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Midswing takes up approximately 50% of the swing phase order malegra fxt plus 160mg amex. Terminal swing occurs with the knee extending and the limb preparing for foot contact discount malegra fxt plus 160mg on line. Body Segments Important in the Gait Cycle To understand the gait cycle in more detail, the body has to be considered as segments linked together. The concept popularized by Perry is to consider the passenger, or cargo segment, and the locomotor segments. The stance phase events that make up these divisions are foot tains the head, arms, and trunk and is abbreviated as the HAT segment (Fig- contact (heel strike) (D), opposite limb toe- ure 7. The locomotor segments are the foot, shank, thigh, and pelvis, off (loading response) (E), forward roll of the which are articulated by the ankle, knee and hip, and lumbosacral junction. Swing phase is broken down into initial swing, mid- segment can be defined by a center of mass that is somewhat higher than the swing, and terminal swing smaller phases (C). The center of mass of the HAT segment The swing events are toe-off (I), both feet in is also somewhat dynamic because this segment allows motion of the head the same transverse plane (initial swing) (J), and arms independently. The focus on the influence of this changing position shank is vertical to the room (midswing) (K) of the center of mass of the HAT segment has not been well defined for the and terminal swing ending with foot con- application of clinical gait analysis. Another breakdown can be related that the body mechanically acts as if all its mass were at that point. The cen- to the ankle rockers, in which the events are ter of gravity is approximately the point on the body where the center of foot contact (K) to foot flat (E), to define first mass is located. The center of gravity is also dynamic and can be changed by rocker. Foot flat (E), to heel rise (G) defines a change in body shape, but in an upright standing position, the center of second rocker, and heel rise (G) to toe-off (I) gravity is typically just anterior to the first sacral vertebra. The basic cycles of running are very similar to walking, except there is no double limb support and there is, instead, float time. Running is defined as a gait pat- tern in which there is a period of time that the body is not in contact with the ground. As a mechanism for under- standing gait, the body can be divided into a its shape. This concept holds true consistently for the pelvis, thigh, and shank motor segment that includes the pelvis and segments, but is much less stable for the foot and HAT segments. The cen- lower limbs, on which rides the cargo seg- ment of the HAT segment (A). The goal of ter of mass can be changed significantly by swinging arms, trunk bending, gait should be to move this cargo segment and head movement in the HAT segment. For the foot segment, the change forward with as small a vertical oscillation of in center of mass is less dramatic than the problem of the foot not being a the cargo mass as is possible. Lifting this mass rigid segment, as assumed in gait modeling. Flexibility of the supposed rigid vertically and letting it drop with each step is segment can cause additional problems for gait measurement. For the gait cycle to have maximum efficiency, the center of mass of the HAT segment should move in a single forward direction of the intended motion only; however, this is not physically possible. Therefore, the goal is to minimize the vertical and side-to-side oscillation of the center of mass of the HAT segment (Figure 7. The body’s center of mass is lo- cated just anterior to the sacrum. The most energy-efficient gait requires the least move- ment of this center of mass out of the plane of forward motion. In actual fact, the motion of the center of mass is really a path that looks like a screw thread in which there is vertical and sideways oscillation (A). There is a significant component of side-to-side movement (B). B motor control adjusting limb lengths through sagittal plane motion of the joints connecting the locomotor segments. Understanding these relationships is easier by looking at the individual joints and at how each joint functions in normal gait throughout the full gait cycle. Ankle The ankle is mechanically modeled as the joint that connects the foot to the shank. The ankle is modeled as a single axis of motion in flexion extension, with mechanical perspective of the gait measurement. However, this descrip- tion is a great oversimplification and the measures of rotation around the vertical axis and varus–valgus motion are recorded as well. The ankle joint measurements of rotation and varus–valgus motion are primarily reflections of motions in the foot itself through the subtalar joint; therefore, these measurements are not very useful because of the inaccuracy associated with marker placement and mathematical assumptions of the foot as a single rigid segment. Therefore, it is better to think of the ankle as having only plantar flexion and dorsiflexion ability and then separately consider flexibility and stability issues of the foot as a segment.

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The glycosaminogly- can chains of proteoglycans are degraded by lysosomal enzymes that cleave one sugar at a time from the nonreducing end of the chain best malegra fxt plus 160 mg. An inability to degrade proteoglycans leads to a set of diseases known as the mucopolysac- charidoses purchase malegra fxt plus 160mg with visa. Adhesion proteins, such as fibronectin and laminin, are extracellular glyco- proteins that contain separate distinct binding domains for proteoglycans, collagen, and fibrin. These domains allow these adhesion proteins to bind the various components of the extracellular matrix. They also contain specific binding domains for specific cell surface receptors known as the integrins. These integrins bind to fibronectin on the external surface, span the plasma membrane of cells, and adhere to proteins, which, in turn, bind to the intracellular actin filaments of the cytoskeleton. Integrins also provide a mechanism for signaling between cells via both internal signals as well as through signals generated via the extracellular matrix. This is accomplished by a variety of matrix metal- loproteinases (MMPs) and regulators of the MMPs, tissue inhibitors of matrix metalloproteinases (TIMPs). Dysregulation of this delicate balance of the regula- tors of cell movement allows cancer cells to travel to other parts of the body (metastasize) as well as to spread locally to contiguous tissues. THE WAITING ROOM Sis Lupus (first introduced in Chapter 14) noted a moderate reduction in pain and swelling in the joints of her fingers when she was taking a 6-week course of high-dose prednisone, an anti-inflammatory steroid. As the dose of this drug was tapered to minimize its long-term side effects, however, the pain in the joints of her fingers returned, and, for the first time, her left knee became painful, swollen, and warm to the touch. Her rheumatologist described to her the underlying inflammatory tissue changes that her systemic lupus erythematosus (SLE) was causing in the joint tissues. Ann Sulin complained of a declining appetite for food as well as severe weakness and fatigue. The reduction in her kidneys’ ability to maintain normal daily total urinary net acid excretion contributed to her worsening metabolic acidosis. This plus her declining ability to excrete nitrogenous waste products, such as creatinine and urea, into her urine (“azotemia”) are responsible for many of her symptoms. As it approached a level of 5 mg/dL, she developed a litany of complaints caused by the multisystem dysfunction associated with her worsening metabolic acidosis, reten- tion of nitrogenous waste products, and so forth (“uremia”). Her physicians dis- cussed with Ann the need to consider peritoneal dialysis or hemodialysis. COLLAGEN Collagen, a family of fibrous proteins, is produced by a variety of cell types but principally by fibroblasts (cells found in interstitial connective tissue), muscle cells, and epithelial cells. Type I collagen [collagen(I)], the most abundant protein in mammals, is a fibrous protein that is the major component of connective tissue. It is found in the extracellular matrix (ECM) of loose connective tissue, bone, tendons, skin, blood vessels, and the cornea of the eye. Collagen(I) contains approximately 33% glycine and 21% proline and hydroxyproline. Hydroxyproline is an amino acid produced by posttranslational modification of peptidyl proline residues (see Chap- ter 7, section V. Procollagen(I), the precursor of collagen(I), is a triple helix composed of three polypeptide (pro- ) chains that are twisted around each other, forming a rope-like structure. Polymerization of collagen(I) molecules forms collagen fibrils, which provide great tensile strength to connective tissues (Fig. The individual polypeptide chains each contain approximately 1,000 amino acid residues. CHAPTER 49 / THE EXTRACELLULAR MATRIX AND CONNECTIVE TISSUE 907 Each turn of the triple helix contains three amino acid residues, such that every third amino acid is in close contact with the other two strands in the center of the struc- ture. Only glycine, which lacks a side chain, can fit in this position, and indeed, every third amino acid residue of collagen is glycine. Thus, collagen is a polymer of (Gly-X-Y) repeats, where Y is frequently proline or hydroxyproline, and X is any other amino acid found in collagen. Procollagen(I) is an example of a protein that undergoes extensive posttransla- The role of carbohydrates in colla- tional modifications. Hydroxylation reactions produce hydroxyproline residues gen structure is still controversial. These reactions The hydroxyproline residues in col- occur after the protein has been synthesized (Fig. Hydroxyproline residues are involved in hydrogen bond forma- the absence of vitamin C (scurvy), the melt- tion that helps to stabilize the triple helix, whereas hydroxylysine residues are the ing temperature of collagen can drop from 42oC to 24oC, because of the loss of inter- sites of attachment of disaccharide moieties (galactose-glucose). These aldehyde residues produce covalent cross-links between collagen molecules (Fig.

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Etiology buy generic malegra fxt plus 160 mg, Epidemiology cheap 160mg malegra fxt plus with mastercard, Pathology, and Diagnosis 39 Epidemiology Because of the wide variety of causes of CP, the exact numbers from differ- ent studies do not completely agree. However, there is remarkable similarity in the prevalence across the world, from Sweden in the 1980s with a preva- lence of 2. A report from England, which is representative of many studies, shows that there has not been much change in prevalence over the past 40 years. However, the patterns of CP have shifted more toward diplegia and spastic quadriplegia and away from hemiplegia and athetosis. Also, multiple births have increased with increasing maternal age,22 and these multiple births have a substantially higher risk of developing CP. The re- ported prevalence rate per pregnancy for singles is 0. There are many ways of classifying CP, one of which is by etiology. However, for the treatment of motor disabilities it is much more important to classify children by anatomic pattern and specific neuromotor impair- ments than by the cause of the CP. Classifying CP in this way provides a framework in which to discuss the functional problems of individuals in their whole environment. A framework for understanding individuals with limited motor function has been agreed to at an international forum held in 1980, organized by the World Health Organization (WHO). The report is entitled “Classification of Impairments, Disabilities and Handicaps. The “handicap” is the result of limits in the environment and society, which limit individuals as a result of their specific disability. Therefore, an individual who uses a wheelchair has a handicap if he wants to visit a friend and the only way into the house is up a long flight of stairs. This inability to socialize is the handicap and, for many adults, is what impedes them from being integrated into full society of jobs, friends, and social entertainment. In 1993, the National Center for Medical Rehabilitation Research (NCMRR) added to the WHO classification by dividing impairments into “pathophysiology” and “impairment. The WHO initially developed a model for disability that was later expanded by the USA National Center for Medical Re- habilitation Research. The concepts of both models are similar, with a focus that expands the understanding that problems of function are related beyond the isolated anatomic prob- lem of an individual person. Anatomic Classification The most useful primary classification for children with CP is based on the anatomic pattern of involvement. This involvement is the first classification used by physicians treating motor impairments, as it gives a very general sense of severity and a general overview of what patients’ problems likely are. Classification into hemiplegia, which involves one half of the body; diplegia, which involves primarily the lower extremities with mild upper ex- tremity involvement; and quadriplegia, which involves all four limbs, is most useful. In general, individuals with hemiplegia and diplegia can walk, and those with quadriplegia use wheelchairs as their primary mobility device. For patients who do not clearly fit these patterns, many other names have been suggested. Double hemiplegia has been suggested for children with upper and lower extremity involvement that is much more severe on one side than the other. Triplegia has been suggested for individuals who have a hemiplegic pattern on one side and a diplegic pattern in the lower extremities. There are rare children who appear to have hemiplegia and diplegia, which would make anatomic sense, so this term triplegia has some merit; however, it does not aid in treatment planning. Etiology, Epidemiology, Pathology, and Diagnosis 41 Monoplegia is used when one limb is primarily involved; however, from a motor treatment perspective, these children are treated as if they had mild hemiplegia. In North America, the term paraplegia implies a pure lower ex- tremity paralysis and is used only for spinal cord paralysis because almost all children with brain origin disability will also have some upper extremity involvement, although it may be very minor. Pentiplegia is occasionally used to define the most severely impaired individuals who have no independent head control. This term adds little over the use of quadriplegia in planning motor impairment treatment; therefore, it has not gained widespread use. Evolutionary Pathology Even though there are many causes of CP, there are few recurring anatomic patterns of involvement because damage to specific areas, regardless of how the damage occurs, creates similar patterns of impairment. However, a spe- cific region of brain injury can cause variation in the impairments because the initial injury also overlies normal development, which continues after the injury. Because all these injuries occur in the young and immature brain, growth and development over time affects the impairment. A brain injury occurring in early pregnancy, meaning most congenital syndromes, has a dif- ferent presentation than an injury occurring in a 4-year-old child. The first aspect of this pathology is to understand the presence of very early primitive reflexes that should disappear as normal children grow. The cutaneous reflexes, mainly finger and toe grasp, occur with stroking of the skin on the palm or on the sole. The sucking and rooting reflexes are simi- larly initiated with stroking of the face and lips (Figure 2.

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Often purchase 160mg malegra fxt plus amex, as these children mature order 160 mg malegra fxt plus, they learn to overcome scissoring and subsequently will slowly do less scissoring. If the musculoskeletal im- pairment is blocking progress, it is reasonable to correct the deformity, usu- ally around 5 to 7 years of age at the youngest. If there is a question of the significance of the musculoskeletal impairment, it may be beneficial to wait until 8 to 10 years of age when a better assessment can be made, with more time to evaluate how these children are changing. Middle Childhood Quadriplegic Ambulators In middle childhood, most children will reach a plateau with motor function. An evaluation of the benefits of correction of musculoskeletal deformities should be performed. If there are limitations that are significantly impairing the children, correction should be made. Correcting the contractures that are causing impairments is often beneficial, and these contractures may include equinus contractures, hamstring contractures, knee flexion contractures, hip flexion contractures, and adductor contractures. Sometimes the parents report that these releases help the caretakers provide personal hygiene more easily, such as easier bathing or dressing. Severe planovalgus foot defor- mities merit correction when they limit orthotic wear. During this time, if children have good cognitive function, a decision should be made to focus less on walking and more on cognitive learning and fine motor skills. If chil- dren have moderate or severe mental retardation, continuing to focus on ambulation is a reasonable option. Some of the children with severe mental retardation will make significant progress in ambulatory skills in middle childhood, even up to age 12 or 13 years. As children approach adolescence, the gait trainer is less useful because the device has to be so large that it does not fit through doors and cannot be functionally used in most homes. Care- takers and parents are encouraged to continue to walk holding the hands of the patients, so as not to lose the ability to do weightbearing transfers. Cor- rection of foot deformities and knee contractures should also be directed at the goal of maintaining these individuals’ ability to do standing weightbearing transfers. Adolescent Quadriplegic Ambulation Adolescence is when individuals will continue to do household ambulation if they can walk with a standard walker, but usually stop walking if it re- quires the use of a gait trainer. Most individuals will be able to maintain weight bearing as a transfer ability. If the limitation is due to a musculo- skeletal deformity, correction should be considered. Typical problems that occur at this age are severe planovalgus feet, which limit the ability of indi- viduals to stand or wear AFOs. This correction is easy to maintain and will not be lost at this age. The second most common major problem is hamstring contractures and fixed knee flexion contractures. Gait 373 idly, the hamstrings will often rapidly recontract after lengthening. If there is a severe knee flexion contracture of more than 30°, this too gets worse. As the knee flexion contracture goes over 30° to 40°, standing rapidly becomes more difficult. Correcting the knee flexion contracture is a difficult decision because the contracture may make standing more difficult, but if individu- als can only stand and spend most of their time sitting in their wheelchairs, correction of knee flexion contracture is not likely to be successful, as the knee will just recontract. Therefore, correction of significant knee flexion contractures should be reserved for individuals who do some community ambulation, or who surgeons believe have the ability to do some community ambulation. Correction of torsional malalignment, such as tibial torsion or femoral anteversion, is indicated if the correction will improve an individ- ual’s ability to sit. Often, the benefit from treatment for sitting takes prece- dence over problems of ambulation unless it is a very severe torsional mal- alignment. The problems of stiff leg gait with rectus spasticity are often much less of a problem in this group of individuals than individuals who are full community ambulators with faster walking speed. Also, the quadriplegic pattern involved individuals have a high tendency for recurrence of knee stiffness in swing phase, sometimes even recruiting the vastus muscles to keep the knees stiff during swing phase if the rectus is removed. It seems these in- dividuals with limited ambulatory ability need the knee stiffness to be able to provide stability and control of their standing. One of the problems that occurs with these quadriplegic patterns is care- takers who insist the children used to walk everywhere but now they can no longer walk, except in the house. Parents and caretakers tend to forget how these children walked 3 years prior, and most often, the video record will show that there is little difference.