Distal Radius Fractures (DRF) Pain Management

Distal Radius Fractures (DRF) Pain Management Explain how pathological processes influence physiotherapy management for a patient with a fracture of the lower end of radius. Distal radius fractures (DRF) account for 16% of fractures seen in accident and emergency. (Tosti 2011) They are often caused by a fall on an outstretched hand, and as the risk of falling and osteoporosis increases with age, elderly patients have a higher risk of DRF. DRF are described as Colles’ fractures (with dorsal angulation) or Smiths fractures (with volar angulation), and treatment varies with fracture type, age of patient and presenting symptoms. Many fractures are reduced under anaesthesia and immobilised in a plaster cast from just below the elbow to the proximal crease of the palm (Alsop 2013). During bone healing, immobilisation ensures bone ends remain aligned and reduces the risk of mal-union. Immediately after a fracture, the local bone tissue becomes necrotic, and is resorbed by osteoclasts. A fracture haematoma forms and osteoblasts produce calcium hydroxyapatite crystals which are laid down on the bone matrix, forming callus (Drake 2010). Callus is visible on x-ray at 6 weeks, which is typically when the immobilisation stage ends. During immobilisation, patients’ clinical priorities are pain management through medication, swelling reduction and prevention of secondary stiffness and muscle wastage in joints above and below the fracture. To decrease levels of exudate in tissues and aid lymphatic drainage, elevation and compression are the main physiotherapy treatments (Cheing 2005). Stretching exercises for the elbow, shoulder, metacarpal phalangeal joints and inter phalangeal joints on the affected side help maintain range of motion (ROM), and strengthening exercises for muscles of the shoulder, elbow and fingers can reduce muscle atrophy. Physiotherapists’ can provide diet education, explaining that the supplementation of vitamin D, calcium, magnesium and vitamin K will aid bone healing (Price 2012). Vitamin C is shown to improve â€Å"mechanical and histological parameters of fracture repair† in a study with rats (Gaston 2007), and to induce osteoblast differentiation, which play an impor tant role in bone healing (Carinci 2005).When the plaster is removed, skin can be flaky, thin and over sensitised. Physiotherapists can explain the importance of gentle washing and moisturising and can perform desensitising treatment if required. Due to their knowledge of fracture pathophysiology, physiotherapists can advise patients on how to protect their wrist, for example, not to lift a full kettle but to continue with functional tasks such as washing dishes. After immobilisation, an important symptom is pain, affecting the patient’s ability to perform functional activities. Pain or fear of pain can impair treatment, as the patient may be nervous to do their prescribed exercises. Effective pain management in the form of paracetamol and ibuprofen, and explanation that a dull aching pain is demonstrative of bone healing may help reduce patient anxiety. Measuring pain allows physiotherapists’ to provide outcome measures and to tailor treatment to patients’ individual needs. Self-reported measures, such as the visual analogue scale, are the gold standard for measuring pain intensity, location, quality and temporal variation (Jones 2013). Nociception from DRF occurs when the sensory receptors at nerve endings in the periosteum are stimulated by noxious insults that are produced through inflammation (DeLisa 2005). An action potential is carried to the dorsal horn of the spinal cord where the pain signal is sent to the brain . As pain is transmitted via the dorsal horn, physiotherapists use modalities that use the pain-gate theory to reduce patient’s discomfort. This theory suggests there is a gating mechanism in the dorsal horn, small nociceptors that carry pain facilitate the gate, but larger mechanoreceptor fibres inhibit the gate. When physiotherapists stimulate mechanoreceptors, the gate is inhibited and pain signals transmitted to the brain are reduced (Moayedi 2012). An example of this is accessory mobilisations, where the physiotherapist recreates athrokinematic movements to stimulate mechanoreceptors, inhibiting nociception. In a DRF, all athrokinematic movements can be used at grade one and two to stimulate mechanoreceptors. Massage uses the pain-gate theory, therefore alongside the physiological effects of massage, such as increasing blood flow and lymphatic drainage, massage stimulates the mechanoreceptors that inhibit the gate, inhibiting pain signals. Stiffness can be caused by a variety of aetiologies. If the fracture involves articular surfaces, blood entering the joint can leave fibrin residue causing fibrous adhesions between the two synovial membranes (Hamblen 2007). This decreases the congruency of the surfaces, therefore decreasing ROM. More commonly, peri-articular adhesions, caused by collections of exudate, reduce the resilience of ligaments and reduces muscles free gliding abilities, causing stiffness. (Hamblen 2007). If the patient has undergone open reduction surgery, scar tissue can cause adhesion of local muscles and tendons, reducing ROM. Proprioceptive neuromuscular facilitation (PNF) is a modality used to treat decreased ROM. PNF uses the proprioceptive stimulation of muscle groups, using voluntary muscle contractions alongside stretching to reduce the reflexive aspect of muscular contraction (Mahieu 2008). Using maximal muscle contraction enables maximum relaxation, which increases stretch efficacy. By using this technique on physiological movements of the wrist, the adhesions are broken down allowing fluent movement. Simple home stretching exercises can be prescribed, to ensure that soft tissues are stretched frequently to reduce stiffness. As well as treating pain, mobilisations are used to decrease stiffness. For stiffness, both accessory and physiological passive mobilisations can be used to increase ROM. When treating stiffness, grade three and four mobilisations taken to the end of range are used, which break down peri-articular adhesions and allow synovial sweep, creating even lubrication and reducing fricti on. After pain, swelling and ROM have been addressed, strengthening excercises are incorporated into treatment to reduce muscle atrophy caused by immobilisation (Powers 2004). Strengthening excercises help to regain muscle mass and strength, by causing neural adaptions, decreasing inhibitory feedback allowing stronger contractions. Stronger contraction is also caused by muscle hypertrophy, where myocytes enlarge, increasing actin and myosin concentration. Excercises should get increasingly more challenging until functional movement is achieved. All excercises should be aimed at functional goals specific to the patient, increasing motivation and also establishing expectations of both the physiotherapist and the patient. Due to NHS cuts, physiotherapists can not see patients as frequently as desired, therefore modalities such as massage and PNF cannot be fully effective. It is therefore important for the physiotherapist to increase motivation for home excercises through explanations of the ir importance and effects . As the most common cause of a DRF is falling on an outstretched hand, physiotherapy falls prevention programmes including gait re-education,walking aids and balance exercises, can reduce the risk of DRF. These programmes have been â€Å"associated with a significantly lower risk of fractures† (El-Khoury 2013), demonstrating that prevention is the most effective physiotherapy management for both patient and physiotherapist. References: Alsop, H. 2013 (2013) Tidy’s Physiotherapy 15th ed. Saunders Elsevier Carinci, F. Pezzetti, F. Spina, AM. Palmieri, A. (2005) Effect of Vitamin C on pre-osteoblast gene expression. Archive of Oral Biology. 50(5): 481-496 Cheing, G. Wan, J. and Lo, S. (2005) Ice and Pulsed Electromagnetic Field to Reduce Pain and Swelling after Distal Radius Fractures. Journal of Rehabilitation Medicine. 37: 372-377 Delisa. J, (2005) Physical Medicine and Rehabiliation: Principles and Practise 4th ed. Volume 1. Philadelphia Lippincott Williams and Wilkins Drake, R. (2010) Gray’s Anatomy for Students. 2nd ed. Philadelphia: Churchill Livingstone Elsevier El Khoury, F. (2013) The effect of fall prevention exercise programmes on fall induced injuries in community dwelling older adults: systematic review and meta-analysis of randomised controlled trials. British Medical Journal. 347: f6234 Gaston, M. Simpson, A. (2007) Inhibition of Fracture Healing. The Bone and Joint Journal. Vol. 89. No. 12. 1553-1560 Hamblen, D. (2007) Adam’s Outline of Fractures, Inluding Joint Injuries. 12th ed. Philadelphia: Churchill Livingstone Elsevier Jones, L. (2013) Tidy’s Physiotherapy 15th ed. Saunders Elsevier Mahieu, N. Cools, A. De Wilde, B. (2008) Effect of propoiceptive neuromuscular facilitation stretching on the plantar flexor mucle-tendon tissue properties. Scandinavian Journal of Medicine and Science in Sports. Vol. 19. 553-560 Moayedi, M. Davis, K. (2012) Theories of pain: from specificity to gate control. Journal of Neurophysiological. Vol 109. No. 1: 5-12 Powers, S. (2004) Mechanisms of disuse muscle atrophy: role of oxidative stress. American Journal of Physiology. Vol. 288. No. R337-R344 Price, C. (2012) Essential Nutrients for Bone Health and a Review of their Availability in the Average North American Diet. The Open Orthopaedics Journal. 6: 143-149 Tosti, R. (2011) Distal Radius Fractures – A Review and Update. Minerva Orthopaedic and Traumatology. Vol 62: 443-457

How the character of Lady Macbeth changes and develops throughout the course of the play Essay

When we are first introduced to Lady Macbeth in Act I, scene v, she is at once perceived as a rather hard, ambitious individual who will stop at nothing to get what she wants. However, throughout the play her character undergoes many changes and in the end she goes insane, because of her heightened sense of guilt, and kills herself. Lady Macbeth’s first 2 soliloquies in Act 1 reveal her character very well. The way she speaks of Macbeth’s character makes it quite clear that hers is very different. She does not feel that she has to achieve things respectably or honourably, and is quick to seize opportunities, unlike Macbeth, as is shown by how she immediately connects the prophecies with the king’s visiting her castle. ‘†¦The raven Himself is hoarse That croaks the fatal entrance of Duncan Under my battlements’. (Act I, scene v, lines 36-8) As soon as the messenger leaves, Lady Macbeth calls upon the spirits of the Underworld to fill her with ‘direst cruelty’ and to let ‘no compunctious visitings of nature shake her fell purpose’. She thinks womanhood and femininity weak, and through this we see her hard, cold, remorseless side, that will do anything to fulfil her desires and ambitions. In Act I Lady Macbeth is only talking about and planning the murder- in Act II we see her spring into action. She is the one behind it all, pushing her weak and unwilling husband to do the deed. In this act it is seen even more clearly that Lady Macbeth has no conscience, or if she does it is lying dormant. Every time Macbeth begins to express his guilt and dismay, his wife cuts him off and says something like ‘These deeds must not be thought/ After these ways: so, it will make us mad.’ (Act II, scene ii, lines 33-4). She is also very much in control of herself and the situation, unlike the verbally incontinent Macbeth (see Act II, scene iii, lines 105-15). When she sees that Macbeth is about to give them away with his babbling, she prudently pretends to faint to draw attention away from him. The banquet and the murder of Banquo take place in Act III. Here we see Macbeth all but fall to pieces when he sees the ghost of the murdered Banquo sitting in his place at the table. Lady Macbeth however, had nothing to do with Banquo’s murder. Now it seems that Macbeth does not need his wife to push and chivvy him anymore- he thinks of and plans evil deeds without help. In this act Lady Macbeth only serves to cover up for her husband when he starts rambling and talking to the ghost. Her domineering character is not needed anymore and her role has dropped from that of the dominant wife, to a smiling one, concealing her husband’s evil deeds. Even at this early stage Lady Macbeth shows signs of growing weaker. In the first 2 acts, she was the one in charge, telling her husband what to do and laying all the plans. But now she seems to depend on him more, e.g. Act III, scene ii, line 45 ‘What’s to be done?’ Lady Macbeth is actually asking her husband what to do, but Macbeth tells her to ‘be innocent of the knowledge’. Macbeth is withholding information from her, and yet she is not upset. It is the beginning of the end for Lady Macbeth. She even regrets what they have done, because of the niggling doubts and insecurities she has about the safety of their position. ‘Nought’s had, all’s spent, Where our desire is got without content ‘T is safer to be that which we destroy, Than by destruction dwell in doubtful joy.’ (Act III, scene ii, lines 4-7) Lady Macbeth is insecure and lives in ‘doubtful joy’ despite the eagerness with which she encouraged Macbeth to kill Duncan and seize the throne. She sees now the futility of merciless ambition, for she has obtained the power she desired, but cannot enjoy it because of the guilt that accompanies it. Lady Macbeth’s sanity seems to have propelled downward very fast, but as we see nothing of her in Act IV, and know nothing of the time span in which Act IV occurred; it is hard to say how quick it happened. In Act V however, ‘Since his majesty went into the field’, says the gentle woman, Lady Macbeth has been showing signs of erratic and insane behaviour- ‘I have seen her rise from her bed, throw her night gown upon her, unlock her closet, take forth paper, fold it, write upon ‘t, read it, afterwards seal it, again return to bed, yet all this while in a most fast sleep.’ In Act V we can see how much Lady Macbeth has changed since the beginning of the play. For in Act I she fears the light as it might show what she was doing, e.g. ‘Come, thick night, And pall thee in the dunnest smoke of hell, That my keen knife see not the wound it makes, Nor heaven peep through the blanket of the dark To cry, â€Å"Hold, hold!†Ã¢â‚¬Ëœ (Act I, scene v, lines 48-52) Compare that statement with this- ‘DOCTOR How came she by that light? GENTLEWOMAN Why, it stood by her: she has light by her continually; ‘t is her command’ (Act V, scene i lines 17- 19) The darkness which she asked for and rejoiced in Act I now worries her, and she must always have light by her. Light is symbolic of goodness, and darkness of evil. She also continually rubs her hands, as if to clean them. This is clarified in her speech- she keeps saying things like ‘Out, damned spot! Out I say!’ as if speaking to the mark of blood. ‘What will these hands never be clean?’ She is speaking of when her hands were coated with blood when she had to go back and smear Duncan’s on his guards. Then she said ‘a little water clears us of this deed’ Now she says ‘all the perfumes of Arabia will not sweeten this little hand.’ In act V, scene v the queen dies. Whether she kills herself or dies of natural causes it is unknown. But as the doctor said in Act V, scene i ‘Yet I have known those which have walked in their sleep, who have died holily in their beds.’ The insane, guilty woman who died at the end of the play was a far cry from the strong, hard, ambitious woman in the beginning.

Arm Length and Heigh Investigation-Science

Arm Length and Height Investigation By: Teresa Gebhardt Our Hypothesis is that, there is a linear correlation between arm length and height. We believe from observing our fellow students in class that taller people have longer arms. We tested this hypothesis by measuring the 24 students arm length compared to their height. Testing this hypothesis is important so that we can solve our theory that taller people have longer arms. The control was one single student who measured the majority of the other students.Shoes were removed to ensure accuracy and we made everyone stand straight against the wall, when being measured to prevent imprecise measurements. We used a meter stick to measure arm length and measuring tape to measure height. We converted the inches from the measuring tape to meters so we had an exact unit. We measured from the tip of your longest finger to under the left arm’s armpit. Our sample size was 24 American students from the ages of 18- 21.The replicate measur es we used were measuring the arm length and height of the same subject (student) three times. We then took the average of those three answers, which were sufficiently similar. Our assumptions are that the wall is straight, the floor is leveled, and that we perfected the way to measure. We found that the taller you are the longer your arms are. The average length of my classes’ arm length is 1. 64M and the average height of my class is . 7 M.The data collected shows that arm length increases as height increases. We used a table with 5 columns labeled: Subject, Trial #, height, arm length, average. Our limitations are that we only tested 24 students. The majority were Americans but of different races. We tested boys and girls. We only tested students of the ages between 18-21. My suggestion for doing this experiment again would be to separate males from females to see if sex is a determinant.

Niobium (Columbium) Chemical and Physical Properties

Niobium, like tantalum, can act as an electrolytic valve allowing alternating current to pass in only one direction through an electrolytic cell. Niobium is used in arc-welding rods for stabilized  grades of stainless steel. It is also used in advanced airframe  systems. Superconductive magnets are made with Nb-Zr wire, which retains superconductivity in strong magnetic fields. Niobium is used in lamp filaments and to make jewelry. It is capable of being colored by an electrolytic process. Niobium (Columbium)  Basic Facts Atomic Number: 41Symbol: Nb (Cb)Atomic Weight: 92.90638Discovery: Charles Hatchet 1801 (England)Electron Configuration: [Kr] 5s1 4d4 Word Origin:  Greek mythology: Niobe, daughter of Tantalus, as niobium is often associated with tantalum. Formerly known as Columbium, from Columbia, America, the original source of niobium ore. Many metallurgists, metal societies, and commercial producers still use the name Columbium. Isotopes: 18 isotopes of niobium are known. Properties: Platinum-white with a bright metallic luster, although niobium takes on a bluish cast when exposed to air at room temperatures for a long time. Niobium is ductile, malleable, and highly resistant to corrosion. Niobium does not naturally occur in the free state; it is usually found with tantalum. Element Classification: Transition Metal Niobium (Columbium) Physical Data Density (g/cc): 8.57Melting Point (K): 2741Boiling Point (K): 5015Appearance: shiny white, soft, ductile metalAtomic Radius (pm): 146Atomic Volume (cc/mol): 10.8Covalent Radius (pm): 134Ionic Radius: 69 (5e)Specific Heat (20 °C J/g mol): 0.268Fusion Heat (kJ/mol): 26.8Evaporation Heat (kJ/mol): 680Debye Temperature (K): 275.00Pauling Negativity Number: 1.6First Ionizing Energy (kJ/mol): 663.6Oxidation States: 5, 3Lattice Structure: Body-Centered CubicLattice Constant (Ã…): 3.300 Sources Los Alamos National Laboratory (2001)Crescent Chemical Company (2001)Langes Handbook of Chemistry (1952)CRC Handbook of Chemistry Physics (18th Ed.)