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By: Abul K. Abbas, MBBS

  • Distinguished Professor and Chair, Department of Pathology, University of California San Francisco, San Francisco, California


No reduction in mortality or overall morbidity was observed in persons in the intensive care unit pulse pressure practice isoptin 40 mg generic, persons undergoing surgery heart attack remixes purchase generic isoptin online, persons with burns hypertension nursing care plan generic 120 mg isoptin with mastercard, or persons with pancreatitis hypertension kidney failure isoptin 40 mg with mastercard. In a randomized controlled trial, no difference in major postoperative complications following major elective abdominal surgery (38% in the enteral nutrition group and 39% in the total parenteral nutrition group), or overall postoperative mortality rate (5. In a retrospective review of home parenteral nutrition therapy, the overall probability of 5-year survival was 60%. Only 20 deaths (9%) were directly attributable to complications of parenteral nutrition. A distinct age-related survival effect was observed, with the probability of 5-year survival by age at initiation of parenteral therapy being 80% for persons younger than 40 years, 62% for persons 40 to 60 years old, and 30% for persons older than 60 years. Access into the superior vena cava can be made through the internal jugular vein, the subclavian vein, or peripheral veins in the arm. Catheters inserted through other sites, such as the femoral vein, have a higher rate of complications. Placement of a catheter should be verified by radiological means to avoid mechanical complications. Complications of parenteral nutrition include catheter-related infections and mechanical complications such as misplacement. Interventions that have not been effective include antibiotic ointment at the insertion site, transparent skin dressings, prophylactic antibiotics, and prophylactic catheter exchange. The magnitude of the effect may have been smaller in this study due to the severity of malnutrition, older age, and poor functional status in these patients. Despite a longer duration of intravenous therapy, the rate of complications, including phlebitis, in this study was low (22%). The normal nutritional requirements must be met in terms of energy, protein, and water (see Chapter 7). Metabolic complications increase when more than 7 g/kg/day of carbohydrates and 2. In critically ill subjects, the maximum of 1 g/kg/day of lipids may be appropriate. Multivitamin preparations do not usually contain vitamin K, which should be supplemented. A variety of nutrients have been added to formulas in attempts to improve nutritional status or clinical outcome. The term immunonutrition has been used to define a variety of enteral and parenteral nutrients such as arginine, glutamine, omega-3 fatty acids, and nucleotides. The greatest benefit was observed in patients receiving high-dose parenteral glutamine. In subgroup analysis, the shorter length of hospital stay was confined to surgical patients, but not in critically ill patients. Nitrogen balance studies have been used most often to assess nutritional efficacy, but may not reflect nutritional status accurately because of comorbid illness. Hyperglycemia is frequent, particularly in diabetic subjects, and may lead to hyperosmolar states. Hypertriglyceridemia may occur in persons receiving fat emulsions and can lead to pancreatitis and affect pulmonary function. Excessive production of carbon dioxide may occur and complicate ventilatory support. A syndrome of fat accumulation in the liver may occur and is reversible with discontinuation of parenteral nutrition. Cholestasis of the liver occurs later, is irreversible, and may lead to progressive liver disease and death. Centrally placed catheters have been associated with major complications, such as septic shock, suppurative phlebitis, metastatic infection, endocarditis, or arteritis in 32% of cases. The point prevalence of phlebitis was 65% in patients receiving peripheral intravenous hyperalimentation compared to 18% in nonhyperalimentation patients. When standard in-living particulate filters were added, the rate of phlebitis was 74% compared to 64% with a sham Prescription for Parenteral Nutrition 319 filter. When the glucose-based solution was replaced with a glycerol-based solution, the incidence of phlebitis decreased from 68% to 27% (p = 0. The rate of phlebitis in this study was 76% even when 5% dextrose alone was infused. Intravenous bolus infusion may be superior to intravenous piggyback continuous infusion, with a time to phlebitis of 45 ± 20. Antiseptic dressings have not been effective, with 3-day phlebitis rates of 60% with povidone-iodine dressing vs. Phlebitis occurred in 53% of patients using a 51-mm catheter in a mean of 3 days, 41% of patients using a 28-cm catheter in a mean of 5 days, and 10% of patients using a 71-cm catheter in a mean of 9 days. In persons who have a functional gastrointestinal tract, enteral nutrition should be the route of choice and should be begun early rather than later in the clinical course. Supplementation of select nutrients, or immunonutrition, has not been shown to be beneficial and may be harmful, with the possible exception of glutamine in burn and trauma patients. Total parenteral nutrition must be carefully monitored to prevent the refeeding syndrome or development of nutritional deficiencies not included in the feeding formula. The predominant complications of total parenteral nutrition are sepsis and catheter-related infections. The prevalence of undiagnosed protein-calorie undernutrition in a population of hospitalized elderly patients. Reduced nutritional status in an elderly population (<70y) is probable before disease and possibly contributes to the development of disease. Percentage of weight loss: a basic indicator of surgical risk in patients with chronic peptic ulcer. Stimulation of intestinal mucosal growth with intracolonic infusion of short chain fatty acids. Enteral versus parenteral nutritional support following laparotomy for trauma: a randomized prospective trial. The role of glutamine in maintaining a healthy gut and supporting the metabolic responses to injury and infection. Does enteral nutrition compared to parenteral nutrition result in better outcomes in critically ill adult patients? Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. Early postoperative enteral nutrition improves gut oxygenation and reduces costs compared with total parenteral nutrition. A metaanalysis of treatment outcomes of early enteral versus early parenteral nutrition in hospitalized patients. Meta-analysis of parenteral nutrition versus enteral nutrition in patients with acute pancreatitis. Survival of home parenteral nutrition-treated patients: 20 years of experience at the Mayo Clinic. Prospective randomized trial of povidone iodine, alcohol, and chlorhexideine for prevention of infection associated with central venous and arterial catheters. Safety and efficacy of a new peripheral intravenously administered amino acid solution containing glycerol and electrolytes. A prospective, randomized clinical study of adjunctive peripheral parenteral nutrition in adult subacute care patients. A prospecitve, randomized trial of intravenous fat emulsion administration in trauma victims requiring total parenteral nturition. Early enteral immunonutrition in patients with severe sepsis: results of an interim analysis of a randomized multicentre clinical trial. Immunonutrition may increase mortality in critically ill patients with pneumonia: results of a randomized trial. Early enteral administration of a formula (Impact) supplemented with arginine, nucleotides, and fish oil in intensive care unit patients: results of a multicenter, prospective, randomized, clinical trial. Comparison of an immunonutrition formula enriched arginine, glutamine and omega-3 fatty acid, with a currently high-enriched enteral nutrition for trauma patients. Glutamine supplementation in serious illness: a systematic review of the evidence.

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There are threshold core temperatures for each of the main temperature-regulating responses and when the threshold is reached the response begins hypertension zyrtec generic 120 mg isoptin free shipping. When it occurs in homeothermic animals blood pressure medication good for kidneys 40 mg isoptin fast delivery, the thermoregulatory mechanisms behave as if they were adjusted to blood pressure bottom number high buy isoptin 120 mg amex maintain body temperature at a higher than normal level prehypertension causes purchase generic isoptin pills, that is, "as if the thermostat had been reset" to a new point above 37 °C. Before the advent of antibiotics, fevers were artificially induced for the treatment of neurosyphilis and proved to be beneficial. Hyperthermia benefits individuals infected with anthrax, pneumococcal pneumonia, leprosy, and various fungal, rickettsial, and viral diseases. A rectal temperature over 41 °C (106 °F) for prolonged periods results in some permanent brain damage. In malignant hyperthermia, various mutations of the gene coding for the ryanodine receptor (see Chapter 5) lead to excess Ca2+ release during muscle contraction triggered by stress. This in turn leads to contractures of the muscles, increased muscle metabolism, and a great increase in heat production in muscle. The increased heat production causes a marked rise in body temperature that is fatal if not treated. This usually produces chilly sensations due to cutaneous vasoconstriction and occasionally enough shivering to produce a shaking chill. The temperature rise in experimental animals injected with a pyrogen is due mostly to increased heat production if they are in a cold environment and mostly to decreased heat loss if they are in a warm environment. These cytokines are polypeptides and it is unlikely that circulating cytokines penetrate the brain. The fever produced by cytokines is probably due to local release of prostaglandins in the hypothalamus. In addition, the antipyretic effect of aspirin is exerted directly on the hypothalamus, and aspirin inhibits prostaglandin synthesis. It is presumably beneficial because it has evolved and persisted as a response to infections and other diseases. Many microorganisms grow best within a relatively narrow temperature range and a rise in temperature inhibits their growth. When the skin or the blood is cooled enough to lower the body temperature in nonhibernating animals and in humans, metabolic and physiologic processes slow down. Respiration and heart rate are very slow, blood pressure is low, and consciousness is lost. At rectal temperatures of about 28 °C, the ability to spontaneously return the temperature to normal is lost, but the individual continues to survive and, if rewarmed with external heat, returns to a normal state. If care is taken to prevent the formation of ice crystals in the tissues, the body temperature of experimental animals can be lowered to subfreezing levels without producing any detectable damage after subsequent rewarming. Humans tolerate body temperatures of 21­24 °C (70­75 °F) without permanent ill effects, and induced hypothermia has been used in surgery. On the other hand, accidental hypothermia due to prolonged exposure to cold air or cold water is a serious condition and requires careful monitoring and prompt rewarming. Neural connections run between the hypothalamus and the posterior lobe of the pituitary gland, and vascular connections between the hypothalamus and the anterior lobe of the pituitary. In most mammals, the hormones secreted by the posterior pituitary gland are vasopressin and oxytocin. Other complex autonomic mechanisms that maintain the chemical constancy and temperature of the internal environment are integrated in the hypothalamus. Different portions of the cortex are activated when hearing, seeing, speaking, or generating words. Other techniques that have provided information on cortical function include stimulation of the exposed cerebral cortex in conscious humans undergoing neurosurgical procedures and, in a few instances, studies with chronically implanted electrodes. Valuable information has also been obtained from investigations in laboratory primates, but it is worth remembering that in addition to the difficulties in communicating with them, the brain of the rhesus monkey is only one-fourth the size of the brain of the chimpanzee, our nearest primate relative, and the chimpanzee brain is in turn one-fourth the size of the human brain. List the parts of the brain that appear to be involved in memory in mammals and summarize the proposed role of each in memory processing and storage. Describe the abnormalities of brain structure and function found in Alzheimer disease. Define the terms categorical hemisphere and representational hemisphere and summarize the difference between these hemispheres. Summarize the differences between fluent and nonfluent aphasia, and explain each type on the basis of its pathophysiology. These techniques make it possible to determine the activity of the various parts of the brain in completely intact normal humans and in humans with many different diseases. They have been used to study not only simple responses but complex aspects of learning, memory, and perception. Learning is acquisition of the information that makes this possible and memory is the retention and storage of that information. Priming is facilitation of recognition of words or objects by prior exposure to them. An example is improved recall of a word when presented with the first few letters of it. In associative learning, the organism learns about the relation of one stimulus to another. Explicit memory and many forms of implicit memory involve (1) short-term memory, which lasts seconds to hours, during which processing in the hippocampus and elsewhere lays down long-term changes in synaptic strength; and (2) long-term memory, which stores memories for years and sometimes for life. During short-term memory, the memory traces are subject to disruption by trauma and various drugs, whereas longterm memory traces are remarkably resistant to disruption. Working memory is a form of short-term memory that keeps information available, usually for very short periods, while the individual plans action based on it. Explicit or declarative memory is associated with consciousness-or at least awareness-and is dependent on the hippocampus and other parts of the medial temporal lobes of the brain for its retention. Clinical Box 19­1 describes how tracking a patient with brain damage has led to an awareness of the role of the temporal lobe in declarative memory. Implicit or nondeclarative memory does not involve awareness, and its retention does not usually involve processing in the hippocampus. Explicit memory is divided into episodic memory for events and semantic memory for facts (eg, words, rules, and language). Explicit memories initially required for activities such as riding a bicycle can become implicit once the task is thoroughly learned. In all but the simplest of cases, the alteration involves protein synthesis and activation of genes. In animals, acquisition of long-term learned responses is prevented if, within 5 min after each training session, the animals are anesthetized, given electroshock, subjected to hypothermia, or given drugs, antibodies, or oligonucleotides that block the synthesis of proteins. If these interventions are performed 4 h after the training sessions, there is no effect on acquisition. The human counterpart of this phenomenon is the loss of memory for the events immediately preceding brain concussion or electroshock therapy (retrograde amnesia). This amnesia encompasses longer periods than it does in experimental animals-sometimes many days-but remote memories remain intact. His case has been studied by many scientists and has led to a greater understanding of the link between the temporal lobe and declarative memory. He maintained long-term memory for events that occurred prior to surgery, but he suffered from anterograde amnesia. His short-term memory was intact, but he could not commit new events to longterm memory. His case is the first to bring attention to the critical role of temporal lobes in formation of long-term declarative memories and to implicate this region in the conversion of short-term to long-term memories. Later work showed that the hippocampus is the primary structure within the temporal lobe involved in this conversion. These changes are of great interest because they represent forms of learning and memory. One form of plastic change is posttetanic potentiation, the production of enhanced postsynaptic potentials in response to stimulation. This enhancement lasts up to 60 seconds and occurs after a brief (tetanizing) train of stimuli in the presynaptic neuron. The tetanizing stimulation causes Ca2+ to accumulate in the presynaptic neuron to such a degree that the intracellular binding sites that keep cytoplasmic Ca2+ low are overwhelmed. Habituation is a simple form of learning in which a neutral stimulus is repeated many times.

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A third criterion must be met: the molecule must evoke the same response as that produced by the release of the naturally occurring neurotransmitter from the presynaptic neuron arrhythmia ecg purchase 120 mg isoptin with mastercard. To assess the postsynaptic actions of a transmitter candidate arteria angularis cheap 40 mg isoptin otc, a method called microiontophoresis is sometimes used blood pressure chart download software cheap isoptin online amex. Most neurotransmitter candidates can be dissolved in solutions that will cause them to blood pressure medication used in pregnancy discount isoptin 240mg acquire a net electrical charge. A glass pipette with a very fine tip, just a few micrometers across, is filled with the ionized solution. The tip of the pipette is carefully positioned next to the postsynaptic membrane of the neuron, and the transmitter candidate is ejected in very small amounts by passing electrical current through the pipette. This method enables a researcher to apply drugs or neurotransmitter candidates in very small amounts to the surface of neurons. The responses generated by the drug can be compared to those generated by synaptic stimulation. A microelectrode in the postsynaptic neuron can be used to measure the effects of the transmitter candidate on the membrane potential (Figure 6. If iontophoretic or pressure application of the molecule causes electrophysiological changes that mimic the effects of transmitter released at the synapse, and if the other criteria of localization, synthesis, and release are met, then the molecule and the transmitter are usually considered to be the same chemical. Studying Receptors Each neurotransmitter exerts its postsynaptic effects by binding to specific receptors. As a rule, no two neurotransmitters bind to the same receptor; however, one neurotransmitter can bind to many different receptors. Each of the different receptors a neurotransmitter binds to is called a receptor subtype. Researchers have tried almost every method of biological and chemical analysis to study the different receptor subtypes of the various neurotransmitter systems. Three approaches have proved to be particularly useful: neuropharmacological analysis of synaptic transmission, ligand-binding methods, and molecular analysis of receptor proteins. Much of what we know about receptor subtypes was first learned using neuropharmacological analysis. For instance, skeletal muscle and heart muscle respond differently to various cholinergic drugs. Receptors: Nicotinic receptor Muscarinic receptor agonist in skeletal muscle but has no effect in the heart. On the other hand, muscarine, derived from a poisonous species of mushroom, has little or no effect on skeletal muscle but is an agonist at the cholinergic receptor subtype in the heart. Nicotinic and muscarinic receptors also exist in the brain, and some neurons have both types of receptors. There are three main subtypes of glutamate receptors, each of which binds glutamate and each of which is activated selectively by a different agonist. Thus, selective drugs have been extremely useful for categorizing receptor subclasses (Table 6. In addition, neuropharmacological analysis has been invaluable for assessing the contributions of neurotransmitter systems to brain function. As we said, the first step in studying a neurotransmitter system is usually identifying the neurotransmitter. However, with the discovery in the 1970s that many drugs interact selectively with neurotransmitter receptors, researchers realized that they could use these compounds to begin analyzing receptors even before the neurotransmitter itself had been identified. The pioneers of this approach were Solomon Snyder and his then student Candace Pert at Johns Hopkins University, who were interested in studying compounds called opiates (Box 6. Opiates are a class of drugs, derived from the opium poppy, that are both medically important and commonly abused. Opioids are the broader class of opiate-like chemicals, both natural and synthetic. Their effects include pain relief, euphoria, depressed breathing, and constipation. The question Snyder and Pert originally set out to answer was how heroin, morphine, and other opiates exert their effects on the brain. They and others hypothesized that opiates might be agonists at specific receptors in neuronal membranes. To test this idea, they radioactively labeled opiate compounds and applied them in small quantities to neuronal membranes that had been isolated from different parts of the brain. If appropriate receptors existed in the membrane, the labeled opiates should bind tightly to them. The radioactive drugs labeled specific sites on the membranes of some, but not all, neurons in the brain (Figure 6. Following the discovery of opioid receptors, the search was on to identify endogenous opioids, or endorphins, the naturally occurring neurotransmitters that act on these receptors. Two peptides called enkephalins were soon isolated from the brain, and they eventually proved to be opioid neurotransmitters. Any chemical compound that binds to a specific site on a receptor is called a ligand for that receptor (from the Latin meaning "to bind"). The technique of studying receptors using radioactively or nonradioactively labeled ligands is called the ligand-binding method. Notice that a ligand for a receptor can be an agonist, an antagonist, or the chemical neurotransmitter itself. Specific ligands were invaluable for isolating neurotransmitter receptors and determining their chemical structure. Special film was exposed to a brain section that had radioactive opiate receptor ligands bound to it. Snyder ike so many events in science, identifying the opiate receptors was not simply an intellectual feat accomplished in an ethereal pursuit of pure knowledge. Instead, it all began with President Nixon and his "war on drugs" in 1971, at the height of very well-publicized use of heroin by hundreds of thousands of American soldiers in Vietnam. Jerome Jaffe, a psychiatrist who had pioneered in methadone treatment for heroin addicts. Jaffe was to coordinate the several billions of federal dollars in agencies ranging from the Department of Defense to the National Institutes of Health. Jerry, a good friend, pestered me to direct our research toward the "poor soldiers" in Vietnam. The notion that drugs act at receptors, specific recognition sites, had been appreciated since the turn of the century. In principle, one could identify such receptors simply by measuring the binding of radioactive drugs to tissue membranes. However, countless researchers had applied this strategy to opiates with no success. About this time, a new Johns Hopkins faculty member, Pedro Cuatrecasas, located his laboratory adjacent to mine, and we became fast friends. Past efforts to identify receptors for hormones had failed because hormones can bind to many nonspecific sites, comprising proteins, carbohydrates, and lipids. The numbers of these nonspecific sites would likely be millions of times greater than the number of specific receptors. To identify the "signal" of insulin receptors binding above the "noise" of nonspecific interactions, Pedro developed a simple filtration assay. Since insulin should adhere more tightly to its receptors than to nonspecific sites, he incubated liver membranes with radioactive insulin and poured the mixture over filters attached to a vacuum that rapidly sucked away the incubation fluid, leaving the membrane with attached insulin stuck to the filters. He then "washed" the filters with large volumes of saline, but did this very rapidly so as to preserve insulin bound to receptors while washing away nonspecific binding. Instead, I had read a paper on nerve growth factor, showing that its amino acid sequence closely resembled that of insulin. Pedro and I soon collaborated in a successful search for the nerve growth factor receptor. Only then did I marshal the courage to extend this approach from proteins such as insulin and nerve growth factor to much smaller molecules such as opiates. Candace Pert, a graduate student in my laboratory, was eager to take on a new research project. Within a few months, we were able to characterize many features of opiate receptors. Knowing the exact sites where receptors are concentrated in the brain explained all the major actions of opiates, such as euphoria, pain relief, depression of breathing, and pupillary constriction.

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Typically blood pressure low range 120 mg isoptin amex, four to blood pressure empty chart generic isoptin 120mg with amex twelve points are stimulated per session arrhythmia omega 3 fatty acids buy isoptin 40 mg low price, with sessions lasting from five to heart attack 40 year old female purchase isoptin on line amex sixty minutes. These have traditionally been held daily, although contemporary American treatment more commonly takes place three times a week. Acupuncture has been gaining popularity in the United States since the 1970s, and, in wake of increasing acceptance by both the public and medical professionals, it is now covered by many insurance policies. In the field of chronic pain medicine, there is a strong body of research supporting the efficacy of acupuncture for headache, osteoarthritis, and musculoskeletal conditions, such as neck and lower back pain. The National Library of Medicine website American Chronic Pain Association Copyright 2018 36 medlineplus. Cigars made of different herbs, small cones of fine sawdust, electrical heating devices or lasers can all be used to provide a steady flow of heat and thereby enhance or substitute the effects of acupuncture in harmonizing Qi flow. Traditionally, cups were made of wood, clay or horn; glass or plastic cups are used today. In cupping, a vacuum is created within the cup by setting a flammable substance on fire inside of it and then allowing it to cool, or by using a rubber pump. Small blood vessels are broken by the vacuum suction, and cupping causes light bruising around the circumference of the cup. The cups may be placed over acupuncture needles, on their own, or moved around to provide vigorous massage of large body areas. Cupping is used to regulate Qi flow and help with pain, inflammation, blood flow, and relaxation. There is limited research on cupping, and its benefits in alleviating pain have not been proven. Scraping causes light bruising and is thought to promote Qi flow and help with chronic pain, inflammation and circulation. As with cupping, the benefits of Gua Sha have not been proven, and some believe that it has no scientific merit. Two traditional systems of exercise, Tai Chi and Qigong, are discussed in corresponding sections of this text. Passive therapies may be useful over the short term but have limited benefit for chronic pain conditions overall. Heat & Cold Using cold (cryotherapy) or heat (thermotherapy) are inexpensive self-treatment approaches with minimal risks. While there are some individuals that find cold helpful for chronic conditions, it is mostly utilized for acute injuries when there are damaged superficial tissues that are inflamed, hot and swollen. Heat and cold therapy modalities are often used despite prevalent confusion about which modality (heat vs cold) to use and when to use it. Most recommendations for the use of heat and cold therapy are based on empirical experience, with limited evidence to support the efficacy of specific modalities. There is limited evidence from randomized clinical trials supporting the use of cold therapy following acute musculoskeletal injury and delayed-onset muscle soreness. There is limited overall evidence to support the use of topical heat in general; heat-wrap therapy providing short-term reductions in pain and disability in patients with acute low back pain; and significantly greater pain relief of delayed-onset muscle soreness than does cold therapy. The therapists use their knowledge of anatomy and physiology along with different manual techniques including but not limited to cross-fiber massage, friction massage, myofascial release, and trigger point therapy. Soft tissue mobilization is a form of manual physical therapy where the physical therapist uses hands-on techniques on the muscles, ligaments and fascia with the goal of breaking adhesions. This procedure is commonly applied to the musculature surrounding the spine and consists of rhythmic stretching and deep pressure. Myofascial Release is a hands-on technique that involves applying gentle sustained pressure into American Chronic Pain Association Copyright 2018 38 the myofascial connective tissue to release restrictions. Myofascial Release Treatment is performed directly on skin without oils, creams or machinery. This enables the therapist to accurately detect fascial restrictions and apply the appropriate amount of sustained pressure to facilitate release of the fascia. While most therapists will use only their hands, tools or instruments can be used with therapeutic massage. The Graston Technique is when a tool is used to perform a specialized form of massage/scraping of the skin. The provider uses his or her hands to evaluate the texture, tightness and movement of muscles, fascia, tendons, ligaments and nerves. It can also help push joint fluid throughout the body and stimulate the lymphatic system, which helps lower inflammation. Ultrasound Ultrasound therapy is using ultrasonic waves or sound waves of a high frequency to stimulate tissues in the body. The ultrasonic waves are caused by the vibration of crystals within the head of the wand/probe. The sound waves that pass through the skin cause a vibration of the local tissues. Ultrasound gel is used in order to reduce friction and assist in the transmission of the ultrasonic waves. Ultrasound is thought to improve healing through increases in tissue relaxation, local blood flow, and scar tissue breakdown. The medication gel is applied to the skin, and then the ultrasonic energy forces the medication through the skin. Although ultrasound is a common modality used in physical therapy treatment, the evidence does not support the use of ultrasound as an effective treatment for pain. Iontophoresis Iontophoresis is a method of delivering medication using electrical stimulation. Iontophoresis is thought to decrease inflammation, decrease pain, decrease muscle spasm, decrease swelling and edema, reduce calcium deposits in the body and manage scar tissue. Iontophoresis is administered in a physical therapy clinic or the patient wears a small battery-operated patch for 24 hours. American Chronic Pain Association Copyright 2018 39 Paraffin (wax) A paraffin treatment uses warm oil-based wax most commonly used on the hands, elbows and feet to provide deep heat therapy. The affected body part is dipped into the paraffin and then removed to allow the paraffin to harden. Paraffin provides the benefits of heat including increased blood flow, increased muscle flexibility and decreasing joint stiffness. Home units are available although one should always use paraffin wax heater which has automatic heat controller to maintain appropriate temperatures. Infrared Light Therapy Infrared Light therapy delivers light energy safely through the skin. Light at longer wavelengths are no longer visible to the human eye and are called infrared. Infrared Light therapy is thought to increase blood circulation, stimulate healing and reduce inflammation. Spinal Traction & Spinal Decompression Spine Traction simply means providing a pulling force that provides a stretch to the spine. Traction is thought to decrease the intradiscal pressure to promote retraction of the herniated disc which would decrease the pressure on the adjacent nerve. However, muscles surrounding this area can contract as the body attempts to protect itself against the stretch, eliminating the benefit. Spinal decompression claims to use computercontrolled force to achieve gradual and calculated increases in traction forces and angles to the spine that creates a vacuum action within the disc. The computerized decompression table continuously monitors spinal resistance and adjusts forces accordingly. The goal of treatment is to create a negative intradiscal pressure to promote repositioning of the herniated disc material and to cause an influx of healing nutrients and other substances into the disc. Spinal Traction and Spinal Decompression have not been proven effective in treatment of pain. There is moderate evidence that home-based patient-controlled traction may be a noninvasive conservative option, if used along with other evidence-based conservative care. Kinesiotape is made up of cotton fibers with polymer elastic strands and is lightweight with heat-sensitive acrylic adhesive. Clinicians that use the tape believe that it can improve blood and lymph flow, provide soft tissue and muscle support, allow for beneficial muscle activation and provide joint protection. Kinesiotape can be American Chronic Pain Association Copyright 2018 40 applied in a variety of patterns on different body parts. Despite the fact that the brightly colored Kinesiotape has been widely seen on Olympic and professional athletes, the scientific evidence for its use remains low.

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