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Protuberance lateral to the capitulum that gives attachment to the extensor muscles of the forearm cholesterol phospholipid ratio buy atorlip-5 5mg free shipping. Roughened area on the anterior surface of the upper part of the ulnar shaft for attachment of the brachialis muscle cholesterol medication liver cheap 5 mg atorlip-5 with amex. Articular surface at the proximal end of the anterior surface of the ulna for articulation with the trochlea of the humerus. Joint surface on the lateral aspect of the ulna at the level of the coronoid process for articulation with the articular circumference of the radius. Rim-like surface on the head of the radius for articulation with the radial notch of the ulna. Roughened prominence on the medial aspect of the radius about 2 cm distal to the proximal end. Bony ridge extending distally from the radial notch for attachment of the supinator muscle. Bony ridge on the posterior aspect of the lower end of the radius between the grooves for the extensor pollicis longus and extensor carpi radialis brevis muscles. Concavity forming the medial surface at the end of the radius for articulation with the ulna. Joint surface on the inferior surface of the lower end of the radius for articulation with the carpus. Anterolateral articular surface of the head of the ulna for articulation with the ulnar notch of the radius. Peg-like process projecting downward from the posteromedial aspect of the lower end of the ulna. Proximal carpal bone situated between the hamate and lunate bones, dorsal to the pisiform bone. Proximal carpal bone residing on the palmar aspect of the triquetrum with which it articulates. Roughened expansions at the distal flexor side of each terminal phalanx for attachment of the tactile pads. Elevation on the palmar side of the trapezium distal to the scaphoid tubercle and radial to the groove for the flexor carpi radialis. Distal carpal bone positioned between the 2nd metacarpal and the scaphoid and between the trapezium and capitate bones. Distal carpal bone located between the 4th and 5th metacarpals, capitate and triquetrum. Hook-shaped process on the palmar aspect of the hamate distal to the pisiform bone. Palmar concavity between the tubercles of the scaphoid and trapezium on the radial side, and the hamulus and pisiform bone on the ulnar side. A transverse ligament converts it into a closed canal (carpal tunnel) for the flexor tendons of the fingers. Notch in the lunate surface of the acetabulum facing the obturator foramen and continuous with the acetabular fossa. A flat ridge situated somewhat in the middle of the ala of the ilium between the fields of origin of the gluteus medius and minimus muscles. Bony ridge between the fields of origin of the gluteus medius and maximus muscles. Bony ridge above the acetabulum between the fields of origin of the gluteus minimus and rectus femoris muscles. Surface of the dorsal segment of the ilium facing the sacrum and consisting of the following two parts. Palpable projection on the external lip of the iliac crest about 5 cm behind the anterior iliac spine at the junction of the anterior gluteal line with the iliac crest. Bony ridge on the inner margin of the iliac crest for attachment of the transversus abdominis muscle. The portion of the pubis located anteroinferior the obturator foramen between the symphysis and the suture line with the ischium.

This fluid-filled space is the site at which the articulating surfaces of the bones contact each other cholesterol lowering diet heart foundation discount atorlip-5 5mg overnight delivery. Also unlike fibrous or cartilaginous joints cholesterol units order atorlip-5 5mg online, the articulating bone surfaces at a synovial joint are not directly connected to each other with fibrous connective tissue or cartilage. This gives the bones of a synovial joint the ability to move smoothly against each other, allowing for increased joint mobility. The joint is surrounded by an articular capsule that defines a joint cavity filled with synovial fluid. The articulating surfaces of the bones are covered by a thin layer of articular cartilage. Ligaments support the joint by holding the bones together and resisting excess or abnormal joint motions. Friction between the bones at a synovial joint is prevented by the presence of the articular cartilage, a thin layer of hyaline cartilage that covers the entire articulating surface of each bone. However, unlike at a cartilaginous joint, the articular cartilages of each bone are not continuous with each other. Instead, the articular cartilage acts as a smooth coating over the bone surface, allowing the articulating bones to move smoothly against each other without damaging the underlying bone tissue. The cells of this membrane secrete synovial fluid (synovia = "a thick fluid"), a thick, slimy fluid that provides lubrication to further reduce friction between the bones of the joint. This fluid also provides nourishment to the articular cartilage, which does not contain blood vessels. The ability of the bones to move smoothly against each other within the joint cavity, and the freedom of joint movement this provides, means that each synovial joint is functionally classified as a diarthrosis. Outside of their articulating surfaces, the bones are connected together by ligaments, which are strong bands of fibrous connective tissue. These strengthen and support the joint by anchoring the bones together and preventing their separation. Ligaments allow for normal movements at a joint, but limit the range of these motions, thus preventing excessive or abnormal joint movements. At many synovial joints, additional support is provided by the muscles and their tendons that act across the joint. As forces acting on a joint increase, the body will automatically increase the overall strength of contraction of the muscles crossing that joint, thus allowing the muscle and its tendon to serve as a "dynamic ligament" to resist forces and support the joint. This type of indirect support by muscles is very important at the shoulder joint, for example, where the ligaments are relatively weak. A few synovial joints of the body have a fibrocartilage structure located between the articulating bones to unite bones to each other, smooth movements between bones, or provide cushioning. This is called an articular disc, which is generally small and oval-shaped, or a meniscus, which is larger and C-shaped. Additional structures located outside of a synovial joint serve to prevent friction between the bones of the joint and the overlying muscle tendons or skin. A bursa (plural = bursae) is a thin connective tissue sac filled with lubricating liquid. It is a connective tissue sac that surrounds a muscle tendon at places where the tendon crosses a joint. Types of Synovial Joints Synovial joints are subdivided based on the shapes of the articulating surfaces of the bones that form each joint. An example of a pivot joint is the atlantoaxial joint, found between the C1 (atlas) and C2 (axis) vertebrae. Here, the upward projecting dens of the axis articulates with the inner aspect of the atlas, where it is held in place by a ligament. This type of joint allows only for bending and straightening motions along a single axis. A good example is the elbow joint, with the articulation between the trochlea of the humerus and the trochlear notch of the ulna. Other hinge joints of the body include the knee, ankle, and interphalangeal joints between the phalanx bones of the fingers and toes.

Therapists working in neurology need to evaluate the impact of their interventions on all of these consequences cholesterol medication dry mouth order atorlip-5 on line. For many years cholesterol levels chart age generic 5mg atorlip-5 with mastercard, clinicians have focused on treating and evaluating impairment, assuming that a change at this level will impact on activity and participation; however, this relationship is not borne out in the literature (Sullivan et al. Bobath therapists work with the patient and their carers and family to identify goals that are individual to them and recognise their participation restrictions and underlying functional deficits. When using this framework to assist in the selection of an appropriate measure to evaluate change in the target outcome, it is important to recognise that patients may have the capacity to carry out an activity in an optimal rehabilitation environment, but external and internal factors can limit their performance in the real world. This problem will be familiar to practising clinicians and should be considered when measures are being selected. An example of this in practice is that 70% of stroke patients are reported to be able to walk independently; however, only a small percentage can walk functionally in the community (Mudge & Stott 2007). A more appropriate approach would be to select the Community Balance and Mobility Scale as it includes multitasking and sequencing of movement components and is more representative of the activity of walking outdoors (Lord & Rochester 2005; Howe et al. Factors influencing measurement selection Defining outcomes Before a measure can be selected, the therapist needs to qualify what it is they are trying to have an influence on. The outcome target needs to be defined and this can be done operationally or constitutively (Ragnarsdottir 1996). Operationalising a concept anchors it to measurable and observable events, whereas defining it constitutively describes its meaning. For example, balance can be defined constitutively as the ability to maintain a posture and deal with internal and external 66 Table 4. Once the outcome target has been defined, the therapist can further refine it by deciding with the patient the elements of it that are particularly important to them within the context of their individual environment. For example, if improved walking is the outcome target, this can be further refined by considering whether speed, distance or the level of assistance is the most important element to the patient. The therapist is now in a position to select the most appropriate outcome measure to reflect change in the selected target. Measurement purpose Measures are developed for a range of reasons including discrimination, prediction and evaluation (Kirshner & Guyatt 1985). Discriminative measures aim to describe individuals within a specific construct at one point in time; they allow clinicians to distinguish between respondents. Predictive measures predict an outcome in the future based on the results of measuring a construct in the present. It is designed to measure change over time and need to have excellent reliability, validity and responsiveness. Measurement properties Levels of data There are four levels of data that can be collected by outcome measures: nominal, ordinal, interval and ratio. Being able to distinguish between the different levels of data has implications for the ability of the user to statistically analyse and interpret the data collected. Nominal data can only categorise outcome, for example the patient does or does not achieve his/her goals. Each of its components is scored on a 5-point ordinal scale, where a score of 4 means the patient performs movements independently or holds positions for the prescribed time and 0 means the patient is unable to perform that particular component at all. It is, however, important to note that the interval between scores is not uniform. These scales are commonly used in rehabilitation and these limitations need to be recognised; in particular, a change of 5 points in one 68 Practice Evaluation patient does not mean they have made the same improvement as another patient with a 5-point change in score. This has implications for the practitioner who wants to compare changes in a range of patients on a scale. Interval and ratio scales are the highest level of measurement, providing data that can be rigorously interrogated. Interval scores have known incremental distances between each point on the scale but do not have a true zero. An example of interval data might be a self-report quality-of-life scale where a score of 0 cannot indicate no quality of life. A ratio scale provides the most superior level of data as it has a true zero as well as having equal distances between each part of the scale. It is important to consider what level of data is being collected when evaluating physiotherapy interventions.

If muscles are not active cholesterol levels range canada generic 5 mg atorlip-5 free shipping, the system is deprived of afferent information including that from muscle spindles and Golgi tendon organs high cholesterol foods bacon discount 5mg atorlip-5 with visa. Glenohumeral stability is dependent on the position of the scapula on the rib cage, the activity of the supraspinatus muscle and the taut superior aspect of the capsule when the upper limb is at rest beside the trunk. However, as soon as the upper limb moves away from the trunk, more active control is required and the deltoid and 157 Bobath Concept: Theory and Clinical Practice in Neurological Rehabilitation. This highlights the lack of congruency between the head of humerus and glenoid fossa which will create an inability to selectively activate the rotator cuff musculature. The important muscles providing this dynamic stability are subscapularis, supraspinatus, infraspinatus and teres minor (Dark et al. The synchronous contraction of these muscles creates a compressive force, enabling the humeral head to pivot and glide in the glenoid fossa. Clinically, it is important to consider the alignment of the shoulder complex in the patient who has decreased muscle activity around this area. Careful positioning and handling of the shoulder complex during both rest and personal care tasks, such as washing and dressing, helps maintain involvement of the upper limb and may prevent trauma to this vulnerable area (see Chapter 8). When a patient is positioned by stabilising the trunk, for example at rest in side lying, the upper limb is allowed to accept the support of the pillow and not the upper limb supporting an unstable trunk. Many authors support the theory that the scapula position on an upright trunk provides an upward, anterior, lateral-facing glenoid fossa which offers an automatic locking mechanism for the shoulder joint with the upper limb in adduction preventing downward subluxation of the glenohumeral joint (Basmajian 1981; 158 Recovery of Upper Limb Function. The posture of the cervical and thoracic spine has a strong influence on the position and mobility of the scapula and therefore the glenohumeral joint (Culham & Peat 1993; Magarey & Jones 2003). The clinical implications of decreased antigravity activity in the trunk include a loss of scapula alignment and instability of the glenohumeral joint. This also applies to positioning the patient in the acute and subacute stages and supporting the hypotonic upper limb, and more importantly, the trunk, with pillows and/or a table to reduce the traction on the soft tissue and muscles of the upper quadrant. Dysfunction, for example weakness in the scapula musculature, will result in an alteration in scapula stability leading to shoulder function becoming less efficient, reducing performance and pre-disposing the individual to injury (Voight & Thomson 2000). Stability at the scapulothoracic joint depends not only on the surrounding musculature (Mottram 1997; Voight & Thomson 2000), notably trapezius and serratus anterior, but also on rhomboid major and minor and levator scapulae. These stabilising muscles must be recruited prior to movement of the upper limb to anchor the scapula (Mottram 1997; Voight & Thomson 2000), and while maintaining dynamic stability, they must also provide controlled mobility. A lack of appropriate activation leads to an inability to achieve an efficient reach pattern. However, changing the direction of movement may allow for a more appropriate pattern of activity and is a useful assessment tool. The scapula is able to move in many directions on the thoracic cage, including elevation, depression, abduction, adduction and rotation (Mottram 1997; Voight & Thomson 2000) and this mobility is important for: improving the congruity of the glenohumeral joint during movement; allowing the acromial arch to elevate, so preventing impingement of the humeral tubercles during elevation of the upper limb; 160 Recovery of Upper Limb Function. The repeated use of compensatory movement strategies by the patient will affect the balance of muscle activity around the shoulder complex, and this will have an impact on functional recovery in the upper limb. This is an area which is particularly difficult to address due to the complex nature of the neurological damage to the systems involved in postural control and efficient coordination of the patterns of movement necessary for upper limb function. As mentioned previously in this chapter, it is important to consider the role of postural stability for mobility and the role of the scapula in achieving range and refinement of movement of the upper limb. Importantly, McQuade and Schmidt (1998) found that when the upper limb was loaded, the ratio changed to 4. The thoracic alignment must also be considered as the scapula must travel around the thoracic cage to allow greater range of movement in the shoulder complex. A kyphotic thoracic spine or broad posterior aspect of the thorax will affect this journey and therefore the dynamics of scapula stability. This is characterised by force couples of paired muscles that control the movement or position of a joint or body part (Kibler 1998; Voight & Thomson 2000), maintaining maximal congruency between the glenoid fossa and the humeral head. Scapular stabilisation requires a force couple between the upper and lower portions of trapezius and the rhomboids coupled with serratus anterior, and then as the upper limb is elevated, activity of the lower trapezius and serratus anterior muscles is coupled with upper trapezius and rhomboids. Functional reach Although there are occasions when the upper limb is taken away from the body with no direct goal of using the hand, for example to wash under your upper limb with your other hand, many upper limb movements are for the purpose of transporting 162 Recovery of Upper Limb Function. When the task is pointing, all segments of the upper limb are controlled as one unit (Shumway-Cook & Woollacott 2007); however, when the task is to reach and hold an object, the hand is controlled independently of the other upper limb segments. Therefore, reach to grasp can be divided into two components, the transportation phase and the grasp phase.