Arthritis Australia

By R. Jared. Minnesota State University Moorhead.

This is because medical care—the goods to be delivered —does not produce much health midamor 45mg on-line, and discount midamor 45 mg without a prescription, with the passage of time, will produce even less. If the commons is thought of as the health of the popula­ tion and not as a pool o f goods to be parceled out by physicians, there is a second way to preserve it. This ap­ proach depends on a reconceptualization of health as some­ thing other than a commodity. W hen this is accomplished, a second step is possible: derivation o f a program for the pursuit of health combining measures of individual respon­ sibility, efficacious curative measures, and interventions into the environm ent. This is not an easy task; in fact because we know so little it is highly problematic. But gradually m easures were developed that worked, even if they were frequently bizarre. Blood was let in sacrifice, dances were danced, incantations were offered, and occasionally medicinals were used. And occasionally, the medicine o f the past worked, often as not because the practitioner was perceptive and sensitive. T he 196 The Transform ations of Medicine first was the discovery that cleansing the environm ent —developing sanitary sewage systems and im proving the potability o f water—appeared to reduce mortality and m or­ bidity. These services were significantly different from most medicine; they were systemic and ecological in nature. They were premised on interventions in the socioenvironment rather than the hum an body. As such they were not mea­ sures that could be reduced to commodities rendered for a price by healers to patients. Eventually, they were not thought o f as medical m atters at all—they were decisions to be m ade by the polity. Medical care, concomitantly, consisted of healing those who were sick—why they were sick, or what cured them if they were cured, was not necessarily relevant. Thus, causes—the conditions and circumstances of life —became divorced from effects. Sickness and its symptoms have been treated ever since, and causes have been neglected. Scientific methodology is a tool of great utility, and scientific problem-solving found a congenial hom e in medicine. Unlike other branches of science, medicine possessed a captive supply of experim ental sub­ jects, and generally found revenue sources for biomedical research easy marks. It cannot be overemphasized that the application of scientific methodology to healing produced substantial benefits. But the case is less convincing today, and will be much harder to make in the future. T he em­ phasis in medicine on material reality—only what can be perceived can be treated and only “symptoms” can be perceived—has driven medicine to extremes. The Eras of Medicine 197 In medicine, as well as in other disciplines, the pursuit of scientific purity results in reductionism of the subject matter. In part, the environm ental crisis we face today stems from our inability to understand our world as an organism—as the spaceship Earth. In chemistry, in biology, and in medicine, increasingly investigators cannot communicate with one another because they have drawn rigid and narrow boundaries around their subjects. In medicine this has re­ sulted in microscopism and specialization—with elegant em ­ pirical fireworks—on smaller and smaller parts of the hum an organism. W hen a physician let blood in the seven­ teenth century, he may not have benefited the patient much, but at least he perceived his patient as a single organism u nder the spell of some “hum our. T he excised organ goes to the pathologist, the physician gets his or her fee, and the patient goes to the tavern. Precisely at a time when it has achieved a feudal, even sovereign status—a state at great variance with its capacity to heal—shifts and ruptures in the larger society expose medicine to changes that will powerfully alter it. M odern medicine shares a certain perception or view of the world and m an’s place in it with the other sciences. This view stresses the separation of hum an beings from their world and their environm ent. Perhaps this world view had survival value when the environm ent was decidedly hostile. We have largely subjugated Na­ ture, although we are beginning to witness its resilience. Slowly the realization is em erging that a new balance must be struck with nature if man is to survive. W hether a new balance can be struck today or w hether m an m ust further evolve in order to strike a new bargain is unanswerable. Nevertheless, contem porary medicine is clearly and 198 The Transformations of Medicine squarely premised on the prevailing world view that sepa­ rates hum an beings from their world. Medicine first seeks to insulate the patient from a supposedly hostile environm ent, and if that protection fails, then deploys its firepower to destroy the hostile agent.

This would imply a relatively inefficient training effect (adaptation) in both the muscles movement mechanism – a kind of one-step-forward 45mg midamor visa, (increased size) and the nervous system (improved one-step-backward motion midamor 45 mg on-line, based on digestive and activation and coordination of muscles) (Sale eliminative cycles. Starfish are categorized as triploblastic acoelomates and, as such, can be viewed as further down the evo- • Indeed, Bompa (1999) explains that neural lutionary road than jelly fish and anemones, and their adaptations to exercise are the primary reason for behavior may be seen in human ontogenetic terms as strength gains in the first 8 weeks of any new the naval radiation pattern in the womb – where the training program, and only after this period does central point of stability (or technically where the hypertrophy predominate as the primary means of fetus is held in a ‘closed chain’ environment1) is via strength gain. At any point beyond 8 weeks in utero, can be explained by the phenomenon of facilitation the four limbs have formed and the head, forming the (see Box 9. This results in forma- Roundworms – radial/direction specific tion of five approximately equal appendages radiat- The emergence of roundworms (see Fig. This pattern in the Neoproterozoic – brought with it changes in the is maintained throughout intrauterine development digestive process. At this stage of development, round- worms now had a unidirectional gut tube, rather than the bidirectional gut tube of the diploblastic and acoe- 1When the body is biomechanically in a closed chain it means lomate triploblastic body plans of earlier designs. Therefore, in These were the first organisms capable of leaving this example, the arms, legs and head are in an open chain traces of their existence through meandering trails, environment as they can overcome resistance of the amniotic fluid, but the fixed point of the fetus – the point that cannot burrows and fecal pellets that could only have been move – is its attachment to the uterine wall via the placenta left by creatures with a complete gut tube (Erwin and umbilical cord. Additionally, such movement patterns 324 Naturopathic Physical Medicine would require a ‘soft skeleton’ of fluid-filled spaces motor control at the spine at the expense of breathing. Many invertebrates use such hydrostatic even under the same perturbation loading – the dia- systems to move, and many vertebrates use hydro- phragm would resume its respiratory function. However, until such time, nificantly to their compressive resistance (Bogduk lumbopelvic stability can be maintained through 1997). Active absorption of foodstuffs Fish (1st dimensional mastery) – lateral into a blood system (hemocele) meant that digestive efficacy was further enhanced and therefore metabolic flexion/direction specific efficiency optimized. This would allow for optimal As the complexity of organisms increased, and the delivery of nutriment to the working parts – whether nervous control of this complexity became more fun- this was the nervous system, the musculature or the damental to the organism’s survival, bony encase- digestive system itself. Such efficacy would allow the ment of the neural components became commonplace worm to evolve greater muscle mass as oxygen deliv- (Kardong 2002). The skull had already formed to ery to the tissues could now operate via the active protect the brain, but the longitudinal cord of nervous vehicle of blood, rather than passive diffusion. Longitudinally the effects of bony spinal development were that there arranged musculature would also allow for some was now a new movement option. Rather than degree of flexion-extension (as seen in the caterpillar); sequential peristaltic contraction, there was now the however, without a bony spine the flexion-extension option to contract the musculature down the entire would be little more than a transient ‘ripple’ down the length of the body on one side, then, using the stretch body segments. This would provide an How this pertains to human development efficient cyclical means of moving forward through and movement rehabilitation water and made use of the viscoelastic properties of In terms of motor control, this movement is exploit- mesodermal (muscle) tissue. In humans, of course, the appen- bony strut would be required to prevent ‘telescoping’ dicular extensions (arms and legs) are also employed of the body under the load of unilateral longitudinal to facilitate movement. This has been demonstrated in work by roundworm bauplans, digestion became less depen- Hodges et al (2001) in which they confirm Lewit’s dent on movement and, in fact, with a decreased utili- (1999) assertion that the diaphragm is a respiratory zation of the peristaltic action of the body wall, would muscle with postural functions, while the transversus require a further functional separation of the digestive is a postural muscle with respiratory function. Therefore, any creature that by Hodges and colleagues (2001) showed that human has mastery of a movement pattern beyond a peristal- subjects, when under perturbation loads, would tic forward creep, must have evolved a celomic cavity recruit both transversus and diaphragm to optimize to allow gross movement without compromising Chapter 9 • Rehabilitation and Re-education (Movement) Approaches 325 digestive efficiency. Indeed this is what the fossil movement skill with them to swamps to clamber over record and morphological studies suggest. On The earliest animals to truly master motion in the land, however, this mastery brought with it some frontal plane (above and beyond the primal dimen- serious limitations. It is at this juncture in evolution (and Gracovetsky (1988) describes how any ground-lying in every vertebrate development after fish) that we objects, such as rocks, stones, fallen trees, would need find development of a celomic cavity. This solution would result initially in axial same layer of embryological tissue (the lateral plate rotation which, when coupled with lateral flexion, mesoderm) as the abdominal wall musculature (see would culminate in motion in the sagittal plane. The structure sequence of events is corroborated by Kent & Carr therefore is interrelated with the function. Gracovetsky (1988) believes that this provided a solution to both the ground-lying How this pertains to human development objects and the fact that, until this juncture, the mass and movement rehabilitation of muscle responsible for moving the organism forward on land was intra-abdominal and therefore • In the infant human, and in many apes, lateral was competing for space with the vital viscera in the flexion is utilized as a primary trunk pattern in abdominal cavity. This seriously limited the potential both gait and other gross movements – such as for significant hypertrophy. One of the characteristics An alternative solution, Gracovetsky (1988) argues, of early gait is a laterally directed arm swing (to was to develop effective flexion-extension of the trunk compensate for frontal plane motion of the trunk), and limb which brought with it a number of benefits as opposed to the drive forward and backward in over lateral flexion: more accomplished sprinters (Haywood & Getchell 2005). In a competitive and found in the gym environment, train the user hostile environment, this would have been primarily in the sagittal plane; hence frontal plane highly desirable. Of course, the story is far more lateral flexion/direction specific/ complex than this, but it does provide a general over- coupled rotation view of our understanding of the evolution of verte- From this point in the evolution of vertebrate design, brate biomechanics – including our own – based on we can turn to the work of Gracovetsky (1988) to the fossil record. This then provides a greater insight provide a concise, insightful description of upcoming to how human biomechanics have evolved and are events. This understanding is fundamental Having mastered motion in the frontal plane in the to helping solve problems when the biomechanics water, the first amphibious pioneers brought this break down. From this, Ahlberg (personal communication, Lateral flexion → Axial rotation → Flexion-extension 2000) agrees it can be inferred that, consistent with How this pertains to human development Gracovetsky’s interpretation, axial rotation may be and movement rehabilitation allowed (as a mechanical necessity) during evolution from lateral flexion to sagittal flexion-extension. Mastery (active) axial rotation When compensation patterns are present, injury may occur either centrally at the spine or Indeed, even in a human infant, it takes many years peripherally in a limb. The end result is an It is interesting to note that the only two true bipeds attempt to increase the power from the arm, alive today are birds and humans, and that both of increasing the tension locally through the arm and them have significant spinal rotation, and both are the grip required on the racket, club or other able to sing and generate rhythm. Across a period of time, cumulative is believed to be intrinsic in the spinal cord circuitry stress to the tendons of the extensor and/or flexor of bipeds – to effectively generate rhythmic gait.

Using Standard Cost of Illness procedures Behan ea (2008) estimate total cost (in millions) of schizophrenia in Ireland discount midamor 45 mg with mastercard, subject to limitations posed by unavailable data order 45mg midamor mastercard, was €460. Incidence: The incidence of schizophrenia is much higher in the unmarried of both sexes than in the married and is probably no higher in Ireland than elsewhere. The figures for schizophrenia vary widely 916 917 depending on admission policies , diagnostic practices , and differing methods of case finding. Taking admission diagnoses made by inexperienced staff and lumping together anything half-resembling 918 schizophrenia all too often represents official statistics. Studies showing a higher incidence among males 919 may suffer from missing late-onset female cases. There is some indication that the risk to siblings for developing schizophrenia in the case of late-onset disorder may be less than for younger onset but higher than for the general population. The study in which these interesting if unexplained figures were reported (Kendler & Walsh, 1995) found no sex difference in age of onset. The same group later found no connection between age of onset and the risk for schizophrenia in relatives. Aleman ea (2003) conducted a meta-analysis of the literature and found that the incidence risk ratios for men to develop schizophrenia relative to women varied from 1. The point prevalence (prevalence at a point in time) of broadly defined schizophrenia in inner London in 1991 was 5. According to Jeste and McClure (1997), the prevalence of schizophrenia is 7% in siblings and 3% in parents of probands with late-onset schizophrenia. A Finnish study (Salokangas ea, 2010) found that annual first admission rates (per 100,000) fell from 1980 to 1991 but increased slightly thereafter. Bed number availability changes, admission policy, and diagnostic practice may explain most variation, and the authors wondered if increased use of illegal drugs and better treatment of depression might be reflected in the increased figures. Earlier work tended to look for ‘nuclear’ (narrow) schizophrenia whereas ‘broad’ definitions yield greater differences between countries. The McGrath ea (2004) systematic review found up to fivefold differences internationally. Not surprisingly, a Danish study (Thorup ea, 2007) found that incidence rates for males significantly exceeded those for females in the age range 17-40 years but by the age of 72 years 1. Peak age of onset of schizophrenia is in the third 922 923 decade ; onset is 3-5 years later in females than in males. Long-term treatment with conventional antipsychotic drugs in women produces better outcomes and, even when controlling for body weight, lower doses are needed than in males. Attempts to equate puberty with age of onset of symptoms have suffered from small numbers and possible recall bias. One group (Cohen ea, 1999) found the earlier was puberty (menarche) in females the later were onset of psychosis and first hospitalisation, with men showing a trend in the opposite direction. A retrospective Chinese study (Phillips ea, 2004) suggests schizophrenia is more prevalent in women than in men, a finding criticised on methodological grounds by Ran and Chen. Inner city areas may attract people who already have, or will later develop, schizophrenia. Aetiology926 ‘It is likely that schizophrenia is the final common pathway for a group of disorders with a variety of etiologies, courses, and outcomes. Instead they suggest, without much in the way of evidence, that schizophrenia represents an end stage in which certain symptoms are shared and which is reached by a gradual decompensation of personality. Bergemann ea (2007) reported significant improvement in psychotic (but not depressive) symptoms in females with schizophrenia during the luteal phase. Also, in a randomised double-blind study, Kulkarni ea (2008) found that adjunctive transdermal oestrogen reduced positive symptoms and general psychopathological symptoms in women with schizophrenia. A fundamental problem with all attempts at finding a cause or causes for schizophrenia arises from the strong likelihood that ‘schizophrenia’ represents a heterogeneous group of disorders. Young, single men, who are living with parents, are at very high risk from this type of ambient 927 tension (Vaughn and Leff, 1976). Various coping mechanisms, such as problem solving, and the neuroleptics, may prevent the effects of stress reaching the non-specific symptomatic stage. A higher frequency of independent life events is probably required to initiate relapse in adequately medicated patients. If relatives can be trained to recognise non-specific symptoms, medication dose could be increased pending consultation. Relapse rates may be reduced by educating the family about schizophrenia and by conducting group sessions for those involved in the care of patients in the community. Whilst it makes sense to concentrate on improving the interpersonal coping skills of individual patients, focusing on the family unit may improve results. In a prospective Danish study, Khashan ea (2008) found an association between death of a relative of the mother during the first trimester of pregnancy and risk of schizophrenia in the offspring.

Persisting 117 neurologic outcome during infective endocarditis: Eustachian valve in adults: relation to patent foramen Section 2: Clinical epidemiology and risk factors ovale and cerebrovascular events discount 45mg midamor with mastercard. Cardiac diseases as a risk factor for stroke in Saudi Recurrent cerebrovascular events associated with children order midamor 45mg amex. Scand J Rheumatol 2005; foramen ovale and the risk of ischemic stroke in a 34:315–9. Patent instrumental findings, additional cardiac and foramen ovale: innocent or guilty? Overview of of clinical features in transient left ventricular the 2007 Food and Drug Administration Circulatory apical ballooning. J Am Coll Cardiol 2003; 41: System Devices Panel meeting on patent foramen ovale 737–42. Neurocrit Prognostic usefulness of left ventricular thrombus by Care 2008; (in press) echocardiography in dilated cardiomyopathy in predicting stroke, transient ischemic attack, and death. Extracardiac medical and of Barth syndrome in adult left ventricular neuromuscular implications in restrictive hypertrabeculation /noncompaction. Paradoxical Cerebrovascular events in adult left ventricular embolism as a cause of ischemic stroke of uncertain hypertrabeculation/noncompaction with and without etiology. Patent foramen up of patients with endomyocardial fibrosis: effects of ovale and brain infarct. The prevalence Frequency of deep vein thrombosis in patients with of deep venous thrombosis in patients with suspected patent foramen ovale and ischemic stroke or transient paradoxical embolism. However, clinical recognition of stroke syn- criteria and seems more accurate [2]. Each subtype of stroke may benefit from to identify clinical clues which can improve the intravenous thrombolysis for example, but only some diagnosis. Anterior circulation syndromes Third, during hospitalization, localization helps to The anterior circulation refers to the part of the brain direct the subsequent work-up. In some individ- is presumed, the cardiac investigation may remain uals, 2–10% according to different authors [3, 4], the limited. Finally, making the correct diagnosis means The anterior circulation can be subdivided into choosing the appropriate secondary prevention. Large-vessel disease suggests an M1 occlusion with or without carotid occlusion and is associated with a rather unfavorable 2. Other etiology intracranial pressure and subsequent subfacial, uncal and transtentorial herniation. Undetermined or multiple possible etiologies ation occurs typically within 48–72 hours, when vigi- lance decreases and initial signs worsen. The artery is subdivided into the M1 segment, leading to an ipsilateral fixed mydriasis and the contra- from which start the deep perforating lenticulostriate lateral cerebral peduncle is compressed against the cere- arteries, the M2 segment, corresponding to the seg- bellar tentorium, leading to ipsilateral corticospinal ment after the bifurcation into superior and inferior signs, such as Babinski’s sign and paresis (Kernohan divisions, and the M3 segment, including the insular notch). Early recognition of frontal, prefrontal, precentral, central sulcus, anterior patients at risk enables the medical team to propose a parietal, posterior parietal, angular and temporal arter- hemicraniectomy for selected patients, a treatment ies, with important variations in their territories. As collateral networks are highly variable, an of the lower limbs are less involved than the face and occlusion of the same artery at the same place may arms. The patient is usually awake or presents mild partial brachiofacial sensitive loss (mainly tactile and drowsiness or agitation, particularly with a right discriminative modalities), transient conjugate ipsilat- infarct. Cognitive signs are always present: in the case eral eye and head deviation and aphasia (aphemia or of a left lesion, aphasia, and most of the time global, Broca aphasia) frequently associated with buccolin- ideomotor apraxia. In the case of a right lesion, gual apraxia in the case of left infarcts and various contralateral multimodal hemineglect (visual, motor, degrees of multimodal hemineglect, anosognosia, 122 sensitive, visual, spatial, auditive), anosognosia (denial anosodiaphoria, confusion and monotone language of illness), anosodiaphoria (indifference to illness), in right lesions. Ischemia in their glect, transcortical motor aphasia and behavioral dis- territory can therefore produce severe deficits with a turbances (with involvement of the supplementary very small-volume lesion. Sensory hemisyndromes affecting mainly minor, except in the case of deafferentation of the cortex the contralateral leg are also described. Clinical function, mutism, anterograde amnesia, grasping, signs include proportional hemiparesis, hemihypesthe- and behavioral disturbances are particularly frequent sia, dysarthria, hypophonia, and occasionally abnormal in ischemia of the deep perforating arteries and the movements in the case of involvement of basal ganglia. Involvement of the corpus callosum can produce The centrum ovale receives its blood supply from the callosal disconnection syndrome, secondary to medullary perforating arteries coming principally interruption of the connection of physical informa- from leptomeningeal arteries. Small infarcts (less than tion from the right hemisphere to cognitive center in 1. Therefore, it is restricted to the deficits are often less proportional than in pontine left hand, which presents ideomotor apraxia, agra- or internal capsule lacunes. A rare but specific visual field defect less severe, with a classic subacute two-phase pre- is a homonymous defect in the upper and lower sentation or even asymptomatic. The two vertebral arteries leave the and repetition but anomia, jargon speech and seman- subclavian arteries, pass through transverse foramina tic paraphasic errors) with left infarct. The manifestations of acute internal carotid occlusion are quite variable, depending on the collateral status Clinical clues to differentiate posterior from and preexisting carotid stenosis. Consciousness is usually more posterior circulation stroke and should be recognized. In contrast, a progressive atherosclerotic occlusion Similarly, headache is more frequent in the posterior is usually less severe, with a classic subacute two- circulation, is typically ipsilateral to the infarct, and phase presentation. Chapter 8: Common stroke syndromes On exam, a disconjugate gaze strongly suggests a eyelid, and hemifacial anhydrosis.