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Description of the index The SPADI was developed for use in an outpatient setting buy discount metformin 500 mg. It was de- signed to measure the impact of shoulder pathology in terms of pain and disability generic 500mg metformin mastercard, for both current status and change in status over time order metformin 500mg free shipping. The initial version of die SPADI consisted of 20 items grouped into pain and disability subscales metformin 500mg low price, items were selected and placed in either the pain or disability subscale by a panel that included three rheumatol- ogists and a physical therapist. The face validity of each subscale was addressed by selecting items that the panel felt reflected pain and dis- ability associated with shoulder problems. In an effort to improve reliability and validity and to decrease the time required to complete the index, some items were eliminated from each subscale. Items were excluded from the final form of the SPADI if test-retest reliability was low or if correlation with shoulder range of motion on the involved side was low. The pain subscale was reduced from nine to five items and the disability subscale was reduced from 11 to 8 items (Table 21). The SPADI was self-administered and, in its final form, required 5±10 minutes to complete. No pain _____________________ Worst pain imaginable _____ Disability scale How much difficulty do you have? No difficulty _____________________ So difficult Required help _____ Scoring system. Visual analog scales seem to reflect more closely what the subject actually ex- periences and are the most widely employed type of scale in die mea- surement of the pain associated with rheumatic disorders. The visual analog scales used in the SPADI consisted of horizontal lines to which ware attached neither numbers nor divisions. Verbal anchors, represent- ing opposite extremes of the dimension being measured, were placed at either end of the line. The patient was instructed to place a mark on the line in the position that best represented his experience during the past week attributable to the shoulder problem. A numeric score was calculated for each item by arbitrarily dividing the horizontal line into 12 segments of equal length. A number ranging from 0 to 11 was attached to this segment to produce a score for each item. The subscale scores ware calculated by adding the item scores for that subscale and dividing this number by the maximum score possible for the items that were deemed applicable by the subject. Any item marked by the patient as not ap- plicable was not included in the maximum possible score. Therefore, scores could theoretically range from 0 to 100 with higher scores indicating greater impairment. The total SPADI score was calcu- 252 19 Scores lated by averaging the pain and disability subscale scores. The SPADI appears to have functioned well in a patient population that consisted primarily of older men. The degree to which these results can be generalized to women and younger individuals with shoulder problems remains to be fully demonstrated. After the initial training session, however, most patients can complete the SPADI without further assistance. The SPADI demonstrates good internal consistency, test-retest reli- ability, and criterion and construct validity. The SPADI should therefore prove to be a useful Instrument both in clinical practice and in clinical research. The purpose of this paper is to present a self-administered questionnaire designed to assess symptoms and function of the shoulder and to report the results of a prospective evaluation of its validity, reliability, and responsiveness to clinical change. Development of the questionnaire A preliminary questionnaire was developed and was completed by thirty patients who were being managed for disorders related to the shoulder. A subset of these patients was interviewed, and each question was as- sessed for clinical relevance, relative importance, and ease of completion a 19. This allowed modifications to be made to produce the re- vised questionnaire that was prospectively assessed. After this assess- ment, questions that had poor reliability, substantially reduced the total or subset internal consistency, or contributed little to the clinical sensi- tivity of the over-all instrument were eliminated to produce the current questionnaire. The Shoulder Rating Questionnaire includes six separately scored do- mains: global assessment, pain, daily activities, recreational and athletic activities, work, and satisfaction (Table 22).

Static posterior subluxa- tion may be associated with glenoid deformations such as classi- fied by Walch and co-workers safe 500 mg metformin. This static subluxation may be 64 7 Classifications of instability present without any rotator cuff deficiencies order 500mg metformin with mastercard. To date cheap metformin 500 mg line, most authors have found static posterior subluxations to be irreversible buy generic metformin 500mg on-line. This may occur from trauma, neurologic injury, septic arthritis, or inadequate restoration of humeral length after arthroplasty. Inferi- or subluxation after trauma and surgery, if not associated with permanent nerve injury, usually resolves within 6 weeks but al- ways resolves within 2 years. Conversely, inferior subluxation caused by infection tends to result in joint surface destruction and only successful treatment of infection results in resolution of the inferior subluxation. Inferior subluxation cause by neurologic in- jury shortening of the humerus also remains symptomatic unless the primary problem can be resolved. Subluxation must be distinguished from traumatic inferior dis- location, which occasionally is encountered as luxatio erecta. This entity is part of the dynamic instabilities that can momentarily be reduced and may recur. Being able to passively displace the humeral head out the gle- noid fossa during physical examination does not describe instability but is a semiquantitative assessment of hyperlaxity. Such translation testing may be a sign of instability if it is significantly different from the asymptomatic side of if it is associated with symptoms of appre- hension. All can be associated with major bony defects of the gle- noid fossa but it often is difficult to assess the size and thereby the relevance of such lesions. If the superoinferior extension of a glenoid rim lesion is larger than half of the largest AP diameter of the gle- noid, instability can be subclassified as with bony lesion, if this is not the case, it can be subclassified as without bony lesion. Anterior or posterior disloca- tion may be associated with a fracture of the surgical neck region that must be recognized before treatment is initiated. The posterolateral Malgaigne or Hill-Sachs compression fracture is found in anterior dislocation, whereas an antero-medial (McLaughlin) compression fracture is found in posterior dislocation. If the humeral head remains outside the glenoid fossa, a disuse atrophy of the humeral head develops. Although these lesions can be identified with radiographs, they are seen best on CT scans or arthrogram CT scans. As opposed the humeral head compression fracture associated with recurrent dislocation, the humeral head defect associated with chronic, locked disloca- tion often needs to be addressed during operative repair of long- standing lesions in patients who do not respond to conservative treatment. Either there is a distinct injury with a frank dislocation requiring reduction by an- other person, or a painful subluxation followed by recurrent epi- sodes of instability. On physical examination, the main finding is a positive apprehension test, either anterior or posterior. There is no sulcus sign and the results of the anterior and the posterior drawer tests are negative. For anterior instability, however, the hy- perabduction test recently described by Gagey and Gagey is posi- 66 7 Classifications of instability tive indicating incompetence of the inferior glenohumeral liga- ment complex. Lesions may be at the humeral insertion site, midsubstance, at the glenoid insertion site, involving the labrum and/or the ante- rior glenoid rim or rarely at the humeral and the glenoid insertion sites. In addition, the passage of the humeral head over the ante- rior glenoid rim causes a posterolateral humeral head defect that is diagnostic of anterior instability. The severity of the two lesions often are related as very large Hill-Sachs lesions often associated with small lesions of the anteroinferior capsulolabrum, whereas large capsulolabral lesions often are associated with small Hill- Sachs lesions. Posterior instabilities without hyperlaxity have pos- terior capsulolabral lesions (posterior Bankart) more frequently than previously recognized. These lesions, less severe than ante- rior capsulolabral lesions, also can be accompanied by an antero- medial humeral head compression fracture (McLaughlin lesion). These instabilities usually can be treated with success by repair of the capsulolabral lesion. If this repair is correct technically, the results of arthroscopic procedures may be comparable with those of open repair. Finally, if a glenoid rim lesion is present and of the size defined above, either glenoid reconstruction using iliac bone or a bone block procedure may be necessary to restore sta- bility. It includes disloca- tions requiring reduction, dislocations reduced by the patient, and painful subluxation followed by frequent and almost pain-free epi- sodes of recurrence, generally self-treated.

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In this diagram buy metformin 500 mg with amex, the amplitude generic 500mg metformin overnight delivery, frequency and phase of the stimulus input are shown in light gray order 500 mg metformin with amex, while the amplitude of the beam motion (at the midpoint along the beam) is shown in black discount metformin 500mg on-line. The image on the left depicts motion at a non-resonant frequency below the fundamental (first) resonance mode, and the image on the right depicts motion at the fundamental resonance frequency. A constant ampli- tude stimulus was applied to the vibrissa tip at frequencies from 0–600 Hz, and the relative change in vibrissa motion amplitude recorded using an optical sensor placed at the mid-point of the vibrissa length. The fundamental resonance frequency in this example occurred at ~160 Hz (grey vertical bar). The most famous proposal that resonance enhances frequency specific process- ing was made by Helmholtz, who suggested that the resonance properties of the cochlea generated a spatial segregation of frequency bands similar to the separation of frequencies on the strings of a piano, with low frequencies localized at one end of the cochlea and higher frequencies at the other. As such, the biomechanics of the cochlea form a spatial tonotopic map in which vibration, in response to a given frequency, is translated into increased © 2005 by Taylor & Francis Group. The spatial organization of these auditory fibers is preserved in an ascending system of neural tonotopic maps. This position-specific frequency amplification is believed to provide a place code in which the increased mean firing rate at a given position within a central auditory map is employed by an animal to make sound frequency judgments. While cochlear place coding is an important component of stimulus representation, several findings suggest that the fine timing of neural activity evoked by auditory stimuli may also play an essential role in stimulus representation and perception. The Vibrissa Resonance Hypothesis We and others have recently discovered that the biomechanical properties of vibrissae may play a central role in frequency transduction. The first prediction is that vibrissa resonance enhances the detection of small amplitude high frequency stimuli because mechan- ical amplification of these signals generates a detectable increase in the neural mean firing rate. The second prediction is that vibrissa resonance facilitates the discrimi- nation or identification of high frequency information in part through the tuning of individual vibrissae and their corresponding neural representation and in part through a place code provided by the systematic mapping of frequency preference across the face and in central somatic representations. The third prediction is that vibrissa resonance contribute to temporal coding of high frequency information by enabling the recruitment of precise temporal neural activity, most importantly in response to otherwise subthreshold small amplitude stimuli. Within this framework we predict that vibrissa resonance enhances the detection and discrimination of high frequency information generated in a variety of contexts, including airborne stimuli and tex- tured surfaces. VIBRISSA RESONANCE: RATE CODING AND PLACE CODING OF FREQUENCY-SPECIFIC TACTILE INFORMATION A. VIBRISSA RESONANCE Vibrissae resonance demonstrates oscillations of greater amplitude when stimulated at a narrow range of frequencies (Figure 2. As such, an anterior- posterior map of vibrissa frequency tuning is present across the face. In support of this suggestion there is initial supporting evidence that resonance may not be expressed in behaving animals when discrete contact of a vibrissa is made onto a vertical bar. However the existing data suggest that the range of fundamental resonance frequencies present in a set of adult rat vibrissae may be well positioned to encode this aspect of their surrounding environment. Costa (2000) used a laser displacement sensor to show that natural surfaces, specifically 20 mm and 10 mm samples of concrete blocks and sandpaper, respectively, follow a power law distribution of spatial frequencies, 1/fb (b = 2. As sug- gested,27,28 depending on surface friction, the stiffness of the vibrissa, and the force of contact, vibrissa-texture interactions will fall on a continuum between a slip- stick behavior and a more reliable gliding movement (like that of a record player needle). In all cases, natural surfaces are expected to generate high frequency (>100 Hz) mechanical vibrations: Slip-stick behavior should lead to high frequency vibrations due to the impulsive, spectrally dispersed forces on the vibrissa, and the amplitude of these vibrations may be texture-specific. Whereas record player behavior should transduce the features of the surface more faithfully. We have observed a one-to-one translation of spatial frequencies to temporal frequencies © 2005 by Taylor & Francis Group. A Textured Surface Vibrissa Motion Direction Smooth of Wheel Surface B C D A4 Grating Model A4 Grating Experiment 440 mm/sec 200 20 200 20 20 Grating Smooth 400 400 5 600 600 880 mm/sec 20 800 800 1000 1 1000 1 5 400 1200 2000 400 1200 2000 Velocity, mm/sec Frequency, Hz E 220 mm/s 440 mm/s 660 mm/s 2 2 2 Vibrissa Position 0 0 0 –2 –2 –2 –40–20 0 20 40 –40–20 0 20 40 –40–20 0 20 40 Time (ms) FIGURE 2. Half of a smooth wheel was covered with a textured surface, either a grating or sandpaper, and was moved at different velocities while contacting a vibrissa. This motion in turn drove vibrations in the vibrissa that were monitored with an optical sensor. Plots comparing the power spectra of vibrissa oscillations driven by a grating at different speeds of wheel motion. In C, increasing wheel speed caused an increased rate of vibrissa vibration as predicted by a one-to-one translation of the predominant frequencies of the grating as a function of wheel velocity (increased diagonal band of activation bounded by green lines).

Moreover buy metformin 500mg low cost, the articular surfaces of the joints in type 1 are smaller than those of the other two types cheap 500mg metformin free shipping, which may be another factor that predisposes the articular cartilage to degenerative alterations purchase metformin 500 mg without a prescription. The injury is classified into three grades based on the degree of in- jury to the ligaments metformin 500mg visa. There is no gross deformity and no more than a suggestion of separation as seen in roentgenogram. Roentgenograms taken by the recommended technique (zanca-view) show the acromioclavicular joint to be sepa- rated approximately one half; that is, the clavicle is displace cephalad about one half the normal superior-inferior depth of the joint as compared with the normal side. In addition, the distance between the inferior cortex of the clavicle and the superior tip of the coracoid process is increase (again, compared with the normal side). We measure both bony relationships, but the more significant for estab- lishing the grade of injury is the coracoclavicular one. Roentgenograms show de- finite separation of the acromioclavicular joint, greater than one half its normal depth; but more important, there is wide separation of the coracoclavicular relationship. This indicates that the conoid and the trapezoid ligaments have been completely torn. Pain is minimum, although point tenderness usually can be elicited over the acromioclavicular joint. The roentgenogram is negative ini- tially, but later it may show subperiosteal calcification about the dis- tal end of the clavicle. Roentgenograms reveal the clavicle riding higher than the acromion, but to an extent that is usually less than the width of the clavicle, even while downward stress is applied to the arm. Whenever an acromioclavicular-joint injury is suspected, stress roentgenograms of both shoulders with a 10- to 15-pound weight suspended from each wrist should be included in the work-up. Pain and tenderness are noted over the acromiocla- vicular joint and usually over the distal third of the clavicle and cora- coid process. Deformity is obvious, and the distal end of the clavicle is easily palpable and ballotable. On the roentgenogram, the distal end of the clavicle is above the superior surface of the acromion, and the distance between the clavicle and coracoid process is increased. Special mention should be made of posterior displacement of the distal end of the clavicle. The mechanism of injury is usually a direct blow on the distal end of the clavicle; however, the injury may result from a fall on the posterosuperior aspect of the shoulder. This condition frequently is missed because, even on stress roentgenograms, the clavicle may not show an upward displacement. The treatment of ªcompleteº acromioclavicular dislocations remains contro- versial. However, since the treatment for the majority of type IV, V, and VI injuries is operative, it seems reasonable and practical to remove them from all-inclusive type III category and to create an expanded, more accurate classification system. Type II A moderate force to the point of the shoulder is severe enough to rup- ture the ligaments of the acromioclavicular joint (Fig. The scapula may rotate medially, producing a widening of the acromioclavicular joint. There may be a slight, relative upward displacement of the distal end of the clavicle sec- ondary to a minor stretching of the coracoclavicular ligament. In a ªclassicº type III injury, the acromioclavicular and coracoclavicular ligaments are disrupted (Fig. The distal clavicle appears to be displaced superiorly as the scapu- la and shoulder complex droop inferomedially. Type III Variants Most often, complete separation of the articular surfaces of the distal clavicle and acromion is accompanied by complete disruption of the ac- romioclavicular and coracoclavicular ligaments. Children and adoles- cents occasionally sustain a variant of complete acromioclavicular dislo- cation. Radiographs reveal displacement of the distal clavicular meta- physic superiorly with a large increase in the coracoclavicular inter- space. These injuries are most often Salter-Harris type I or II injuries in which the epiphysis and intact acromioclavicular joint remain in their anatomical locations while the distal clavicular metaphysis is displaced superiorly through a dorsal longitudinal rent in the periosteal sleeve. The importance of recognizing this injury is that the intact coracoclavi- cular ligaments remain attached to the periosteal sleeve.

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