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Maternal and infant complications in high and normal weight infants by method of delivery gastritis symptoms uk macrobid 100mg overnight delivery. European Journal of Obstetrics gastritis toddler discount 100 mg macrobid amex, Gynecology and Reproductive Biology 1998; 77: 51?59 gastritis symptoms shortness breath order macrobid visa. Incidence of persistent birth injury in macrosomic infants: association with mode of delivery gastritis symptoms nhs purchase macrobid with mastercard. The role of external version in the intrapartum management of the transverse lie presentation. The fetus with gastroschisis: impact of route of delivery and prenatal ultrasonography. Fetal gastroschisis and omphalocele: is Cesarean section the best mode of delivery? Does Cesarean Section on Request Protect Women from Sexual Dysfunction Later in their Life. Background ing spontaneous vaginal delivery, contribute to the high caesarean Cesarean section is a life saving intervention, which contribute section rates [2]. In countries In fact, women request an elective cesarean delivery based in where there still are regions with lack of conditions to carry out the information they received from different sources, but the most cesarean section, mothers and newborns still die for obstructed important source of information is their attending obstetrician. With the progressive improvement of surgical technique Many obstetricians are not interested in promoting vaginal birth and methods of anesthesia, the safety of this surgical procedure has for the reason described above, and they tend to convince their greatly improved, which has made that many obstetricians consider patients to accept an elective cesarean programmed before the cesarean delivery as safe or safer than vaginal delivery. For many 39th week of gestation to prevent a spontaneous labor, which will decades the rates of cesarean delivery remain below 15 and 10%, interfere in his or her normal routines [3]. Although started to increase exponentially in some countries, as specifically fear of pain during labor and delivery may be the most important occurred in Brazil, where it has reached nearly 90% of deliveries reason to select elective cesarean, another important reason given among private health security patients [2]. Cai L, Zhang B, Lin H, Xing W, Chen J (2014) Does vaginal delivery affect cesarean or a vaginal birth with minimal or no perineal trauma. Blustein J, Liu J (2015) Time to consider the risks of caesarean delivery the most severe perineal injuries can have long term for long term child health. Am J Obstet Gynecol 184(5): 881 had a significantly higher risk of not being sexually active one 890. With that exception, sexual function beyond Rate of dyspareunia after delivery in primiparae according to mode of six month after delivery shows very little if any difference between delivery. European Journal of Obstetrics & Gynecology and Reproductive Biology 124(1): 42-46. There is one study Which factors determine the sexual function 1 year after childbirth? Thus, the review of the literature leave no doubt that the prevention of sexual 16. Gungor S, Baser I, Ceyhan T, Karasahin E, Kilic S (2008) Does mode of to prevent severe perineal trauma during vaginal delivey. The New York State Department of Health wants you and your family to have the safest and most rewarding childbirth possible. To do this, start now to make plans with your family and with your caregiver (doctor or licensed midwife). This booklet will help you better understand childbirth and the choices available to you. With that understanding, you can work with your caregiver to develop a Birth Plan. It contains information you will need at the time you are giving birth, and includes opportunities for you to make choices about your labor and delivery. This can be your husband, or partner, a friend, a family member or whomever you wish. Be sure this person meets your caregiver, and is included in your planning and decision-making. As you read this booklet, you will fnd there are many ways your support person can help you. And be sure to talk with your caregiver about any special needs you may have that are required by your religion, family traditions or culture. Covering the Cost of Prenatal Care and Childbirth Do you need help covering the cost of prenatal care and childbirth? With Medicaid, your baby will be covered for all health care services until his or her frst birthday. Benefits include well-child visits, sick visits, immunizations, x-rays and lab tests, dental care, vision, speech, and hearing exams. It might midwife, hospital, or birth center at help to take a few trial runs to the hospital or birth center to find the any time of the day or night. You may want to buy nightgowns with nursing slits or button-fronts that make it easy to put the baby to breast without undressing. If you need help getting clothes or supplies for your baby, talk with your caregiver or hospital social worker. Call your local health department or the Growing Up Healthy Hotline 1-800-522-5006 to find out what services are available in your area. If you need help getting maternity clothes, talk with your caregiver or hospital social worker. To find out where you can borrow one, call the hospital or birth center, your city or county health or social services department, or your community health center. If you?ll be going home in a taxi, it is important to use a car seat to keep your baby safe. Before, during and after the delivery of your baby, In the last few weeks before labor starts, your uterus you will meet many health care providers. If Licensed Midwife a person specially trained to you feel these early contractions (sometimes called care for healthy women during pregnancy and false labor), you may wonder if you have started delivery labor. Usually, in true labor, contractions get longer, Obstetrician a doctor who specializes in caring for stronger and closer together over time. If your contractions do not get stronger or closer Pediatrician a doctor who has special training in together, or if the contractions stop when you rest or caring for babies, children and teens. But if Family Nurse Practitioner a nurse with extra your contractions do not go away, call your caregiver. For most women, the first sign of labor is a discharge Labor and Delivery Nurse a nurse trained to assist of faintly blood-tinged mucus from the cervix with labor and help delivery care. This is often called the Dietitian/nutritionist provides information and mucus plug or show. Some labors begin when the fluid from the sac that Childbirth educator teaches families about having surrounds the baby leaks. If this happens, call your and parenting skills are part of the classes they teach. Do not use tampons or any vaginal need, such as Medicaid, to help pay for care for you cleansing products. Public health nurse/home visitor visits you at Labor usually starts very slowly, with mild home to assist you and your baby. But remember, visitor a person from your community who helps every labor is different. If your labor starts slowly, you may have 10 to 30 minutes between contractions in the beginning. Later, when contractions are stronger and closer together, you will still have time between contractions when you will feel better. With the cervix fully opened, the contractions move the baby out through the birth canal (vagina). Labor is divided into three stages: First Stage the cervix dilates so that the baby can pass through. When the cervix is open to its fullest 9 to 10 centimeters (about 4 inches) it is large enough for the baby to pass through. Second Stage by pushing (bearing down), you move the baby out through the birth canal, and the baby is born. Third Stage your uterus continues to contract, and the placenta (afterbirth) is pushed out. When to Go to the Hospital or Birth Center About a month before your due date, ask your caregiver what you should do when you start labor. Most doctors and licensed midwives advise first-time mothers to contact them when contractions are 5 minutes apart (timed by a clock) for 30 minutes.

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Bedside echocardi diac ultrasonographic examination in patients with suspected cardiac ography by emergency physicians gastritis diet евроспорт cheap macrobid 100 mg line. Outcome in cardiac arrest patients found to gastritis diet молодежка buy 100 mg macrobid otc temporary medical patients: detection before hemodynamic embar have cardiac standstill on the bedside emergency department echo rassment gastritis diet of speyer order 100mg macrobid mastercard. Phila gency physician assessment of left ventricular ejection fraction and delphia: Elsevier Saunders; 2004 gastritis special diet order macrobid 100 mg line. Emergency echocardiography to detect peri echocardiography improves outcome in penetrating cardiac injury. Implications of echocar sion of the right atrium: a new echocardiographic sign of cardiac diographically assisted diagnosis of pericardial tamponade in con tamponade. Use of transthoracic echo cardiography combined with clinical and electrocardiographic data to predict acute pulmonary embolism. Systematic review and meta-analysis of strategies for the diagnosis of suspected pulmonary embolism. Echocardiogra phy Doppler in pulmonary embolism: right ventricular dysfunction as a predictor of mortality rate. Up to Introduction 62% of patients with ruptured aneurysms die before reaching the hospital, and the overall mortality rate after rupture may exceed 2 90%. Indications/Anatomy Indications may include abdominal pain, back pain, chest pain, a pul satile abdominal mass, renal colic, syncope, hypotension, weak ness, or neurologic changes in the extremities. One high-risk group, in particular, includes older males with hypertension and a history of tobacco abuse. You will need to scan from this mid-epigastric location caudally to the bifurcation of the aorta, visualizing the transverse high, mid, and low aorta. Again, you will scan As you scan cephalad to caudad (head to toe), identify the follow from the mid-epigastrium to the bifurcation at the umbilicus. The vertebral body is horseshoe-shaped with an intense echogenic anterior surface and posterior shadowing. Scan caudally to the aortic bifurcation with Transverse aorta with celiac trunk (seagull sign); Hep A = methodical real-time hepatic art, Spl A = splenic art, * = aorta) visualization, without skipping any section of the aorta. Imaging impediments due to bowel gas usu dinal view of ally originate from the transverse colon, which sits in the epigastrium. To avoid this error, Pearls and Pitfalls adjust the gain so that aortic lumen is black. If possible, decrease the dynamic range to improve the contrast between vessel wall and lumen. Systematic, continuous scanning in both longitudinal and transverse planes is essential to prevent a false negative diagnosis. Emergency department ultra sound scanning for abdominal aortic aneurysm: accessible, accurate and advantageous. For the last several decades the main stay for initial diagnostic imaging has been the chest radiograph. The biggest challenges for thoracic ultrasound are to get the Lung Ultrasound is a paradigm shift physician to think in a radically different way about how to visualize pathology and to empower the clinician to feel that the thoracic ultra sound images are an equal, if not a more valid, indication of pathol "The voyage of discovery is not in seeking new landscapes but ogy and disease. Rib shadows help to orient the sonographer by serving as a landmark for pleural line identi? As the ribs approach the sternum, they become carti laginous, and so sound can penetrate through the rib at this point. Image of normal pleura the pleural line Effusion separating visceral from parie must be deep to the rib shadow. If you see this anteriorly, a large effusion or one that is located anteriorly is suspected. It is important to remember that a normal lung has well-aerated alveoli and very thin intersti tial tissue holding the alveoli together. It is also important to remember that air does not transfer sound well, but instead scatters it so that the sound does not return to the probe in an organized fashion (Figure 4. Drawing demonstrating the disorgan ized scatter from air low density air molecules reflect sound in a non uniform pattern. Instead, the bouncing back and forth between the skin surface and the pleural line creates a horizontal reverbera tion artifact that is called an A-line (Movie 4. These vertical lines are called B-lines and are a marker of interstitial thickening (from? There are a few features of B-lines that should be highlighted to ensure that what is seen is truly a marker of interstitial? First, the B-line starts at the pleural line and travels at least to a depth of 18 cm (the minimum depth the screen should be set at when looking for this). In addition, B lines will move back and forth with respiration as the pleural line moves. There is a spectrum of B-lines ranging from none (when A-lines are usually seen), to mild, moderate, and severe, when there is often complete coalescence of single B-lines into white curtains of B-lines. It is also useful for orientation to start with the probe in a longitudinal position and orient with rib shadows at ei ther edge of the screen (Movie 4. Instead, a reverberation artifact can line, is shimmering back and forth and appears grainy. On m-mode, the chest wall still appears as straight lines, but Comet tail with lung sliding. When air is interposed between the visceral and parietal pleura, the It is important to remember that lack of lung sliding can be seen in visceral pleura separates from the parietal pleura. Therefore, the pa surgical scarring, pneumonia with adhesions, and others pathologic rietal pleura will be the last structure visualized by the ultrasound ma diseases. Care must be taken to clinically differentiate these from chine and will appear as a? When examining a su pine patient, the probe should be placed over the anterior rib spaces, as air will tend to layer here. It stands to reason that the more complete the evaluation of the thoracic cavity, the more sensi tive the lung ultrasound will be for ruling out pneumothorax. How ever, studies have shown that the only pneumothoraces that would be missed if the anterior chest wall alone were scanned would be iso 3 lated apical pneumothoraces. If there is a high degree of suspicion for a pneumothorax and the anterior chest wall shows lung sliding, scanning superiorly or even supraclavicularly to better evaluate the apices may be helpful. This is seen when Barcode sign you scan the position where the visceral pleura reattaches to the chest wall. When the probe is held in this location, one half of the berations can still be seen with absent lung sliding and can help 73 ultrasound screen will demonstrate lung sliding and one half of the screen will show a? On m-mode, you will see alternating seashore and barcode signs, which vary with respirations (Figure 4. The lung point can be found by moving the probe around the chest wall, from areas of lung sliding to areas with out lung sliding, until both are seen in the same location, as the pa tient breathes (Movie 4. Fernando Silva) shows how you can use the lung point to estimate the extent of a pneu mothorax. Again, research Pleural Effusion has shown not only is lung ultrasound comparable to chest radiogra phy, it may be superior. In addition to its diagnostic value, thoracic 4-6 ultrasound is able to assist in procedural guidance as well. This application takes advantage, again, of the ability of the well aerated lung to scatter sound. When looking in the anterior or poste rior axillary line in the longitudinal plane with a low frequency probe, the diaphragm should be identi? Pericardial effusions and pleural effusions can be differentiated based on position of? The lack of a mirror image artifact indicates that neously breathing patient (Figure 4. The spinous In this case, the ultrasound machine will assume the sound wave trav processes and vertebral bodies are deep to the kidney and spleen/ eled in a straight line, and so liver tissue re? Right-sided effusions can be seen deep to the diaphragm in a subxi phoid cardiac view (Movie 4.

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If the thrombus is large gastritis diet юлмарт order macrobid 100mg otc, it is impacted at the bifurcation of the main pulmonary artery (saddle embolus) gastritis diet утуб order 100 mg macrobid with visa, or may be found in the right ventricle or its outflow tract gastritis diet coconut water buy macrobid 100mg line. Gross appearance Head pale gastritis ruq pain order 100mg macrobid amex, tail red No distinction in head and tail; smooth surface dry dull surface 5. Microscopy Platelets and fibrin in layers, Mixed with blood clot, Lines of Zahn seen lines of Zahn rare are then impacted in a number of vessels, particularly iii) Pulmonary infarction. The clinical features include chest pain embolus from right heart into the left heart through atrial or due to fibrinous pleuritis, haemoptysis and dyspnoea due ventricular septal defect. The clinical features are haemoptysis, Pulmonary embolism occurs more commonly as a compli dyspnoea, and less commonly, chest pain due to central cation in patients of acute or chronic debilitating diseases location of pulmonary haemorrhage. Women in their reproductive period are at higher risk such as in late be concomitant pulmonary infarction. The effects of pulmonary embolism depend mainly on (60-80%) are resolved by fibrinolytic activity. These patients the size of the occluded vessel, the number of emboli, and are clinically silent owing to bronchial circulation so that lung on the cardiovascular status of the patient. These are the sequelae of instantaneous death, without occurrence of chest pain or multiple small thromboemboli undergoing healing rather dyspnoea. Numerous small emboli may this is the type of arterial embolism that originates comm obstruct most of the pulmonary circulation resulting in acute only from thrombi in the diseased heart, especially in the right heart failure. These arterial emboli invariably cause infarction at the sites of lodgement which include, in descending order of frequency, lower extremity, brain, and internal visceral organs (spleen, kidneys, intestines). Thus, the effects and sites of arterial emboli are in striking contrast to venous emboli which are often lodged in the lungs. Fat Embolism Obstruction of arterioles and capillaries by fat globules constitutes fat embolism. If the obstruction in the circulation is by fragments of adipose tissue, it is called fat-tissue embolism. Following are the important causes of fat embolism: i) Traumatic causes: Trauma to bones is the most common cause of fat embolism Figure 5. The pathologic findings in the brain are Diabetes mellitus petechial haemorrhages on the leptomeninges and minute Fatty liver haemorrhages in the parenchyma. Pancreatitis Microscopically, microinfarct of brain, oedema and Sickle cell anaemia haemorrhages are seen. Renal fat embolism present in the glomerular Extrinsic fat or oils introduced into the body. The following mechanisms are proposed Other effects include tubular damage and renal to explain the pathogenesis of fat embolism. Besides the brain and kidneys, other findings in systemic fat embolism are petechiae in the skin, i) Mechanical theory. Mobilisation of fluid fat may occur conjunctivae, serosal surfaces, fat globules in the urine following trauma to the bone or soft tissues. Some of the fat globules may further pass through into the systemic circulation to lodge in other organs. Air, nitrogen and other gases can produce bubbles within the circulation and obstruct the blood vessels causing damage ii) Emulsion instability theory. Two main forms of gas embolism?air embolism pathogenesis of fat embolism in non-traumatic cases. According to this theory, fat emboli are formed by aggrega tion of plasma lipids (chylomicrons and fatty acids) due to Air Embolism disturbance in natural emulsification of fat. Air embolism occurs when air is introduced into venous or iii) Intravascular coagulation theory. The blood vessels of lungs are chemically injured by high plasma accidental opening of a major vein of the neck like jugular, levels of free fatty acid, resulting in increased vascular or neck wounds involving the major neck veins, may allow permeability and consequent pulmonary oedema. During childbirth by embolism depend upon the size and quantity of fat globules, normal vaginal delivery, caesarean section, abortions and and whether or not the emboli pass through the lungs into other procedures, fatal air embolism may result from the the systemic circulation. Air embolism tures of bones, presence of numerous fat emboli in the may occur during intravenous blood or fluid infusions if only capillaries of the lung is a frequent autopsy finding because positive pressure is employed. During angiographic procedures, air may obstruction of pulmonary circulation due to extensive be entrapped into a large vein causing air embolism. The effects of venous air embolism depend upon the following factors: Microscopically, the lungs show hyperaemia, oedema, i) Amount of air introduced into the circulation. This results in similar effects as in 123 as little as 40 ml of air may have serious results. The effects of decompression sickness depend in the pulmonary arterial trunk in the right heart. If bubbles upon the following: of air in the form of froth pass further out into pulmonary Depth or altitude reached arterioles, they cause widespread vascular occlusions. If Duration of exposure to altered pressure death from pulmonary air embolism is suspected, the heart Rate of ascent or descent and pulmonary artery should be opened in situ under water General condition of the individual so that escaping froth or foam formed by mixture of air and Pathologic changes are more pronounced in sudden blood can be detected. Entry of air into pulmonary those who decompress from low pressure to normal levels. Acute form occurs due to acute obstruction of small blood ii) Paradoxical air embolism. This may occur due to passage vessels in the vicinity of joints and skeletal muscles. The of venous air emboli to the arterial side of circulation through condition is clinically characterised by the following: a patent foramen ovale or via pulmonary arteriovenous i) The bends, as the patient doubles up in bed due to acute shunts. During arteriographic procedures, air ii) The chokes occur due to accumulation of bubbles in the embolism may occur. The effects of arterial air embolism are in the form of iii) Cerebral effects may manifest in the form of vertigo, coma, certain characteristic features: and sometimes death. Chronic form is due to foci of ischaemic necrosis ii) Air bubbles in the retinal vessels seen ophthalmos throughout body, especially the skeletal system. The features of chronic form are iv) Coronary or cerebral arterial air embolism may cause as under: sudden death by much smaller amounts of air than in the i) Avascular necrosis of bones. These include this is a specialised form of gas embolism known by various paraesthesias and paraplegia. Decompression sickness is produced iv) Skin manifestations include itching, patchy erythema, when the individual decompresses suddenly, either from cyanosis and oedema. During labour and in the comes to normal level suddenly from high atmospheric immediate postpartum period, the contents of amniotic fluid pressure, the gases come out of the solution as minute may enter the uterine veins and reach right side of the heart bubbles, particularly in fatty tissues which have affinity for resulting in fatal complications. These bubbles may coalesce together to form large components which may be found in uterine veins, pulmonary emboli. Possibly, they gain entry 124 either through tears in the myometrium and endocervix, or ii) Placental fragments the amniotic fluid is forced into uterine sinusoids by vigorous iii) Red cell aggregates (sludging) uterine contractions. Notable changes are seen vi) Barium emboli following enema in the lungs such as haemorrhages, congestion, oedema vii) Foreign bodies. Ischaemia is defined as deficient blood supply the clinical syndrome of amniotic fluid embolism is to part of a tissue. The cessation of blood supply may be characterised by the following features: complete (complete ischaemia) or partial (partial ischaemia). Sudden respiratory distress and dyspnoea the adverse effects of ischaemia may result from 3 ways: Deep cyanosis 1. Hypoxia due to deprivation of oxygen to tissues; this is Cardiovascular shock the most important and common cause. It may be of 4 types: Convulsions i) Hypoxic hypoxia : due to low oxygen in arterial blood. The cause of death may not be obvious but can occur as a iv) Histotoxic hypoxia: low oxygen uptake due to cellular result of the following mechanisms: toxicity. Inadequate clearance of metabolites which results in liberation of thromboplastin by amniotic fluid. Atheroembolism these causes are discussed below with regard to different Atheromatous plaques, especially from aorta, may get eroded levels of blood vessels: to form atherosclerotic emboli which are then lodged in 1. These emboli consist of from heart block, ventricular arrest and fibrillation from cholesterol crystals, hyaline debris and calcified material, and various causes may cause hypoxic injury to the brain. The commonest and most impor tant causes of ischaemia are due to obstruction in arterial spleen, brain and heart. Blockage of venous drainage may Interarterial anastomoses in the 3 main trunks of the 125 lead to engorgement and obstruction to arterial blood supply coronary arterial system. Blood supply to some organs and i) Luminal occlusion of vein: tissues is such that the vitality of the tissue is maintained by a) Thrombosis of mesenteric veins alternative blood supply in case of occlusion of one. For b) Cavernous sinus thrombosis example: ii) Causes in the vessel wall of vein: Blood supply to the brain in the region of circle of Willis.

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In such cases gastritis diet 3121 purchase generic macrobid, the primary trigger point is still the key to gastritis diet лайф cheap macrobid 100mg otc therapeutic intervention and the satellite trigger points often resolve once the primary point has been effectively rendered inactive nodular gastritis definition buy macrobid in india. The corollary is also true in that satellite points may prove resilient to gastritis diet сбербанк order 100mg macrobid overnight delivery treatment until the primary central focus is weakened; this is often the case in the para-spinal and/or abdominal muscles. Attachment Trigger Points As discussed towards the end of Chapter 1, myofascia is a continuum. This may well be the result of the existing forces travelling across these regions. It has been also suggested (ibid) that this may result from an associated chronic, active myofascial trigger point. This is because the tenderness has been demonstrated to reduce once the primary central trigger point has been treated; in such cases, the point is described as an attachment trigger point. Diffuse Trigger Points Trigger points can sometimes occur where multiple satellite trigger points exist secondary to multiple central trigger points. This is often the case when there is a severe postural deformity such as a scoliosis, and an entire quadrant of the body is involved. These diffuse trigger points often develop along lines of altered stress and/or strain patterns. Inactive (or Latent) Trigger Points this applies to lumps and nodules that feel like trigger points. However, these trigger points are not painful, and do not elicit a referred pain pathway. The presence of inactive trigger points within muscles may lead to increased muscular stiffness. It has been suggested that these points are more common in those who live a sedentary lifestyle. It is worth noting that these points may re-activate if the central or primary trigger point is (re)stimulated, or following trauma and injury. A variety of stimulants can activate an in-active trigger point such as forcing muscular activity through pain. The term denotes that the trigger point is both tender to palpation and elicits a referred pain pattern. Trigger Points and Trigger Point Formation 37 Trigger Point Symptoms Referred Pain Patterns Pain is a complex symptom experienced differently and individually. You may be used to the idea of referred pain of a visceral origin; an example of this is heart pain. A myocardial infarct (heart attack) is often not experienced as crushing chest pain, but as pain in the left arm and hand, and in the left jaw. This type of pain is well documented, and known to originate from the embryological dermomyotome; in this case, the heart tissue, jaw tissue and arm tissues all develop from the same dermomyotome. This map is consistent, and stimulating an active trigger point generates either part or all of the entire map of pain. Patients describe referred pain in this map as having a deep, aching quality; movement may sometimes exacerbate symptoms, making the pain sharper. The patient often describes a pattern of pain, or ache, which can sometimes be aggravated and made sharper by moving the head and neck. The intensity of pain will vary according to the following factors (this list is not exhaustive). The autonomic nervous system is responsible for regulating many of our automatic or vegetative functions such as sweating and digestion. From our discussion on the physiology of trigger points, it can be seen that autonomic nerve fibres are implicated in the pathogenesis of a trigger point. Physical Findings the language for describing sensation is not highly sophisticated; unfortunately we have not yet evolved a suitable language to classify what we feel with our hands. Examination Examination may be conducted by either standing, sitting or lying down. The choice depends on both the area being examined and the type of muscle fibre suspected. You may want to examine a muscle under load if you suspect this is an aggravating factor. By way of example, from this point forward, I will describe the examination and stretching of the pectoralis major and its trigger point(s). The main trigger points in the pectoralis major are to be found in the clavicular portion of the muscle. A pincer-like grip is the best way of examining for a trigger point in this region, whilst trigger points in the parasternal region of the muscle are best palpated with a flat-handed contact. Ask patient to abduct the arm 90 degrees to put the muscle into moderate tension;. Trigger Points and Trigger Point Formation 39 Advice to Patient Once a therapeutic intervention has been performed, it is advisable to encourage the patient to get involved in managing his or her own symptoms. As a more general overview, you might want to include hints, tips, and advice using the following elements or components. Weakness is often a contributory factor in the pathogenesis of myofascial trigger points. This is because the body overcompensates for the weakness and strains in the muscle; overloading and overstimulating the motor end plate. If you decide to offer strengthening exercises, it is advisable to put them in context. An overall stretching programme should be advised, perhaps utilizing a yoga-based regime. Care must be taken to isolate the stretch to the specific muscle as far as possible. As a rule, stretches should be performed three times, slightly deepening the stretch with an out-breath each time. This sequence should be performed several times per day, for a total of approximately 15-20 minutes. In the example of the pectoralis major muscle you may ask the patient about their stress or anxiety levels (rib breathing mechanics). If your patient has large, heavy breasts, you may want to advise on a more appropriate bra or support. Faulty sitting and/or standing postures are both a pathogenic and maintaining factor for trigger point activity. Advice and exercises for posture is often the key to unlocking both central and satellite points. This is sometimes to reduce the pain from either active, or stiff latent trigger points; in such cases patients often opt for a sleeping position that shortens the affected muscle. For example, sleeping with either the hands above the head (supraspinatus), or the arms folded over the chest (pectoralis major). In other cases, it may be that the sleeping position is a pathogenic or a maintaining factor. Work Posture Some patients may have manual or repetitive working activities; these may well have a role to play in trigger point pathogenesis or maintenance. Habitual Activity, Hobbies, and Sports Similarly it is important to ask the patient if they perform any repetitive or habitual activities. Sitting in a cross-legged position may affect a range of muscles such as the hip flexors (iliopsoas), the buttock muscles (gluteals and piriformis) and the thigh muscles (quadriceps). Heavy smokers may develop trigger points in the shoulder (deltoid) and arm (biceps brachii) muscles. Similarly, certain hobbies and sports may lead to an increased incidence of trigger point pathogenesis. It is often useful to run through these activities and set the patient certain activity goals to achieve in between treatment sessions. Initially you should seek to relax the patient sufficiently to gain access to vulnerable and potentially painful treatment. A thorough case history with thoughtful and directed questioning is essential, as is an engaging approach with the patient. Involving the patient is a key step, as you rely on feedback to locate the exact centre of the trigger point. You will need a dermometer to accurately measure reduced skin resistance (needs calibration), and an algometer for measuring point tenderness and pain generated by pressure. At first, you should discover that it is easier to locate a central trigger point.

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