphragmatic weakness; seen in congenital myopathies and glycogen storage disorders. Antenatal onset suggested by polyhydramnios, reduced foetal movements, unusual foetal presentation in labour, contractures (arthrogryposis including foot deformity), congenital dysplasia of the hip. Associated features/system enquiry ?Toe walking: Duchenne, Becker, Emery?reifuss, Charcot?arie Tooth. Examination ?Examine parents and siblings: especially when considering neuropathies, myotonic dystrophy. This latter is particularly a consideration in the presence of myoclonic seizures (see b p. The six commonest diagnostic groups were leukoencephalopathies (7% combined), neuronal ceroid lipofuscinoses (5% combined), mitochondrial diseases (5%), mucopolysaccharidoses (4%), gangliosidoses (4%), and peroxisomal disorders (3%). Ask about history of sudden infant death, unexplained illness, or neurological presentations in family members. The epidemiology of progressive intellectual and neurological deterioration in childhood. Clues from imaging, electrophysiology and ophthalmology examination For approach to white matter abnormalities see b p. It can be hard to tell whether the problem is, in fact, longstanding, but has recently come to light due to increasing academic expectations. Parental observations should be supplemented by reports from schoolteachers and/or educational psychologists. Examination the child will be older and a formal (adult style) neurological examination with assessment of higher mental function (see Box 1. Non-rapid eye movement sleep Stage 1 (5?0% of sleep) ?Occurs at sleep onset or following arousal from another stage of sleep (see Figure 3. Rapid eye movement sleep Physiologically very different: ?Brain metabolism is high. Examination Pay particular attention to physical factors that may disturb sleep. Excessive daytime sleepiness Likely to be due to poor nocturnal sleep hygiene but consider obstructive sleep apnoea and narcolepsy (under-recognized) (see b p. Disturbed episodes related to sleep (parasomnias) these are recurrent episodes of behaviour, experiences, or physiological changes that occur exclusively or predominantly during sleep. Decide whether these are primary, or secondary to neurodevelopmental or neuropsychiatric issues (see b p. Measures the time taken to get to sleep during 5 opportunities at least 2 h apart during the day. Conceptual framework Speech and language disorder ?Secondary to cognitive disability, hearing impairment or environmental adversity. Neuromotor speech disorders Apraxia Abnormal planning, sequencing, and coordination of articulation not due to muscle weakness.