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This usually depends on a weakened tion amplitudes of the VMO and VL in AKP quadriceps muscle but a normal strength of the patients are consistent with a lateral tracking of hamstrings effective minocycline 50mg, which subsequently results in a the patella during eccentric contractions discount 50 mg minocycline fast delivery. Using EMG in a measurements have been performed with an randomized double blind, placebo controlled isokinetic dynamometer, where torque values trial Cowan et al. This is probably the reason showed that after six-treatment sessions of why VM hypotrophy is a common finding in physical therapy over a six-week period the AKP patients,15,49 and that the patients also often onset of VMO preceded VL in the eccentric present with a reduced electromyography phase and occurred at the same time in the con- (EMG) activity of the VM in their symptomatic centric phase of a stair-stepping task. VMO:VL ratio has also been is to enhance patellar stabilization within the reported to be lower in AKP patients compared patellofemoral joint and to prevent lateral patel- with healthy subjects. VMO pulls the patella mainly medially reported VMO to be active during the full range and vastus medialis longus (VML) more proxi- of knee extension. Furthermore, most healthy leg and single-leg squat and raise from a chair individuals present with higher EMG activity of and sit down using one leg. These tests could be the VL compared to VM, but there are also those used to evaluate both quadriceps muscle func- that show higher EMG activity of the VM than tion and the patient’s subjective knee pain. VL and there is also a third group of healthy Loudon et al. Since the AKP patients often report treatment protocol for patients with AKP. When symptoms during eccentric quadriceps work, bilateral problems exist, I suggest that one rely walking downstairs is a good knee-related func- on the EMG activity pattern of the less sympto- tional test for eccentric control of the quadriceps matic leg. When the aim is to evaluate muscle function, those tests should be performed Flexibility slowly, which makes it easier to observe possible Soft tissue or muscle length is essential to mus- patellar maltracking. However, those tests can culoskeletal evaluation and has specific implica- also be evaluated according to the patient’s sub- tions in patients with AKP. A tight iliotibial band will result in During the last decade many knee-scoring sys- deviation of the patella laterally, lateral tracking tems for subjective evaluations have been uti- and lateral tilting and usually also weakening of lized (e. While signs such as effusion, the medial retinaculum. Furthermore, the most optimal functional walking and running. Furthermore, AKP score should be tested for validity or sensitivity patients sometimes show tightness of the lateral and thereby tailored for a specific diagnosis. The Werner functional knee score Knee-Related Functional Performance Tests (Table 9. There are different types of pain (unpublished data). Fifty points at this particular provocation tests that comprise knee function. Werner functional knee score for anterior knee pain Table 9. Werner functional knee score for anterior knee pain Please circle what usually applies to your knee problem(s): following ACL reconstruction Pain Sitting with flexed knees Please circle what usually applies to your knee problem(s): None 5 > 30 min Pain Sitting with flexed knees Slight & infrequent 3 No problems 5 None 5 > 30 min Constant pain 0 Slightly impaired 4 Slight & infrequent 3 No problems 5 Occurrence of pain Difficulties 2 Constant pain 0 Slightly impaired 4 Unable 0 Occurrence of pain Difficulties 2 No activity-related pain 15 Squatting Unable 0 During or after running 12 No activity-related pain 15 After > 2 km walk 9 No problems 5 During or after running 12 Squatting After < 2 km walk 6 Slightly impaired 4 After > 2 km walk 9 No problems 5 During normal walk 3 Difficulties 2 After < 2 km walk 6 Slightly impaired 4 During rest 0 Unable 0 During normal walk 3 Difficulties 2 Feeling of patellar Walking upstairs During rest 0 Unable 0 instability No problems 5 Kneeling Walking upstairs Never 5 Slightly impaired 4 No problems 5 No problems 5 Sometimes 3 Difficulties 2 Slightly impaired 4 Slightly impaired 4 Frequently 0 Unable 0 Difficulties 2 Difficulties 2 Arretations-Catching Walking downstairs Unable 0 Unable 0 Never 5 No problems 5 Arretations -Catching Walking downstairs Sometimes 3 Slightly impaired 4 Never 5 No problems 5 Frequently 0 Difficulties 2 Sometimes 3 Slightly impaired 4 Unable 0 Frequently 0 Difficulties 2 Sum of points: _____ Unable 0 Sum of points: _____ 0 means maximal knee problems. Due to the required to treat AKP patients successfully. This score has shown a good repro- Patient education is one of the key factors in ducibility when tested three times in the same the management of AKP. Furthermore, it has been a clear understanding of why the symptoms shown to be most sensitive for patients with ante- have occurred and what needs to be done to rior cruciate ligament injuries (to be published). Therefore, the patient should be informed already from the very start Treatment that the treatment period sometimes can last Nowadays most orthopedic surgeons agree that several months. This is due to the gradually pro- patients with AKP and without any malalign- gressive treatment protocol, often including a ment should be treated nonoperatively. Therefore it is important should be restored before starting to train the with a thorough clinical examination based on entire quadriceps muscle group. Training of Vastus Medialis Obliquus Furthermore, the patient’s history should be Muscular hypotrophy and a reduced and/or included in order to design an individual treat- delayed EMG activity of the VM is very common ment program based on each patient’s specific in patients with AKP (e. Therefore, the initial treatment could initially be supported by a patellar stabi- should consist of restoring the function of VMO lizing brace or patellar taping during the physi- in an attempt to enhance patellar stabiliza- cal therapy treatment. I recommend either taping or bracing in increase the number of repetitions rather than patients with a lateral or a medial hypermobil- load. The external patella the rate of strength development for the VM has supports, irrespective of what type, bracing or been shown to be slower than for the VL and the taping, should then gradually be removed when rectus femoris,36,48,70 which might create the the patient improves and his or her symptoms potential for patellar tracking dysfunction and are reduced.

In the cortex discount 50 mg minocycline with visa, there are and vibration sense discount minocycline 50mg on-line, and the hair cells in the cochlea for primary areas that receive the information, other cortical hearing, as well as the rods and cones in the retina. These association areas that elaborate the sensory information, and receptors activate the peripheral sensory fibers appropriate still other areas that integrate the various sensory inputs. The peripheral nerves have their On the motor side, the outgoing motor fibers, called cell bodies in sensory ganglia, which belong to the efferents, originate from motor neurons in the brainstem and peripheral nervous system (PNS). These motor nuclei are under the control down), these are the dorsal root ganglia, located in the of motor centers in the brainstem and cerebral cortex. The trigeminal gan- turn, these motor areas are influenced by other cortical areas glion inside the skull serves the sensory fibers of the head. The central process of these peripheral neurons enters the Simpler motor patterns are organized as reflexes. In CNS and synapses in the nucleus appropriate for that all cases, except for the myotatic (muscle) reflex, called sensory system (this is hard-wired). In general, these pathways consist of fibers- beyond simple reflexes, therefore involves a series of neu- synapses-fibers, with collaterals, creating a multisynaptic ronal connections, creating functional systems. These chain with many opportunities for spreading the informa- include nuclei of the CNS at the level of the spinal cord, tion, but thereby making transmission slow and quite inse- brainstem, and thalamus. The newer pathways that have evolved have larger in humans, the cerebral cortex is also involved. The axonal axons that are more thickly myelinated and therefore con- connections between the nuclei in a functional system duct more rapidly. These form rather direct connections usually run together forming a distinct bundle of fibers, with few, if any, collaterals. The latter type of pathway called a tract or pathway. These tracts are named accord- transfers information more securely and is more special- ing to the direction of the pathway, for example spino- ized functionally. The sensory information is “processed” by these axons may distribute information to several other various nuclei along the pathway. Three systems are con- parts of the CNS by means of axon collaterals. This group of nuclei comprises a rather old touch is the ability to discriminate whether the skin is being touched by one or two points system with multiple functions — some generalized and some involving the sensory or the motor systems. Some simultaneously; it is usually tested by asking sensory pathways have collaterals to the reticular forma- the patient to identify objects (e. The reticular formation is partially responsible for this act requires interpretation by the cortex. The explanation of the reticular formation will be pre- movement (again with the eyes closed). Vibra- sented after the sensory pathways; the motor aspects will tion is tested by placing a tuning fork that has be discussed with the motor systems. These sensory recep- tors in the skin and the joint surfaces are quite CLINICAL ASPECT specialized; the fibers carrying the afferents to Destruction of the nuclei and pathways due to disease or the CNS are large in diameter and thickly injury leads to a neurological loss of function. How does myelinated, meaning that the information is the physician or neurologist diagnose what is wrong? He carried quickly and with a high degree of fidel- or she does so on the basis of a detailed knowledge of the ity. The disease that is causing the formerly called the lateral spino-thalamic and loss of function, the etiological diagnosis, can sometimes ventral (anterior) spino-thalamic tracts, respec- be recognized by experienced physicians on the basis of tively. The important clin- Some of the special senses will be studied in detail, ical correlate is that destruction of a pathway may affect namely the auditory and visual systems. Each has unique the opposite side of the body, depending upon the location features that will be described. Other sensory pathways, of the lesion in relation to the level of the decussation. All these pathways, except for olfaction, relay section are presented on the CD-ROM with flash anima- in the thalamus before going on to the cerebral cortex (see tion demonstrating activation of the pathway.

The CD4+ T cells order 50 mg minocycline mastercard, also known as helper T cells discount 50mg minocycline with mastercard, help orchestrate the antibody responses, and the CD8+ T cells—also called cytotoxic (destructive to cells) or suppressor T cells—are involved in cell-mediated immunity that targets infected cells celiac disease inability to digest and absorb a protein found in wheat, resulting in poor absorption of nutri- ents from the foods because of damage to the lining of the small intestine; also called gluten intolerance or non-tropical sprue cervicitis inflammation of the cervix, the part of the uterus that protrudes into the vagina thefacts 155 AS-App 2(151-172) 5/29/02 5:56 PM Page 156 Ankylosing spondylitis: the facts chromosome a thread-like structure within the nucleus of a cell that contains the genes. There are 46 chromo- somes in the nucleus of a human cell; 22 of them are in pairs that are given the numbers 1–22, and the remain- ing two are the X or Y chromosomes (sex chromo- somes) that determine a person’s sex—males have one X and one Y chromosomes, and females have two X chromosomes Chlamydia trachomatis a bacterium that has a predilection to infect the genitourinary tract. Such an infection is the more commonly recognized initiator of reactive arthritis in the US Clostridium difficile bacteria that are normally present in the large intestine, can cause a serious illness called pseudo-membranous colitis in people taking anti- biotics, and can sometimes trigger reactive arthritis collagen and connective tissue a set of fibrous proteins and supporting framework that form the main building blocks of the body, including the internal organs, liga- ments, tendon, cartilage, bone, and skin conjunctivitis commonly known as pink eye; it is an inflammation of the delicate outer membrane that lines the inside of the eyelids and the white of the eye contracture arthritis or prolonged immobility can result in the involved joint becoming less freely moveable. Associated with shortening and wasting of muscles control group in clinical studies the control group, which is given either the standard treatment for a medical condition under study or an inactive substance (called a placebo), is compared with a group given an experimental treatment to find its efficacy for the disease under study coping the psychological processes following any stress- ful situation cortisone a natural hormone made by the adrenal gland. Sometimes wrongly used as a synonym for corti- costeroids 156 thefacts AS-App 2(151-172) 5/29/02 5:56 PM Page 157 Appendix 2: Glossary corticosteroids a group of related compounds which, like cortisone, reduce inflammation and irritation caused by many disease processes, including many forms of arthritis, and skin and bowel diseases Crohn’s disease a chronic inflammatory bowel disease (also called ileitis or regional enteritis), that can affect the entire gastrointestinal tract, though it usually involves the lower small intestine, (the ileum) and the adjacent part of the colon C-reactive protein (CRP) its measurement in the blood can be used to detect or grade inflammation cytokine a soluble protein, produced by white blood cells, that acts as a messenger between cells, either stimulating or inhibiting the activity of various cells of the immune system. There is normally a very delicate balance among the various cytokines cytoplasm a liquid compartment in the cell, sur- rounding the central nucleus. The cytoplasm contains mitochondria and other structures or components responsible for normal protein formation, secretion and other cell functions DEXA bone scan a means of measuring the bone density to detect osteoporosis at a much earlier stage as compared to a standard X-ray. X-ray absorption at two different quantum energies or wavelengths disorder a synonym for disease disability in the context of health experience, a dis- ability is a restriction or lack (resulting from an impair- ment) of ability to perform an activity in the manner or within the range considered normal (see WHO, 1980) distal farther away from the trunk. The opposite is proximal DNA a double-stranded, helical molecule that carries genetic information, primarily present within the nucleus of each cell in plants and animals. It tells the cells exactly what to do and how to perform their functions thefacts 157 AS-App 2(151-172) 5/29/02 5:56 PM Page 158 Ankylosing spondylitis: the facts double-blinded a doubled-blinded trial produces more objective and unbiased results because neither the research investigators nor the study participants know who is receiving the investigational drug and who is receiving the placebo duodenum the first part of the small intestine. An ulcer on its inner lining is called a duodenal ulcer dowager’s hump hump in the upper back (thoracic kyphosis) in an elderly woman with osteoporosis dysentery an infectious disease of the intestine that causes bloody, mucus-filled diarrhea, which can be accompanied by abdominal pain or cramps, fever, and dehydration from excessive diarrhea. It is caused by enteric infections, usually with Shigella, and can some- times trigger reactive arthritis elimination diet requirement that certain foods should not be eaten enteritis an inflammation (irritation) of the small intestine enthesis site of attachment of ligament or tendon to bone enthesitis inflammation of an enthesis enthesopathy an all-inclusive term that covers all abnormalities of an enthesis (e. It is the basic unit of heredity; all information in the genes (genetic information) is passed from parent to child generic name see brand name genetic counseling informing people about genetic facts that may guide them in making a decision based on a knowledge of disease risk. The word genetic refers to any characteristic that is inherited genetic marker a gene that is used to identify an indi- vidual disease or trait, or trace its inheritance within a family thefacts 159 AS-App 2(151-172) 5/29/02 5:56 PM Page 160 Ankylosing spondylitis: the facts genitourinary tract the genitalia, the bladder, and the urethral tube through which the bladder empties gut a word in common use to describe the large and small intestine (see bowel, large intestine; small intestine) handicap in the context of health experience, a handi- cap is a disadvantage for a given individual, resulting from an impairment or a disability, that limits or pre- vents the fulfillment of a role that is normal (depend- ing on age, sex, and social and cultural factors) for that individual (see WHO, 1980) H2-blockers medicines such as cimetidine (Tagamet), ranitidine (Zantac), or famotidine (Pepcid), used to treat acid indigestion, heartburn, and ulcer pain. They are so called because they act by blocking histamine-2 signals to reduce the amount of acid produced by the stomach heartburn symptoms caused by stomach acid flowing back into the esophagus Helicobacter pylori a corkscrew-shaped bacterium found in the stomach that can predispose to stomach and duodenal ulcers. Previously called Campylobacter pylori heterozygote and homoozygote an individual inherits a set of two alleles for each HLA locus from his or her parents. For instance, an individual may inherit HLA- B27 from one parent and HLA-B8 from the other. Most individuals do not inherit the same gene (belong- ing to a locus) from both parents, and are said to be heterozygotes. HLA-B27, from both parents is homozygous for HLA-B27 HLA human leucocyte antigens. These are cell surface proteins, detected by blood testing, that vary from person to person. They are also called tissue antigens or histocompatibility antigens because ideally organ donors and recipients must have compatible HLA; 160 thefacts AS-App 2(151-172) 5/29/02 5:56 PM Page 161 Appendix 2: Glossary otherwise the transplanted organ is recognized as non- self (‘foreign’) and is rejected. HLA are related to the workings of the immune system; they present self- and foreign-derived (e. They are of two broad types, called class I and class II HLA. Their genes are located on chromosome 6; the loci are given the letters A, B, C, D, and so on HLA-B27 an HLA class I molecule that has been assigned the number 27; its gene is present at the B locus. There are quite a few HLA antigens that confer susceptibility to certain diseases: HLA-B27 to AS, and HLA-DR4 to rheumatoid arthritis, for example hydrotherapy physiotherapy in a pool (usually heated) idiopathic of unknown cause or explanation ileum the major part of the small intestine (see small intestine) ilium (or iliac bone) major bony component of the pelvis. There is one on each side, joined to the sacrum via the right and left sacroiliac joints impairment in the context of health experience, an impairment is any loss or abnormality of psychological, physiological or anatomical structure or function (WHO, 1980) incidence the rate of occurrence of some event, such as the number of individuals who get a disease divided by a total given population, per unit of time (usually per year). In contrast to prevalence, incidence describes the number of new cases of a disease among a certain group of people for a certain period of time, i. It may be acute (as in a burn or in gouty arthritis) or chronic (as in rheumatoid arthritis or chronic infections such as tuberculosis) thefacts 161 AS-App 2(151-172) 5/29/02 5:56 PM Page 162 Ankylosing spondylitis: the facts inflammatory bowel disease a chronic (long-lasting) inflammatory disease of the gut, e. Most joints are composed of cartilage, joint space, fibrous capsule, joint lining (synovium) and ligaments juvenile chronic arthritis arthritis in children 16 years of age or less, that has been present for at least 3 months, and for which no other cause is obvious. It is now preferably called juvenile idiopathic arthritis keratoderma blennorrhagica rash on palms of the hands and soles of the feet which may occur in reactive arthritis (Reiter’s syndrome); it resembles a form of psoriasis kyphosis forward stooping (bowing) of the spine (‘humpback’ deformity) large intestine part of the intestine that changes stool from a liquid to a solid form by absorbing water.