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A Grade 1 laboratory is a basic one using reagents buy cilostazol 50 mg with visa, whether obtained in bulk or as commercial kits cilostazol 50mg cheap, from an outside source discount cilostazol 100 mg online, with minimal production of reagents confined to standards and quality control material for the simpler analytes cheap 50mg cilostazol mastercard. A Grade 2 laboratory would similarly use primary reagents obtained from elsewhere but in addition produce its own tracers 50 mg cilostazol mastercard, at least for selected 125 procedures, using I produced elsewhere in the country or obtained from abroad. A centre that, in addition to all of the above activities, also produces polyclonal antibodies falls into Grade 3. There may of course be exceptions, such as renin–angiotensin assays, where incubation is at low temperature, and centrifugation, if the protocol so demands, will need to be under similar conditions. Radiation monitor Drying oven (b) Additional requirements for a Grade 2 laboratory The equipment required is listed in Table 3. It applies to a small to medium scale in vitro monoclonal antibody production facility ranging from 250 to 5000 mg per month. Hollow fibre technology, home-made or commercial, may serve as a cost effective alternative. Neither of the above is included in the following list nor was considered in the aforementioned report. Introduction The range of facilities required varies markedly depending on the category of the laboratory. The radiopharmacy needs the equipment necessary to provide radiopharmaceuticals of the desired quality for patient adminis- tration. The facilities should be adapted to suit the radioactive nature of the product and the fact that many radiopharmaceuticals are administered parenterally and thus need to be sterile. The radiopharmacy will also require quality control procedures, as well as areas for the receipt and storage of radioactive materials and radioactive waste prior to its disposal. Whatever functions are being performed, it is crucial that laboratories offer protection to the operator, the product and the environment. The operator needs to be protected from radiation emitted by the products, and facilities must minimize both external radiation hazards and internal hazards arising from unintended ingestion of radioactive materials, particularly via the inhalation of volatile products. In situations where blood labelling is performed, there is a potential biological hazard to the operator. The product needs protection from unintended contamination arising during its preparation. The environment needs to be protected from unintentional discharges of radioactive material from the radiopharmacy. The majority of radioactivity handled will be in the form of unsealed sources with an existing potential for accidents and spillages. Basic design criteria The layout of the department should enable an orderly flow of work and avoid the unnecessary carriage of radioactive materials within the department. Attention must be given to the location of the laboratory in relation to the other facilities. While there are advantages in situating it close to the nuclear medicine department, the presence of high levels of radioactivity is a factor in considering its proximity to, for example, gamma cameras, patient waiting areas and offices. It is also important to consider whether there are working areas above or below the radiopharmacy laboratory, in order to avoid unnecessary radiation exposure to people working in those areas. Details of layout will need to be worked out locally, depending on the accommodation available. All surfaces of the radiopharmacy — walls, floors, benches, tables and seats — should be smooth, impervious and non-absorbent, to allow for easy cleaning and decontamination. Floor surfaces and benches should be continuous and coved to the wall to prevent accumulation of dirt or contami- nation. Such features are necessary for radiation safety and to provide a suitable environment for the handling of pharmaceutical products intended for administration to patients. Radiation protection will require the use of shielding made from lead or other dense materials. This may be incorporated into the walls of the laboratory or can be used locally, adjacent to the source that yields the highest dose rate. This means that floors, benches and other work surfaces must be sufficiently strong to bear the weight of shielding. It is imperative that dose rates outside the laboratory, especially in areas to which the public have access, 99m be kept below specified limits. Although the generators contain internal shielding, additional external shielding may also be required depending on the activity of molybdenum present. The range of products to be prepared will influence the scale and complexity of facilities required, and need to be appropriate for their intended function. Basic facilities The simplest facility will be in departments that only prepare radiophar- maceuticals using a 99mTc generator and purchased kits. The type of generator most commonly used consists of 99Mo, as molybdate, absorbed onto an alumina column. Technetium-99m is eluted from the generator by drawing sterile saline through the column. This is achieved by the use of a sterile evacuated vial supplied with the generator so that the operator does not need to be in close proximity to the generator during the process.

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Such struc- The rapid expansion of the human brain didn’t begin tural adaptations to use are discussed further in until less than 2 million years ago – millions of years Chapter 2 order cilostazol 50mg online. Bipedalism there- This is in line with Ingber’s (1999) evidence that gene fore was the forerunner of neocortical development – expression alters when structural features are modi- rather than the result of it 50mg cilostazol mastercard. Because human gait fied as in the weightlessness affecting astronauts pre- demands alternating contraction of the anterior venting normal metabolism in cells whose cytoskeleton oblique slings for forward propulsion (see sling tensegrity structures have warped in zero-gravity systems below) discount cilostazol 50 mg on line, across time this would have remolded conditions discount 100mg cilostazol mastercard. Recent studies confirm that alterations in the cellular In his classic paper on human gait generic 50mg cilostazol otc, Lovejoy (1988) force balance can influence intracellular biochemistry demonstrates how the pelvic anatomy has adapted within focal adhesion complexes that form at the site over millions of years from our closest living relatives, of integrin binding as well as gene expression in the the chimpanzees, through to ‘Lucy’ our first known nucleus. These results suggest that gravity sensation bipedal ancestor, and on to modern-day human pelvic may not result from direct activation of any single design (Fig. Instead, gravitational forces However, Lovejoy (2005, Lovejoy et al 2003) goes on may be experienced by individual cells in the living to describe how it may not be correct to assume that organism as a result of stress-dependent changes in evolutionary stressors remolded the musculoskeletal cell, tissue, or organ structure that, in turn, alter architecture. Lovejoy suggests that developmental extracellular matrix mechanics, cell shape, cytoskeletal biology may hold more accurate clues as to how our organization, or internal pre-stress in the cell-tissue connective tissues have been determined principally, matrix. In other words, the control of This seems to have implications for other forms new anatomic designs may be purely down to geneti- of structural distortion via age, adaptation, etc. It is interesting then, to consider that, firstly, the Form following function period through which this process of field develop- ment occurs is the first 8 weeks of gestation. During To build on Lovejoy’s commentary, the assertion that this embryonic period, there is huge cellular differen- anatomic adaptation may be down to biochemical tiation and the developing embryo is relatively small events at the genotypic and/or phenotypic level still and therefore freer to move within the womb (Bradley does not explain what the stimulus was to drive these 2001). The implications of this are that: events – the implication, it seems, being that it is pure chance. Reproduced with permission from Lovejoy (1988) 330 Naturopathic Physical Medicine 2. Backster (2003) also be affected to some degree by the movements describes similar processes involving identification of of the mother pulses in the unfertilized chicken egg – implicating an 4. There are several similarities in behav- ior between the developing human and chick. By halfway through the prenatal period, The genes are more responsible for the hardware human fetuses can suck their thumbs and chicks chew of the nervous system while extrinsic factors (such as their toes. Both begin to generate breathing move- the mother’s movement patterns) contribute to ments in the final third-stage of prenatal develop- the trillions of finer connections between nerve cells ment, and both as neonates can make alternating (Haywood & Getchell 2005). This process includes, in its rudimentary state, second half of development as body size increases, the entire locomotor system. Hence, it is in this first 8 buoyancy diminishes, plus the rigid shell wall (similar, weeks of gestation that the pattern formation of the though not identical, to the muscular human uterine musculoskeletal system Lovejoy (2005, Lovejoy et al wall) increasingly constrains movement, eventually 2003) describes is at its most prolific and significant. It seems that as the cells of a body part – a limb, for The human fetus experiences similar changes relative example – begin to develop, each cell is able to recog- to its environment during development. Work by nize and respond to positional information within the Bradley (2001) sought to determine whether these limb which instructs it to proliferate, or to migrate, or movement experiences play an instructive role as to change shape, or to commit ‘suicide’ – cellular motor control is established. Bradley’s (2001) research has shown that parameters This means that, even if a clump of cells is severed of embryonic movement are altered by environmental or removed from the developing limb, other cells in perturbations, such as a reduction in buoyancy and the locality are able to recognize the changes and fully fixation of a single limb joint. Two lines of evidence restore the limb to its original, pre-specified dimen- were identified to suggest that alterations in moti- sions (Lovejoy et al 2003). How the cells know lity patterns are attributable to more than transient their role is not yet fully understood, but is believed mechanical phenomena: (1) mechanical constraint of to be based on an informational map formed by leg motions significantly alters the patterns of wing deployment of chemical signals and cell-to-cell movement, and (2) physical constraint can yield a net communication. Interestingly, this assertion bears striking resem- Lovejoy and colleagues (2003) conclude their discus- blance to observations made by physicists, such as sion by describing an important consequence of the Brennan (1988), who have used Kirlian photography genetic regulatory function in evolution – a phenom- to document the effects of severing or removing a enon known as ‘transcriptional heterochrony’. The remaining portion of the leaf, (1996) concurs that the prevalent view is that hetero- and the area that the removed portion formerly occu- chrony is the most common mechanism for evolution- pied, remain intact on Kirlian photography, as if the ary changes of animal form. In other words, small energetic matrix holding the leaf together remains in differences in timing and spatial expression patterns place even when the physical leaf tissues have been of developmental loci – as controlled by cis-regulatory Chapter 9 • Rehabilitation and Re-education (Movement) Approaches 331 architecture – can account for significant differences Homo sapiens arrived at this juncture may be at least in the entire morphology of the organism. If bipedalism brought with likely that an adaptation-inducing piezoelectric it some advantage – such as being able to intimidate stressor from maternal movement patterns will affect potential predators, to hunt or gather more effectively, the cis-regulatory elements. Simply put, it is the cis- and to carry foods back to a home base (Lovejoy 1988) regulatory elements that can influence phenotypic – then surely the first apes within a tribe (or troop) to expression of the gene – and it is they that are most hone this skill would be the most desirable for the adaptable or ‘plastic’. Since, in the When one considers that the entire organism is world of sexual attraction it is known that like attracts formed of interwoven chains of piezoelectric dipolar like – an athletic male most commonly attracts an ath- molecules – each capable of oscillation due to its spiral letic female – in this way a simple precursor of bipedal nature – it is of little surprise that alterations in the gait may have driven mating selection and successful functional capacity of this three-dimensional, ubiqui- hunting, defending and reproduction. Indeed this is the premise for how athlete requires that you pick your parents well’, it manual techniques applied to adult tissues may facili- is the expression (phenotype) of these genes that is tate change in the polarity potential of the tissue, pro- dependent on what the individual is or isn’t exposed ducing a therapeutic effect (Oschman 2000, Schleip to in their ontogenetic development. Vital force and tissue organization To summarize the above discussion, if a primitive hominid found itself able to stand upright and, with Discussing the properties of the living matrix of an some practice, to walk, it doesn’t mean that this skill organism – which would include the developing is automatically encoded in that individual’s genetic embryo – Oschman (2000) states that connective hardware. More likely, however, this skill may exert tissues form a mechanical continuum, extending a mating preference (especially amongst those who through the animal body, even into the innermost desire or who have this skill) and may additionally parts of each cell. Each tension, each compression, result in phenotypic expression in progeny of females each movement causes the crystalline lattice of the able to walk bipedally during pregnancy – similar to connective tissues to generate bioelectronic signals the wading chimps of the Congo delta (Attenborough that are precisely characteristic of those tensions, com- 2002). Interestingly, a naturopathic slant on this discussion is that Claude Bernard, who famously stated that the Benefits of bipedalism terrain was more important than the seed, also had Arguably, the most significant benefit of bipedal the foresight in 1839 to state: ‘The genes create struc- adaptation was the ability to be able to defend (and tures, but the genes do not control them; the vital force to hunt) from a distance. Tetrapods have to rely on does not create structure, the vital force directs them’ teeth and claws – which are both somewhat found (Oschman 2000). The ability to stand brought with it the ability to punch and with that, the ability Ontogenic adaptive loads to stab, and with that, the ability to throw. As Morris In an ape, such as a chimp not proficient in bipedal (1982) points out, that what started quite literally as gait, the side-to-side lurching would have a very dif- an ‘arms’ race has simply grown metaphorically with ferent effect on the developing embryo than in a slings, bows and arrows, guns and now long-range modern-day human, for example.

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Surface level involves The term ‘pressure threshold’ is used to describe the touch without any pressure at all buy generic cilostazol 50mg on-line. Rejection level is where pressure least amount of pressure required to produce a report meets a sense of the tissues ‘pushing back’ defensively purchase 50 mg cilostazol with mastercard. By of pain order 100mg cilostazol amex, and/or referred symptoms discount 50mg cilostazol with mastercard, when a trigger reducing pressure slightly from the rejection level discount cilostazol 100 mg fast delivery, the contact point is compressed, and this will vary depending on arrives at the working level, where perception of tissue change should be keenest, as well as there being an ability to distinguish the depth of the trigger in different tissues, locations normal from abnormal tissues (hypertonic, fibrotic, edematous, etc. Reproduced with permission from Chaitow (2005) Finding a ‘working level’ occur at different degrees of pressure, in How much palpation pressure different areas and in different circumstances. When you are at the rejection level there is a feeling • When working with or on the skin: surface of the tissues pushing back or resisting, and this has level to be overcome to achieve a sustained compression. Pick (1999b) has usefully described identification of If a constant degree of stimulation of these receptors these levels of tissue that you should try to reach by is being sustained by the palpating hand, sensitivity application of pressure, when assessing and/or treat- tends to reduce as the firing rate of the receptors ing the patient. Pick described the different levels of tissues to be The alteration in sensitivity resulting from rapid accessed as: adaptation to light touch is something that can be • Surface level: This is the first contact, molding modified by practice. However, because mechanore- to the contours of the structure, involving ceptors serving joint and muscle are slow adapters, as no actual pressure. This is just touching, are pain receptors, some experts such as Upledger & without any pressure at all, and is used to Vredevoogd (1983) suggest that use of these proprio- start treatment via the skin – as described ceptive receptors should be incorporated into palpa- below. Most of you have been taught to palpate or touch with Within this level the practitioner can feel your fingertips. Once melding and synchronization have Chapter 6 • Assessment/Palpation Section: Skills 131 At times during palpation too much information is Box 6. The brain cannot process everything • Touch the tissues and then slowly apply pressure at once. By concentrating only on the portion you (sink into the tissues) until you feel a sense of want, it becomes easy and fast to detect areas of ‘rejection’ – as though the tissues are pressing back significant tissue texture abnormality. Kappler et al (1971) found that when student exam- • Then try to identify a point somewhere between iners were compared with experienced practitioner these two levels – between superficial and deep. Physical therapy students have been taught to accurately produce specific degrees of pressure on request. They were tested applying posteroanterior pressure force to lumbar tissues, and after training, occurred, use your own proprioceptors to determine using bathroom scales to evaluate pressure levels, what the palpating part of your own body is doing. Meeting barriers Ford (1989) reminds us that we commonly ‘project’ Elasticity is a feature of all tissues – even bone. When our sense of touch, giving the example of writing with pressure is applied to tissues, a very first sense of a pencil. Exercises that incorporate are writing not at our skin surface, or in our fingertips, these first sensed barriers are included later in this but at the end of the pencil, thus demonstrating how chapter. See the notes on evaluation of shortness in our proprioceptive awareness can be projected. Ford suggests you experiment by: If greater pressure is slowly applied, more resistance Changing the pressure with which you grasp the is felt, while further pressure would probably induce pencil – you’ll quickly discover that you can’t write. The pressure exerted to hold the pencil needs to be This first sign of resistance is the point at which the constant so you can extend your perception to [the] mechanical properties of the tissue reach the end of pencil tip and thereby control the complex task of their easy elasticity. This can easily be missed if the of the saw, a machinist’s to the end of a wrench, a searching digit moves too rapidly or too heavily. Introduction • The contact between the examiner’s hands and the Examiners should always strive to use the least amount patient’s body should be as broad as possible (i. When • The hands should increase pressure slowly, move palpating deeper structures, it is more difficult to slowly, and transition from one area to another slowly. This exercise allows the student to In learning to trust that the examiner will be gentle and experience palpation of a deep structure (the psoas not perform any unexpected movements, the patient muscle in the abdomen) and pay especially close will relax and allow for easier access to deeper attention to the amount of pressure applied. Examiner’s mind • Visualizing the structures being palpated can be very General tips for making palpation easier and helpful. Mental tension can be patient to be tense or guarded, palpation and therapy decreased by first noticing its presence, slowly taking are impeded. The air should be warm enough for the the hands off the patient’s body, taking two or three patient to stay warm with skin exposed. Attention must deep breaths, shaking and softening the hands, and be paid to noise and light. Blankets and an eye mask gently, slowly, replacing the hands on the patient’s are useful. Patient positioning Practical exercise: palpating the psoas • The patient should be well-supported with pillows, in the abdomen bolsters, etc. Note: This exercise should not be performed on anyone • A comfortable, stable treatment table of adequate with inflammatory bowel disease or a history of width is essential. The This exercise should take about 10 minutes for a novice examiner should not be reluctant to ask the patient to palpation student to complete. Patient position • When palpating deeper structures, position the Supine with the abdomen exposed, the knees and hips patient so that more superficial muscles are passively slightly flexed by propping the knees on a bolster or shortened. This position puts slack in the abdominal and soften them so that palpating through them is easier. Standing at the side of the table at the level of the umbilicus or slightly inferior to the umbilicus, facing the Examiner positioning patient.

Patients are given a score ranging from 0 to 9 buy cheap cilostazol 100 mg on line, based on 1 point being allocated for the ability to perform each of the following tests unilaterally order 100 mg cilostazol with amex, and 2 points if they perform them bilaterally generic cilostazol 100 mg amex. Can the patient: • passively dorsiflex the 5th metacarpophalangeal joint to more than 90° (1 point each side) • oppose the thumb to the volar aspect of the ipsilateral forearm (1 point each side) • hyperextend the elbow by more than 10° (1 point each side) (Fig trusted cilostazol 50mg. Journal of Bodywork permission from Keer & Grahame (2003) and Movement Therapies 2005;9:310–317 Chapter 6 • Assessment/Palpation Section: Skills 171 4 buy cilostazol 50mg with visa. An empty end-feel is one in which the patient ‘path’ through any particular normal movement is stops the movement (or asks for it to be axiomatic (Kapanji 1987). This articular track – stopped) before a true end-feel is reached, as a incorporating spin, slide, glide, rotation, etc. These are employed in all joints, including the • You sit so that your buttock rests on the patient’s facet (apophyseal) joints, while the patient slowly, toes, stabilizing the foot to the table. The head of the repetitively and painlessly introduces previously fibula is grasped between thumb and index finger of restricted movements. For • Care should be taken to avoid excessive pressure on example: the posterior aspect of the fibular head, as the • With hinge joints such as the elbow and knee, peroneal nerve lies close by (Kuchera & Goodridge the bones lie end to end and articulate in the 1997). With hinge joints, joint play/ the fibula should be reinforced by placing the thumb of the other hand over it. With A movement that takes the fibular head firmly posteriorly and anteriorly, in a slightly curved manner (i. Restrictions at the distal fibula are, therefore, likely to influence behavior proximally and vice versa. Reproduced with permission from Chaitow (2002) 172 Naturopathic Physical Medicine C1 C2 Fixed C3 bone C4 C5 C6 C7 T1 Figure 6. Reproduced with permission from Chaitow (2002) T1 L1 T2 the elbow, for example, a lateral glide of the L2 forearm would be introduced on a fixed T3 humerus. T4 L3 • In parallel joints the bones lie alongside each other with their articulation being T5 L4 characterized by variations in that parallel T6 relationship. In treatment settings, one of the pair would be stabilized and the other would be T8 repositioned while the patient performed active movements (Fig. Gliding permission from Exelby (2002) of a facet joint requires that the movement takes account of the orientation of the side combined with rotation to the opposite (Ward particular facet planes (Fig. The concept that general spinal coupling takes Palpation of mobility, stability and place in a predictable manner (apart from in the functionality of joints cervical region) has been challenged (Gibbons & Tehan 1998). Exercise sequences covering palpation of mobility, The exercise sequence outlined in Box 6. Palpation of the spine and spinal articulations Assessment of spinal segmental facilitation (involving viscerosomatic Normal physiology dictates that side-flexion and rota- tion in the cervical area (C3–C7) is usually ‘Type 2’, reflexes) i. Only five descriptors were consistently used to indi- Exceptions occur if a cervical spinal segment is trau- cate what was being felt on palpation. The four listed matically induced into a different format of dysfunc- below were significantly more frequently identified tion, in which case there could be side-flexion to one Text continued on p. Hinging should occur at the hip A with form closure augmented; B with force closure augmented. Reproduced with permission from Chaitow (2006) 176 Naturopathic Physical Medicine Box 6. C7 • If, however, translation of the segment towards the • The middle finger pads will be on C5, the ring finger right from the left produces a sense of resistance/ pads on C4 and the little finger pads on C3, bind, then the segment is restricted in its ability to stabilizing these segments. B With the head/neck in a neutral position, the practitioner sequentially guides individual segments into translation in both directions in order to sense indications of restriction and tissue modification. If a restriction is sensed, its increase or decrease is evaluated for retesting with the segment held in greater flexion and then extension. Reproduced with permission from Chaitow (2006) 178 Naturopathic Physical Medicine Box 6. Is there a springing sensation, or a harsh In this way you can assess both the quality and quantity end-feel? Does the repeated with your thumb contact on L4, L3, L2 and segment ‘spring’ appropriately? Once the lumbar joints have been assessed on one side the process is repeated on the other. Anteroposterior movement • The patient should be side-lying with knees and hips flexed, and with both knees just off the edge of the table. This hypothesis is based on the (left side): similar embryological origin of the innervation of somatic and visceral tissue. According to Lewit (1999a), the first signs of viscero- In a randomized study, Nicholas et al (1987) observed somatic reflexive influences are vasomotor (increased that: ‘Myocardial infarction is accompanied by char- skin temperature) and sudomotor (increased moisture acteristic paravertebral soft tissue changes which are of the skin) reactions, skin textural changes (e. Chapter 6 • Assessment/Palpation Section: Skills 179 Korr (1976) has compared any facilitated area of the • T6 central and right 6th rib, resistant to passive spine to a ‘neurological lens’, in which stress factors axial rotation to the left, side-bending right, which impinge upon any aspect of the body or mind flexion; translation anterior and left. Cholelithiasis linkages McFarlane Tilley (1961) listed the possible implica- tions of segmental facilitation, in various spinal • ‘At 10th (and sometimes 11th) thoracic level regions, based on osteopathic clinical observations: the paraspinal tissues will usually display responses to facilitation’ (Larson 1977), • Myocardial ischemia: rigid musculature in any resulting in immediate increased tissue two adjacent segments between T1 and T4 resistance to passive axial rotation to the left, (usually left, but not essentially so). An exercise • Female and male reproductive organ problems: derived from Beal’s work is illustrated in Box 6. These observations from premier osteopathic re- Johnston’s recommendations regarding searchers should inform naturopathic practitioners and physicians of the potential for influencing somatic somatic findings of visceral origin structures in order to encourage resolution of dys- Johnston, over many years of clinical research, has functional segmental patterns and indirectly (reflex- identified a number of predictable segmental (spinal) ively) the somatic sources of these patterns.