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Microsoft word - gonarthrose saggini english _figures added_.doc

EUR MED PHYS 2004;40(Supp. 1 to No. 3):594-8 Gonarthrosis: treatment with horizontal therapy
electrotherapy. Multicenter study
R. SAGGINI1, R. CARNIEL2, V. COCO3, F. CANCELLI2, M. IANIERI2, D. MACCANTI1 1 Chair of Physical and Rehabilitative Medicine, University “G. D’Annunzio”, Chieti; 2 C.U.M.S. University “G. D’Annunzio”, Chieti; 3 School of Specialization in Physical and Rehabilitative Medicine, Osteoarthritis is a degenerative joint pathology characterized by the progressive destruction of joint cartilage, bone sclerosis and particular osteochondral proliferation, which is clinically manifested by pain exacerbated by movement (initially localized to one or few joints) and progressive functional impotence. Symptomatology onset, often limited to just one joint, is insidious and undermined by subjective symptoms: pain is initially exacerbated by movement of the joint, especially after a period of immobility, typically on waking in the morning. In a successive phase the pain also appears after prolonged use of the joint, especially in the evening, and goes away on resting. In severely affected joints the pain may Figures 1-2 – Radiography demonstrating the reduction in reappear even during nightly rest. Intensification in articular rim of the knee joint. In figure 1 (initial stage), the pain may occur on the appearance of a more important reduction is not uniform, while in figure 2 (advanced stage) it inflammation, independently of joint use. There is also a muscular contribution to the onset of pain, as there is often an accompanying antalgic contraction. Pain is which act as excellent pain symptom reducers. often intensified by changes in the weather. Morning Pharmacological therapy can also make use of stiffness lasting just a few minutes is common, such chondroprotecting drugs which offer excellent basic duration being considerably less than that seen with inflammatory joint diseases. The stiffness recedes with Rehabilitation objectives are regaining of function, gradual mobilization of the joint which progressively possibility of recovering new, more developed motor “warms up” and regains functionality. behavior and the adaptability of a skeletal region to Objectively, the joint may present hard swellings more motor tasks. It is often the case that even for the due to osteophytic proliferation and capsule thickening. most common motor actions the patient is constrained Palpation may highlight localized pain. The skin above to use altered movements, in which compensation is may be hot, but is not usually reddened, unless sometimes excessive in comparison with that actually inflammation is increased in which case fluid build-up needed: the rehabilitative intervention will act exactly may also be noted. On passive mobilization there may be joint crepitation, demonstrating the loss of kneecap However, while the problem of joint limitation and reduced muscle recruitment can be confronted with In addition, there will also be some limitation in appropriate use of therapeutic exercise in its various joint function, at first limited to a few of the possible applicative possibilities, the approach to pain is more movements, initially due to antalgic muscular complex, above all in relation to the multitude of contraction and subsequently to altered knee cap possible originating structures and causes. This characterizes the therapeutic choice after careful and Osteoarthritis therapy is multi-disciplinary. When the affected joint is not too painful, gradual As already noted, pharmacological treatment of exercise is useful in maintaining mobility. painful symptomatology in these cases is obviated Especially painful attacks may benefit from the through opportune assumption of pain relievers. assumption of various drugs, such as salicylates However, pharmacological therapy can also be flanked (acetylsalicylic acid) or other non-steroidal anti- or even substituted in some case by the use of specific inflammatories (NSAIDS) such as naproxen, electric currents with an analgesic action. Numerous ibuprofen, ketoprofen, diclofenac, and nimesulide, studies have demonstrated the efficacy and usefulness of electric therapies in the treatment of the pain create an action potential, and simultaneously keeping characteristic of degenerative pathologies, while in the intensity constant, for biochemical effects. international literature there have even been papers Bioelectrical effects are thus produced by creating the illustrating the action of new electrotherapy forms in a action potentials. Biochemical effects are achieved by keeping the intensity constant. It is clearly noted that Electrotherapy is considered as a branch of Horizontal® Therapy is able to achieve both effects physical therapy which uses electrical current for simultaneously in the same treatment area. By varying the frequency, i.e. how many times a second the All live tissue cells use both electricity and stimulation threshold is crossed, various bioelectric chemistry in every process: for example, electrical effects can be obtained. With regard to intercellular processes are used in metabolism, in trans-membrane effects, chondrocyte energy production occurs mechanisms in transmission of pain signals, in primarily through glycolysis, i.e. anaerobically. inflammatory processes, in muscular contractions and Glycolysis begins with the phosphorylation of glucose through the enzyme hexochinase. The necessary All these processes are always accompanied by phosphate is derived from adenosine-triphosphate biochemical processes, and vice versa, i.e. chemical (ATP), creating adenosine diphosphate (ADP). processes are always simultaneously accompanied by Magnesium is necessary to activate hexochinase. In all glycolysis stages the substrates contain one or two The use of electricity in the form of electrical phosphoric acid residues. All substrates in intermediate currents thus has the aim, within the therapeutic products, apart from the sugars glucose, fructose and objectives, of influencing the electrical processes in glycerine, are organic acids. This means that all substrates are in the form of ions and thus directly exposed to the Horizontal® Therapy electric field electrotherapy used in the treatment of osteoarthritis forces. The enzymes, the foundation of the various due to its ability to stimulate both deep-down and glycolysis reaction phases, are also electrically surface joint tissues, simultaneously obtaining both charged. Furthermore, the enzymes and substrate bioelectrical effects (deriving from low frequency, molecules react with one another in well defined variable intensity stimulatory therapies) and positions, through opposite electrical charges. In this biochemical effects (deriving from non-stimulatory, way Horizontal® Therapy has an effect which medium frequency alternating current therapies). facilitates metabolism. Through its alternating electric field, with a frequency of many thousands of Interferential therapy
oscillations per second, the probability of an encounter between substrate and enzyme is increased. The This form of therapy was developed by combining probability of an encounter between a substrate the action mechanisms discovered in both classes to molecule and an enzyme molecule in their specific produce greater inter-cell communication (function reaction position is improved. These effects prevalently occur in the cells, favoring metabolism. Chondrocytes Interferential therapy requires the application of 4 and cells, involved in the inflammatory process, thus electrodes: crossing two medium frequency circuits (e.g. 4000 and 4010 Hz) where in the centre, the In synovial liquid and the cartilage tissue matrix, meeting point of the two circuits, the frequencies rich in water, an alternating electric field induces the neutralize each other, producing low frequency i.e. effect of equilibrating concentrations. Only inorganic bioelectric effects (4010-4000 = 10 Hz). and organic ions are directly exposed to the electrical Interferential therapy is characterized by the force of the alternating field and they move in different effects obtained in diverse treatment zones: oscillation. This Horizontal® Therapy effect favors live tissue in the centre of the treatment area is deeply diffusion and thus distribution of pain mediators and is bioelectrically stimulated. In areas beyond the meeting particularly important for patients with osteoarthritis, point (near the electrodes) surface biochemical effects who due to pain are forced to control and reduce their joint movement. Through higher intensities, well In contrast with the various forms of traditional tolerated by the joints, a further effect is added which electrotherapy, Horizontal® Therapy is able to simultaneously combine all action mechanisms, The aim of this multimember study, effected in 5 horizontally exceeding the stimulation threshold and Italian centers and coordinated by the Chair of Physical utilizing a constant electrical intensity setting, with and Rehabilitative Medicine of the University G. biochemical-type frequencies (over 1000 Hertz). D’Annunzio, was to verify the usability and efficacy of According to Wyss, an increase in frequency leads to Horizontal Therapy in a functional re-education an equal increase in intensity, achieving a program in a sample of subjects with moderate physiological effect. Horizontal® Therapy exploits this concept, keeping electrical intensity constant and In effect, we are “horizontally” crossing the stimulation threshold in the low frequency rhythms to Materials and Methods
Data were recorded and statistically analyzed with the SPSS program 7.5 for Windows 95 (Tab. III). After abundant analysis of the tool’s physical characteristics and the cellular modifications it induces, Table III Most common symptoms in analyzed patients 200 subjects, 100 male and 100 female, mean age 62 (56-74) were enrolled in this study in the period December 02 to April 03. They were studied for 12 months and were selected on the following basis: patients who were diagnosed with a moderate osteoarthritic process in the knee joint classification, enrolling subjects presenting The application method with respect to frequency Some patients presented one or more of these and electrode position was chosen from those suggested in the international instruction manual tables. The frequencies used in our osteoarthritis-specific The 200 cases were followed meticulously, with treatment are those given in the programs already particular attention to pain, swelling and joint memorized in the Hako-Med PRO ElecDT® 2000 movement limitation, as the most frequently apparatus in the “osteoarthritis” file. encountered elements. Their modification was From the three sub-files present the two used evaluated vertically for the 200 subjects (that is, at the during our study were: Osteoarthritis with strong pain, end of treatment and 1, 3, 6 and 12 months after its in 125 cases, and Osteoarthritis with strong swelling, in 65 cases where there was fluid build-up (Tab. IV). With respect to management aspects, HT requires a longer treatment time than traditional electrotherapies, with c. 30 mins therapy plus 5 mins for electrode positioning. The 200 patients analyzed in our study had a mean age of 62 (max. 74, min. 56) (Tabs. I and II) Analysis of results
In the cases analyzed the use of Horizontal Our main objective in this study was to evaluate Therapy was proposed through cycles of 10 sessions. the efficacy of Horizontal Therapy in articular 18 men and 12 women left the study and follow up pathology such as osteoarthritis, both immediately after and were excluded from statistical analysis, as they had the end of the cycle effected in patients and in the short undergone physical treatments of various types, all term of one month after the end of treatment, medium from the end of the third month of treatment. term of 6 months and long term of 12 months. The VAS values before treatment (baseline), at the Parameters considered for evaluation were the end of treatment and at 6 and 12 month follow-ups subjective pain index through VAS scale, variation in were processed for arithmetical means and standard assumption of pain relievers (Tabs. VI and VII) deviations. Anova for repeated measurements enabled following therapy and improvement in joint range (Tab evaluation of statistical significance among VAS variations during the follow-up (within STEP factor). The Wilcoxon test was applied to evaluate the Table VI – drugs used before Horizontal Therapy statistical significance of VAS modifications at diverse control STEPS of the experimental group. The different VAS results at every STEP were verified with the Mann-Whitney test, whose results are reported in the figure. Table VII – drugs used after Horizontal Therapy As can be seen from Table VII, in the short term Table XIII –VAS 1 month after end of treatment after Horizontal Therapy assumption of non-steroidal anti-inflammatories and pain relievers completely stopped. Table XIV –VAS 3 months after end of treatment Table XV –VAS 6 months after end of treatment As can be seen from the table, in the short term following Horizontal Therapy assumption of non-steroidal anti-inflammatories and pain relievers completely stopped and this data remained significant (p≤0.001) at 3 months and also at 6 months (p≤0.05). Figure 1. Reference measurements used in evaluation of joint
In the vast majority of cases, 58 out of 65, the values of the considered parameters improved with a visible reduction of swelling in those subjects where it Table XVI –VAS 12 months after end of treatment was present (although this was not demonstrable Table XVII –VAS subjective improvement in pain at end of 7.43±1.64 3.88±1.71* 3.9±1.38** 5.80±1.34*** *p<0.01 Wilcoxon test: end treatment vs. baseline values **p<0.01 Wilcoxon test: 6 months vs. end treatment *** p<0.01 Wilcoxon test: 12 months vs. 6 months † p<0.01 Wilcoxon test: 12 months follow-up vs. end Considerations and conclusions
From examination of the results obtained in Table XVIII –VAS subjective improvement in pain 1 month after this study, it can be seen that treatment with statistically significant way in the short and significant reduction of pain (Tab. XXII); the stabilization expressed by objective and subjective VAS and the reduction in anti- statistically significant for up to three months for the sample of 200 subjects and Table XIX –VAS subjective improvement in pain 3 months after treatment then in a population sample reduced by 15% at 6 months. In the 12 month checks Use of this form of physical energy is thus important in the size of therapeutic impact that the physiatrist must plan in formulating the rehabilitative treatment of subject with Table XX –VAS subjective improvement in pain 6 months after osteoarthritis, in particular in the knee. Table XXI –VAS subjective improvement in pain 12 months after treatment Table XXII – Results of follow-up after treatment with HAKO in 170 patients with gonarthrosis

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