Public Interest Law Initiative


By S. Olivier. Mount Holyoke College. 2018.

Oriscello 4 3 Legal Issues Aaron Rubin 8 4 Field-Side Emergencies Michael C purchase bupropion 150 mg on line depression zodiac. Sallis 66 13 Basic Principles of Exercise Training and Conditioning Craig K order bupropion 150mg fast delivery depression symptoms wanting to be alone. Fields, Michael Shea, Rebecca Spaulding, and David Stewart 95 17 Playing Surface and Protective Equipment Jeffrey G. Jenkins and Scott Chirichetti 102 Section 2 EVALUATION OF THE INJURED ATHLETE 107 18 Diagnostic Imaging Leanne L. Seeger and Kambiz Motamedi 107 19 Electrodiagnostic Testing Venu Akuthota and John Tobey 111 20 Exercise Testing David E. Casey Kerrigan and Ugo Della Croce 126 22 Compartment Syndrome Testing John E. Brown 220 CONTENTS vii 38 Overtraining Syndrome/Chronic Fatigue Thomas M. Reamy 232 Section 4 MUSCULOSKELETAL PROBLEMS IN THE ATHLETE 239 40 Head Injuries Robert C. Miller 248 43 Magnetic Resonance Imaging: Technical Considerations and Upper Extremity Carolyn M. Pierre 268 46 Sternoclavicular, Clavicular, and Acromioclavicular Injuries Carl J. Basamania 273 47 Shoulder Superior Labrum Biceps and Pec Tears Jeffrey S. Bobby Chhabra 311 55 Upper Extremity Nerve Entrapment Margarete DiBenedetto and Robert Giering 320 56 Magnetic Resonance Imaging: Lower Extremity Carolyn M. Schepsis 356 viii CONTENTS 61 Soft Tissue Knee Injuries (Tendon and Bursae) John J. Warme 382 66 Lower Extremity Stress Fracture Michael Fredericson 390 67 Nerve Entrapments of the Lower Extremity Robert P. Wilder, Jay Smith, and Diane Dahm 396 Section 5 PRINCIPLES OF REHABILITATION 405 68 Physical Modalities in Sports Medicine Alan P. Alfano 405 69 Core Strengthening Joel Press 412 70 Medications and Ergogenics Scott B. Flinn 415 71 Common Injections in Sports Medicine: General Principles and Specific Techniques Francis G. O’Connor 426 72 Footwear and Orthotics Eric Magrum and Jay Dicharry 433 73 Taping and Bracing Tom Grossman, Kate Serenelli, and Danny Mistry 442 74 Psychologic Considerations in Exercise and Sport Nicole L. Jonas 453 Section 6 SPORTS-SPECIFIC CONSIDERATIONS 461 76 Baseball James R. Butcher 475 81 Bicycling Injuries Chad Asplund 480 82 Figure Skating Roger J. Howard 553 Section 7 SPECIAL POPULATIONS 559 96 The Pediatric Athlete Amanda Weiss Kelly and Terry A. Reed 594 102 Cancer and the Athlete Brian Whirrett and Kim Harmon 598 103 The Athlete with HIV Robert J. Abrams, MD, Director, Princeton Orthopedic and Rehabilitative Associates, Attending Orthopedic Surgeon, University Medical Center at Princeton, Princeton, New Jersey W. Bruce Adams, MD, Senior Medical Officer, Director of Sports Medicine, Officer Candidate School, Quantico, Virginia Terry A. Adirim, MD, MPH, Associate Professor, Pediatrics and Emergency Medicine, George Washington University School of Medicine and Health Sciences Washington, DC Venu Akuthota, MD, Associate Professor, Department of Rehabilitation Medicine, University of Colorado Health Sciences Center, Aurora, Colorado Keith S. Albertson, MD, Chief, Orthopedic Service, Dewitt Army Community Hospital, Fort Belvior, Virginia Alan P Alfano, MD, Associate Professor of Clinical Physical Medicine and Rehabilitation, Department of Physical Medicine and Rehabilitation, Medical Director, UVA-HEALTHSOUTH Rehabilitation Hospital, University of Virginia Health System, Charlottesville, Virginia Robert A. Arciero, MD, Professor, Orthopedic Surgery, Orthopedic Consultant, University of Connecticut, Department of Orthopedics, University of Connecticut Health Center, Farmington, Connecticut Edward S. Ashman, Sports Medicine Fellow, Nirschl Orthopedic Center for Sports Medicine and Joint Reconstruction, Arlington, Virginia Chad A. Asplund, MD, Chief Resident, Family Practice Residency Program, DeWitt Army Community Hospital, Fort Belvoir, Virginia Geoffrey S. Baer, MD, PhD, Resident in Orthopedic Surgery, University of Virginia Health System, Charlottesville, Virginia Thad Barkdull, MD, Clinic Director, US Army Health Clinic, Dugway Proving Grounds, Utah Carl J.

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For the proximal casionally pronounced sclerosis is visible around the femur cheap 150mg bupropion amex depression symptoms in seniors, an intertrochanteric valgus osteotomy and stabili- focus purchase bupropion 150 mg without a prescription depression symptoms treatment. On the MRI scans the tissue signal is low in all zation with a gamma-nail is appropriate. The shaped fibrous trabeculae embedded in a moderately sleeve and the nail are inserted from the greater trochan- cell-rich fibrous stroma. The trabeculae show flat- ter and the nail can be transfixed at the distal epiphysis tened cells on the surface rather than cuboid osteo- with a screw. In a In the initial stages (particularly in relation to the sample of approx. However, the frosted-glass opacity and Osteofibrous dysplasia (according to Campanacci) bowing are both absent. On the lower leg monostotic fibrous dysplasia can be Definition confused with an osteofibrous dysplasia (see below), Congenital, probably hamartomatous, predominantly although the latter almost always affects the tibia intracortical lesion consisting of osteofibrous tissue, alone and shows osteolytic-sclerotic changes in the almost invariably located in the tibia, rarely in the fibula cortical bone. The condition was described in 1976 by Cam- Treatment, prognosis panacci. Provided no major deformation is present, surgical treat- Synonyms: Congenital fibrous defect of the tibia, ment is not usually required. Nor does a biopsy need to be Campanacci’s disease, ossifying fibroma 608 4. The lesion is rarer than fibrous dysplasia and does not Fractures should be treated conservatively. The male sex is more fre- possible only after the completion of growth) is indicated quently affected. The disease usually manifests itself if the bone is greatly weakened, or if substantial bowing within the first five years of life and occurs almost or pseudarthrosis are present. If the x-rays raise doubts exclusively in the tibia, and only rarely in the fibula. It about the possibility of an adamantinoma (intramedullary tends to start in mid-shaft and then spread distally or involvement! Not infre- Clonal, possibly neoplastic, proliferation of Langerhans quently, a pathological – possibly incomplete – fracture cells with activation of lymphocytes, eosinophils, mac- can occur. Recovery can sometimes be problematic, and rophages, multinuclear giant cells and Langerhans cells. The foci are ▬ Synonyms: Histiocytosis X, eosinophilic granuloma located not in the medullary cavity of the bone but in the cortex, which gradually bends and may show mi- crofractures. The picture is also characterized by re- Occurrence, site modeling processes and callus formation (⊡ Fig. Boys are ▬ Histology: In contrast with fibrous dysplasia, the im- twice as frequently affected as girls. The disease can be mature bone trabeculae, which are likewise embedded found in all bones. It is especially common in the man- in a fibrous stroma, are occupied by cuboid osteo- dible and skull, but can also affect all long bones, the ribs, blasts. The lesions are structured in zones with a cen- the spine and the flat bones. Langerhans cell histiocytosis occurs in the following forms: ▬ The most important differential diagnosis is an ada- monostotic form , mantinoma, a low-grade malignant tumor that al- polyostotic form , most always occurs in the tibia and typically shows polyostotic form with visceral involvement, intralesional epithelial cell islands ( Chapter 4. While the radiological appearance is similar, sinophilic granulomas, diabetes insipidus and exoph- the adamantinoma is always located in the medul- thalmos , lary cavity, in contrast with osteofibrous dysplasia. Abt-Letterer-Siwe disease: Malignant (fatal) form of Both lesions can also occur next to each other. A possible connection between an adamantinoma and osteofibrous dysplasia has been discussed, Etiology but has not been proven to date. The disease must This condition probably involves a dysfunction of the im- also be differentiated from fibrous dysplasia, which is mune system. Apart from a slight play a certain role, as do genetic aspects [18, 58]. Recent narrowing, the latter does not show any cortical studies have shown a clonal proliferation of the Lang- alterations and also shows a much more uniform erhans cells, which suggests that it may be a neoplastic radiological picture, with the typical frosted-glass process with a high degree of variability in its biological opacity. Treatment, prognosis Clinical features The course of the disease varies considerably.

In the absence of inhalation injury cheap 150mg bupropion amex depression chemical imbalance test, however generic bupropion 150mg without prescription depressive symptoms among jordanian youth, lung water content does not increase. Early infusion of colloid solutions may decrease overall fluid requirements in the initial resuscitation period and reduce nonburn edema. However, injudicious use of colloid infusion may cause iatrogenic pulmo- nary edema, increasing pulmonary complications and mortality. The current rec- ommendation is to add 25% albumin solution to maintain serum albumin 2. Albumin solution 5% should be used instead of 25% solution in unstable patients with hypovolemia. Hypotension is a late finding in burn shock; therefore, pulse rate is much more sensitive than blood pressure. Normal senso- rium, core temperature, and adequate peripheral capillary refill are additional clinical indicators of adequate organ perfusion. Fluid shifts are rapid during the acute resuscitation period (24–72 h), and serial determinations of hematocrit, serum electrolytes, osmolality, calcium, glucose, and albumin can help to direct appropriate fluid replacement. Although overresuscitation is usually easy to detect, based on increasing edema and high urine output; underresuscitation may be much more difficult to diagnose and categorize. Persistent metabolic acidosis on measurement 28 Barret FIGURE 10 Approach to the nonresponding patient. Resuscitation fluids must be reviewed and corrected (including fluid boluses) before any other further action is taken. Initial Management and Resuscitation 29 of arterial blood gases may be indicative of continuing hypoperfusion from hypovolemia. As a general rule, patients who have a bad response to the standard Parkland formula and fluid boluses, and present with a continuous high base excess with increased lactate levels, are monitored with a pulmonary artery catheter. Patients with a low cardiac output despite correct resuscitation are candidates for inotropic support. On the other hand, if cardiac output is normal, patients are candidates for colloid administration. If patients do not respond to any of the resuscitation measures, continuous hemofiltration or plasmapheresis should be attempted (see Fig. MONITORING AND PATIENT CONTROL Patients with major burns should receive full monitoring, including: Continuous electrocardiograph monitoring Continuous respiratory rate monitoring Pulse oximetry Central venous pressure Arterial line Foley catheter and urine output Temperature probes Capnometry (ventilated patients) Pulmonary artery catheter (unstable severe burn patients) Esophageal Doppler monitoring (alternative to Swan-Ganz catheters) Doppler monitor for compartment syndromes Central lines and arterial lines do carry some morbidity in burned patients. Judi- cious use of these otherwise helpful monitoring devices is advised. Monitoring of central venous pressure is indicated in patients with massive burns, those refractory to normal resuscitation maneuvers, elderly patients, and patients with significant pre-existing diseases. In general, a stable patient with burns under 40% BSA without significant pre-existing diseases can be managed without central line catheters. Control of blood pressure, pulse rate, pulse oximetry, respiratory rate, temperature, weight, and urine output should suffice in most of the patients. In most cases, however, indirect measure of blood pressure along with the physiological parameters mentioned earlier and the valuable addition of pulse oximetry are more than enough to monitor the patient. Arterial lines should be reserved for use in unstable patients, those with inhalation injury, unstable patients receiving ventilatory support, and patients who will need repeated blood gas analysis. With the advent of modern indwelling cathe- ters, and strong policies for periodical line change, the incidence of catheter- related sepsis has declined dramatically. Nevertheless, increasing evidence suggests that lines do not need to be changed unless they become infected. The question arises in the burn patient of differentiating between acute systemic inflammatory response syndrome and sepsis. Every burn center should make an effort to determine which protocol serves the best interest of patients in terms of infection control. General intensive care unit (ICU) guidelines regarding line protocols should be used. Care of the line should include daily inspection of entry point and daily dressing with dry compresses. Occlusive dressings and antibiotic creams are not effective to control infection, and there are reports that they may even increase the risk of infection. After initial management in the admission room, patients are then trans- ferred to their room.

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Tolerance to opioid-induced euphoria discount 150mg bupropion mastercard depression symptoms period, however buy generic bupropion 150mg on line depression symptoms not eating, does develop rapidly, necessitating higher doses to achieve the same effect. Patients with active addiction thus tend to escalate the dose of opioid to attain this euphoric state. This pattern of behavior probably highlights an addic- tive response to the opioid in a way that promotes continued use of the drug despite adverse consequences. Of course, pain specialists should consider other possible causes of aber- rant behavior such as pseudoaddiction, i. Recognizing patterns of aberrant behaviors, rather than isolated behaviors, will aid in assessing for addiction. Compulsive use of opioids leads to a loss of control over drug use and rep- resents addictive behavior. In this circumstance, patients lose control over med- ication use due to an intense craving for the substance. In the context of treating chronic pain, patients may overuse opioids and request early prescription refills. Such patients may report theft or loss of medications, pills falling into the toilet or down the drain, or pets consuming opioid prescriptions. Indeed, these excuses may indicate impaired control over opioid medications. Patients may also impute overuse of opioids to inadequate treatment of pain and display withdrawal symptoms at the appointment because they have depleted the opi- oid supply in advance. While these circumstances may occasionally occur in patients using opioids properly, a pattern of such aberrant behavior should raise concern about addiction. When assessing for possible addiction in chronic pain patients receiving opioids, it is important to examine a preoccupation with drug use due to crav- ing. Many patients who receive opioids for chronic pain understandably desire continual relief of pain through an uninterrupted supply of opioids. Such patients may show intense interest in maintaining regular availability of opioids to ensure analgesia and forestall withdrawal. Further, they may inquire about the physician’s vacation plans or demand reminders about clinic hours. Though this behavior does not indicate addiction, it may suggest an addictive response Christo/Grabow/Raja 130 to opioids if the patient fails to comply with other treatment modalities. For instance, the pain specialist should confirm whether the patient actively partic- ipates in physical therapy, occupational therapy, and cognitive behavioral inter- ventions, takes adjuvant medications, and appears amenable to considering other strategies for managing pain. If patients display no interest in applying nonopioid approaches to their analgesic regimen, then their preoccupation with opioid use suggests addiction. If the pain specialist does not detect a pattern of aberrant behavior, he or she can be fairly confident that the patient does not suffer from an active addic- tive disorder. In general, patients in the pain treatment setting who comply with recommended interventions, report meaningful pain relief from opioid therapy, use opioids as prescribed, and improve their functional capacity are likely responding to the medications appropriately and not engaging in addictive behavior. Although patterns of positive behavior support the proper use of opi- oids, growing evidence reveals that monitoring behavior without confirmatory urine toxicology screening may fail to detect opioid misuse. For instance, both Katz and Fanicullo and Belgrade found that self-reports of inappro- priate drug use among chronic pain patients correlated poorly with urine toxicology findings. In short, incorporating observed patterns of behavior, interviews with significant others, review of medical records, and urine toxicology monitoring can improve patient management with chronic opioid therapy. Depression Many physicians have argued that chronic opioid therapy increases depressed mood and disability. An examination of the relationship between chronic pain and depression may permit a more thorough understanding of the influence of depression on patients suffering from chronic pain. In fact, patients with chronic pain and depression tend to report greater pain inten- sity, greater disability, decreased activity levels, poor adjustment, and poor treatment outcome compared with chronic pain patients who are not depressed. Yet, the literature fails to describe the extent to which chronic pain and depression coexist, whether a causal relationship exists, or the mechanism through which depression and pain intermingle.

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From an evolutionary perspective order bupropion 150mg fast delivery anxiety and high blood pressure, this is a failure of the defense re- sponse as adaptation; it represents surrender to suffering buy cheap bupropion 150mg on-line depression symptoms blaming others. Extrapolating this and related observations to patients, Bremner and colleagues (1996) suggested that persons who have once encountered overwhelming stress and suffered exhaustion of central noradrenergic resources may respond excessively to similar stressors that they encounter later. The Ventral Noradrenergic Bundle and the Hypothalamo-Pituitary-Adrenocortical (HPA) Axis The ventral noradrenergic bundle (VNB) originates in the LC and enters the medial forebrain bundle. Neurons in the medullary reticular formation pro- ject to the hypothalamus via the VNB (Sumal, Blessing, Joh, Reis, & Pickel, 1983). Sawchenko and Swanson (1982) identified two VNB-linked norad- renergic and adrenergic pathways to paraventricular hypothalamus in the rat: the A1 region of the ventral medulla (lateral reticular nucleus, LRN), and the A2 region of the dorsal vagal complex (the nucleus tractus soli- tarius, or solitary nucleus), which receives visceral afferents. These medul- lary neuronal complexes supply 90% of catecholaminergic innervation to the paraventricular hypothalamus via the VNB (Assenmacher, Szafarczyk, Alonso, Ixart, & Barbanel, 1987). The noradrenergic axons in the VNB respond to noxious stimulation (Svensson, 1987), as does the hypothalamus itself (Kanosue, Nakayama, Ishikawa, & Imai-Matsumura, 1984). Moreover, nociception-transmitting neu- rons at all segmental levels of the spinal cord project to medial and lateral hypothalamus and several telencephalic regions (Burstein et al. These projections link tissue injury and the hypo- thalamic response, as do hormonal messengers in some circumstances. The hypothalamic paraventricular nucleus (PVN) coordinates the HPA axis. Neurons of the PVN receive afferent information from several reticular areas including ventrolateral medulla, dorsal raphé nucleus, nucleus raphé magnus, LC, dorsomedial nucleus, and the nucleus tractus solitarius (Lopez, 74 CHAPMAN Young, Herman, Akil, & Watson, 1991; Peschanski & Weil-Fugacza, 1987; Sawchenko & Swanson, 1982). Still other afferents project to the PVN from the hippocampus, septum, and amygdala (Feldman, Conforti, & Weidenfeld, 1995). Nearly all hypothalamic and preoptic nuclei send projections to the PVN. This suggests that limbic connections mediate endocrine responses during stress. In responding to potentially or frankly injurious stimuli, the PVN initiates a complex series of events regulated by feed back mechanisms. These proc- esses ready the organism for extraordinary behaviors that will maximize its chances to cope with the threat at hand (Selye, 1978). Although laboratory studies often involve highly controlled and specific noxious stimulation, real-life tissue trauma usually involves a spectrum of afferent activity, and the pattern of activity may be a greater determinant of the stress response than the specific receptor system involved (Lilly & Gann, 1992). Traumatic injury, for example, might involve complex signaling from the site of injury including inflammatory mediators, baroreceptor signals from blood volume changes, and hypercapnea. Diminished nociceptive transmission during stress or injury helps peo- ple and animals to cope with threat without the distraction of pain. Labo- ratory studies with rodents indicate that animals placed in restraint or subjected to cold water develop analgesia (Amir & Amit, 1979; Bodnar, Glusman, Brutus, Spiaggia, & Kelly, 1979; Kelly, Silverman, Glusman, & Bodner, 1993). Lesioning the PVN attenuates such stress-induced analge- sia (Truesdell & Bodnar, 1987). The medullary mechanisms involved in this are complex and include the response of the solitary nucleus to baroreceptor stimulation (Ghione, 1996). Stressor-induced, increased blood pressure stimulates carotid barorecep- tors, and these in turn activate the solitary nucleus, which then initiates ac- tivity in descending pathways that gate incoming nociceptive traffic at the dorsal horn of the spinal cord. This mechanism links psychophysiological response to a stressor with endogenous pain modulation. Some investigators emphasize that neuroendocrine arousal mechanisms are not limited to emergency situations, even though most research empha- sizes that such situations elicit them (Grant, Aston-Jones, & Redmond, 1988; Henry, 1986). In complex social contexts, submission, dominance, and other transactions can elicit neuroendocrine and autonomic responses, modified perhaps by learning and memory. This suggests that neuroendocrine proc- esses accompany all sorts of emotion-eliciting situations. The hypothalamic PVN supports stress-related autonomic arousal through neural as well as hormonal pathways. It sends direct projections to the sympathetic intermediolateral cell column in the thoracolumbar spinal 3. PAIN PERCEPTION AND EXPERIENCE 75 cord and the parasympathetic vagal complex, both sources of preganglionic autonomic outflow (Krukoff, 1990). In addition, it signals release of epineph- rine and norepinephrine from the adrenal medulla. ACTH (adrenocortico- trophic hormone) release, although not instantaneous, is quite rapid: It occurs within about 15 seconds (Sapolsky, 1992).

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