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Involvement of the dorsal columns of the spinal twine, at or above the lumbar degree is also be|can be} a chance. The pathologically increased reflexes within the arms together with the presence of primitive reflexes are "upper motor neuron signs" and recommend involvement of the corticospinal tract above the level of the cervical spinal twine. The ataxic heel knee to shin maneuver, additionally factors to aberrant enter to the cerebellum, which comes by way of massive fibers. All of these findings recommend involvement at quantity of} levels of the nervous system. The imaging examine confirms involvement of myelinated areas within the spinal twine, particularly the dorsal columns and within the mind. Another clue on bodily analysis is the abnormal tongue and prematurely graying hair. The spinal twine is a tubular structure originating from the medulla of the mind and increasing by way of the bony backbone to the coccyx. Ascending sensory and descending motor white matter tracts are positioned peripherally; posterior columns govern joint position, vibration and pressure, lateral spinothalamic tracts pain and temperature, and ventral corticospinal tracts carry motor indicators. Vitamin B12 Deficiency Vitamin B12 deficiency normally presents as paresthesias within the palms and feet and lack of vibratory sense. There is a diffuse effect on the spinal twine, primarily the posterior lateral columns, explaining the early lack of vibratory sense. The structure of B12 is based on a corrin ring, which is analogous to the porphyrin ring present in heme, chlorophyll, and cytochrome. Dietary cobalamin (Cbl), obtained by way of animal foods, enters the abdomen certain to animal proteins. Absorption requires many components together with abdomen acid, R-protein, and intrinsic issue from parietal cells, and the distal 80 cm of the ileum for transport. In addition there are a variety of inborn errors of metabolism that may each interfere with the absorption and action of vitamin B12. This situation can progress to sensory loss, gait ataxia, and distal weak spot, notably within the legs. Specific findings on examination are lack of vibratory and joint position sense, weak spot, spasticity, hyperreflexia, and extensor plantar responses. The syndrome of sensory loss as well as|in addition to} spastic paresis related to pathologic lesions within the dorsal columns and lateral corticospinal tracts is referred to as subacute combined degeneration. There are additionally effects on other body methods, most conspicuously hematologic with the macrocytic anemia. Differential Diagnosis the manifestations of vitamin B12 deficiency are famous in Table 22­1. The differential analysis for progressive spastic paraplegia contains degenerative, demyelinating, infectious, inflammatory, neoplastic, dietary, and vascular disorders. Laboratory Confirmation Testing for vitamin B12 deficiency features a direct assay of the vitamin as well as|in addition to} wanting at the oblique effect of abnormal reactions leading to altered metabolite levels. In addition, the quantity of} organ methods and subsystems affected are extremely variable from affected person to affected person. Findings in these instances embrace modest expansion of the cervical and thoracic spinal twine and increased sign intensity on T2-weighted pictures, primarily within the dorsal columns and lateral pyramidal tracts. This normally entails intramuscular administration of the vitamin, first to build up shops after which on a monthly basis. Then a thousand µg/mo until trigger of|the purpose for} deficiency is corrected, or for all times within the case of pernicious anemia. Treatment can reverse or stop most if not all of the sequelae of vitamin B12 deficiency. Concentrated oral vitamin B12 Nasal vitamin B12 administration A food regimen excessive in pink meats Intramuscular B12 administration [22. Loss of pain and temperature sensation in extra of vibration and joint position sense C. Severe weak spot with spasticity and lack of all sensory modalities within the legs with a neurogenic bladder D. Loss of vibration and joint position sensation within the feet Positive Babinski signs Slowed nerve conduction velocities Increased sign on T2 imaging within the spinal twine Answers [22. Usually all limbs are concerned to some extent, and extreme involvement of the legs and not arms makes one consider an anatomic lesion within the spinal twine. In addition, vibration and joint position sense are normally concerned much more than pain and temperature. Nerve conduction research can present each demyelinating and denervation features in vitamin B12 deficiency. Intramuscular administration of vitamin B12 is the simplest method of treating this situation and can reverse or stop the neurologic features. Cobalamin (vitamin B[12]) in subacute combined degeneration and past: traditional interpretations and novel theories. As he looked at his textbook, he realized he was having problem reading by way of his left eye. He had no pain in his right eye and had no headache, dizziness, pain, or numbness. Considerations Optic neuritis normally is related to an acute, normally unilateral, lack of visual acuity or visual area or each. Ninety % of sufferers with optic neuritis have ocular pain, normally with eye motion. This disturbance can happen at any age but normally occurs in young adults, younger than 40 years old. Within a number of} weeks following onset of signs, approximately 90% of sufferers with optic neuritis expertise visual improvement to regular imaginative and prescient, or only marginal compromise. Some sufferers have residual deficits in contrast sensitivity, colour imaginative and prescient, depth notion, mild brightness, visual acuity, or visual area. The affected person in this case should see a doctor, have a cautious neurologic evaluation, and have blood research. Lumbar puncture for evaluation of attainable demyelinating disease might also be needed. Differential analysis: congenital, hereditary, infectious, inflammatory, infiltrative, ischemic, demyelinating (optic neuritis), and compressive etiologies. Optic neuritis: A basic term for idiopathic, inflammatory, infectious, or demyelinating optic neuropathy. Patients have signs due to compromise of the optic nerve, however the optic nerve appears regular. It considered one of the|is amongst the|is doubtless one of the} causes of acute lack of imaginative and prescient related to pain primarily due to demyelination and could be idiopathic and isolated. Epidemiology Whites of northern European descent are affected eight instances extra incessantly than blacks and Asians. The imply age of onset is approximately 30 years, with most sufferers presenting from 20­40 years of age. The situation is uncommon in youngsters and is normally related to a postinfectious or parainfectious demyelination. In sufferers older than 50 years of age, optic neuritis is much less frequent and could be mistaken for ischemic optic neuropathy, which is extra frequent in individuals in this age group. These signs normally happen abruptly but can worsen over the next a number of} days to weeks. Examination reveals decreased visual acuity or visual area compromise (or both), and an afferent pupillary defect. However, when mild is immediately shined into the normal eye, not only does the pupil of that standard eye constrict, however the (already dilated) pupil of the concerned eye constricts, signifying that the efferent output to the pupil of the concerned eye is regular. The etiology of optic neuritis is normally idiopathic or attributable to demyelinating disease. Sometimes, optic neuritis is attributable to other disorders, such as famous in Table 24­1 of case 24. Diagnosis the analysis of optic neuritis is normally made on scientific grounds, supplemented by ophthalmologic examination findings. The actual contribution of imaging within the setting of optic neuritis is made by imaging the mind, not the optic nerves themselves.

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Visceral pain is poorly localized and often related to salivation, nausea, vomiting, tachycardia, and sweating. Visceral pain additionally be} referred from the organ involved to a distant area of the body (referred pain). Narcotic analgesics, corresponding to morphine and codeine, cut back the affective response to pain and act on the opiate receptor websites in the cells in the posterior gray column of the spinal twine, nicely as|in addition to} different cells in the analgesic system in the mind. It is believed that opiates act by inhibiting the release of glutamate, substance P and different transmitters from the sensory, nerve endings. To minimize the unwanted side effects} of morphine given by systemic injection, the narcotic may be given by local injection immediately into the posterior gray horn of the spinal twine or by injection indirectly into the cerebrospinal fluid in the subarachnoid space. Long-term cancer pain has been handled successfully by the continuous infusion of morphine into the spinal twine. Treatment of Chronic Pain New methods, corresponding to acupuncture and electrical stimulation of the pores and skin, second are|are actually} getting used with success. The anticipation of the aid of pain is believed to stimulate the release of endorphins, which inhibit the traditional pain pathway. Relief of Pain by Rhizotomy or Cordotomy Surgical aid of pain has been used extensively in patients with terminal cancer. Posterior rhizotomy or division of the posterior root of a spinal nerve successfully severs the conduction of pain into the central nervous system. It is a comparatively easy process, but, sadly, the operation deprives the patient of different sensations apart from pain. Moreover, if the pain sensation is entering the spinal twine by way of multiple spinal nerve, it may be essential to divide several of} posterior roots. Thoracic cordotomy has been carried out with success in patients with severe pain originating from the lower abdomen or pelvis. Essentially, the operation consists of dividing the lateral Treatment of Acute Pain Drugs corresponding to salicylates can be utilized to cut back the synthesis of prostaglandin, a substance that sensitizes free nerve endings to painful stimuli. Local anesthetics,corresponding to procaine,can be utilized to block nerve conduction in peripheral nerves. Clinical Notes 167 spinothalamic tracts by inserting a knife into the anterolateral quadrant of the spinal twine. It is important to keep in mind that|do not forget that} the lateral spinothalamic fibers have originated in cells of the substantia gelatinosa in the reverse posterior gray column and that they cross the spinal twine obliquely and reach their tract in the white column three or four segments higher than their posterior root of entry. Cervical cordotomy has been carried out successfully in patients with intractable pain in the neck or thorax. The organism causes a selective destruction of nerve fibers at the level of entrance of the posterior root into the spinal twine, particularly in the lower thoracic and lumbosacral regions. The following symptoms and signs additionally be} present: (1) stabbing pains in the lower limbs, which may be very severe; (2) paresthesia, with numbness in the lower limbs; (3) hypersensitivity of pores and skin to touch, heat, and cold; (4) loss of sensation in the pores and skin of components of the trunk and lower limbs and loss of awareness that the urinary bladder is full; (5) loss of appreciation of posture or passive movements of the limbs, particularly the legs; (6) loss of deep pain sensation, corresponding to when the muscular tissues are forcibly compressed or when the tendo Achillis is compressed between the finger and thumb; (7) loss of pain sensation in the pores and skin in certain areas of the body, such because the side of the nostril or the medial border of the forearm, the thoracic wall between the nipples, or the lateral border of the leg; (8) ataxia of the lower limbs as the result of|the results of} loss of proprioceptive sensibility (the unsteadiness in gait is compensated to some extent by imaginative and prescient; nevertheless, useless of night|at midnight} or if the eyes are closed, the ataxia turns into worse and the particular person might fall); (9) hypotonia as the result of|the results of} loss of proprioceptive info that arises from the muscular tissues and joints; and (10) loss of tendon reflexes, owing to degeneration of the afferent fiber component of the reflex arc (the knee and ankle tendon jerks are lost early in the disease). The afferent neuron enters the spinal twine by way of the posterior root and synapses with the effector neuron or lower motor neuron in the anterior gray column. The lower motor neuron provides the muscle fibers by traveling by way of the anterior roots, the spinal nerves, and peripheral nerves. Normal muscle tone displays a certain resilience or elasticity, and when a muscle is passively stretched by shifting a joint, a certain diploma of resistance is felt. Normal muscle tone depends on by} the integrity of the monosynaptic reflex arc described above and the management superimposed on it by impulses acquired by way of the descending tracts from supraspinal levels. Note that muscle spindles are excitatory to muscle tone, whereas neurotendinous receptors are inhibitory to muscle tone. A sequence of different muscular tissues are made to contract for the purpose of reaching a goal. This would suggest that the descending tracts that influence the exercise of the lower motor neurons are driven by info acquired by the sensory techniques, the eyes, the ears, and the muscular tissues themselves and are affected additional by past afferent info that has been saved in the reminiscence. The limbic buildings seem to play a job in emotion, motivation, and reminiscence and should influence the initiation means of voluntary movement by their projections to the cerebral cortex. Most of the tracts originating in the brainstem that descend to the spinal twine are also receiving enter from the cerebral cortex. The corticospinal tracts are believed to management the prime mover muscular tissues, particularly those liable for the extremely expert movements of the distal components of the limbs. The different supraspinal descending tracts play a serious position in the easy basic voluntary movements and, nicely as}, bring about an adjustment of the muscle tone so that easy and speedy movements of the joints can take place. This influence is completed indirectly by fibers that project to the cerebral cortex and brainstem nuclei, which are the websites of origin of the descending tracts. Muscle Activity Muscle Tone Muscle tone is a state of steady partial contraction of a muscle and is dependent on the integrity of a monosynaptic reflex arc (see description on pp. The receptor Syphilitic lesion Pyramidal and Extrapyramidal Tracts the term pyramidal tract is used generally by clinicians and refers particularly to the corticospinal tracts. The term came into widespread usage when it was discovered that the corticospinal fibers turn into concentrated on the anterior a part of} the medulla oblongata in an area referred to because the pyramids. The term extrapyramidal tracts refers to all of the descending tracts aside from the corticospinal tracts. The nice toe turns into dorsally flexed, and the opposite toes fan outward in response to scratching the pores and skin alongside the lateral facet of solely real} of the foot. Normally, the corticospinal tracts produce plantar flexion of the toes in response to sensory stimulation of the pores and skin of solely real}. When the corticospinal tracts are nonfunctional, the influence of the opposite descending tracts on the toes turns into obvious,and a kind of withdrawal reflex takes place in response to stimulation of solely real},with the good toe being dorsally flexed and the opposite toes fanning out. This reflex is dependent on the integrity of the corticospinal tracts, which exert a tonic excitatory influence on the internuncial neurons. The cremaster muscle fails to contract when the pores and skin on the medial side of the thigh is stroked. The following clinical signs are present with lower motor neuron lesions: Flaccid paralysis of muscular tissues equipped. It happens more usually in the antagonist muscular tissues whose action is no longer opposed by the paralyzed muscular tissues. Normally innervated muscular tissues respond to stimulation by the appliance of faradic (interrupted) current, and the contraction continues lengthy as|so long as} the present is passing. Galvanic or direct current causes contraction only when the present is turned on or turned off. When the lower motor neuron is cut,a muscle will no longer respond to interrupted electrical stimulation 7 days after nerve part, though it nonetheless will respond to direct current. This change in muscle response to electrical stimulation identified as|is called|is named} the response of degeneration. Types of Paralysis Hemiplegia is a paralysis of one side of the body and includes the upper limb, one side of the trunk, and the lower limb. Lesions of the Descending Tracts Other Than the Corticospinal Tracts (Extrapyramidal Tracts) the next clinical signs are present in lesions restricted to the opposite descending tracts: 1. The lower limb is maintained in extension, and the upper limb is maintained in flexion. Exaggerated deep muscle reflexes and clonus additionally be} present in the flexors of the fingers, the quadriceps femoris, and the calf muscular tissues. The muscular tissues, on stretching, all of a sudden give method as a result of} neurotendinous organ-mediated inhibition. Usually, each units of tracts are affected to a variable extent,producing each groups of clinical signs. As the pyramidal tracts normally probably to|are inclined to} increase muscle tone and the extrapyramidal tracts inhibit muscle tone, the balance between these opposing effects shall be altered,producing different degrees of muscle tone. Relationship of Muscular Signs and Symptoms to Lesions of the Nervous System Abnormal Muscle Tone Hypotonia Hypotonia exists when the muscle tone is diminished or absent. It also happens in cerebellar disease as the result of|the results of} diminished influence on the gamma motor neurons from the cerebellum. Hypertonia Hypertonia (spasticity, rigidity) exists when the muscle tone is increased. It happens when lesions exist that involve supraspinal facilities or their descending tracts but not the corticospinal tract.

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In a given area of the nervous system, many different afferent neurons can launch quantity of} completely different neuromodulators that result on} the postsynaptic neuron. Such an arrangement can lead to a wide variety|all kinds} of responses,depending on the input from the afferent neurons. Electrical Synapses Electrical synapses are gap junctions containing channels that reach from the cytoplasm of the presynaptic neuron to that of the postsynaptic neuron: They are rare within the human central nervous system. The bridging channels permit ionic current move to take place from one cell to the other with a minimum of delay. In electrical synapses, the speedy spread of exercise from one neuron to another ensures that a group of neurons performing an identical operate act collectively. Functions of Astrocytes Astrocytes, with their branching processes, type a supporting framework for the nerve cells and nerve fibers. By masking the synaptic contacts between neurons, they might function electrical insulators preventing axon terminals from influencing neighboring and unrelated neurons. They may even type obstacles for the spread of neurotransmitter substances launched at synapses. Astrocytes seem to be able to|be succesful of|have the ability to} take up excess K ions from the extracellular area so that they might have an important operate throughout repetitive firing of a neuron. Astrocytes may function phagocytes by taking on degenerating synaptic axon terminals. Following the death of neurons outcome of} illness, astrocytes proliferate and fill within the areas beforehand occupied by the neurons, a course of known as replacement gliosis. It is possible that astrocytes can function a conduit for the passage of metabolites or uncooked supplies from blood capillaries to the neurons via their perivascular ft. The reality that|proven reality that} astrocytes are linked collectively by gap junctions would enable ions to move from one cell to another with out getting into the extracellular area. Astrocytes may produce substances that have a trophic affect on neighboring neurons. Recent analysis has suggested that astrocytes secrete cytokines that regulate the exercise of immune cells getting into the nervous system in illness. Finally, astrocytes play an important role within the construction of the blood-brain barrier. Here, the astrocyte processes terminate as expanded ft on the basement membrane of blood vessels (see p. Oligodendrocytes are incessantly found in rows alongside myelinated nerve fibers and surround nerve cell our bodies. Electron micrographs show the processes of a single oligodendrocyte joining the myelin sheaths of quantity of} nerve fibers. Functions of Oligodendrocytes Oligodendrocytes are liable for the formation of the myelin sheath of nerve fibers within the central nervous system, a lot as the myelin of peripheral nerves is formed from Schwann cells. This formation and upkeep of myelin round many of the axons of the central nervous system offers the axons with an insulating coat and significantly will increase the pace of nerve conduction alongside these axons (see p. Capillary with astrocytic foot processes Microglial cell Oligodendrocyte A Fibrous astrocytes B Astrocyte Microglial cell Figure 2-26 A: Photomicrograph of a piece of the grey matter of the spinal cord showing fibrous astrocytes. Nucleus of astrocyte Golgi apparatus Cell membrane Cytoplasm of astrocyte Dendrite Figure 2-28 Electron micrograph of a protoplasmic astrocyte within the cerebral cortex. Myelination begins at in regards to the 16th week of intrauterine life and continues postnatally until virtually all the most important nerve fibers are myelinated by the time the kid is strolling. Oligodendrocytes additionally surround nerve cell our bodies (satellite oligodendrocytes) and possibly have an identical operate to the satellite or capsular cells of peripheral sensory ganglia. From their small cell our bodies come up wavy branching processes that give off quite a few spinelike projections. Function of Microglial Cells Microglial cells within the regular brain and spinal cord seem to be inactive and are generally known as resting microglial cells. In inflammatory illness of the central nervous system, they become the immune effector cells. Here,they proliferate and become antigen presenting cells, which along with the invading T lymphocytes confront invading organisms. They are additionally actively phagocytic; their cytoplasm becomes crammed with lipids and cell remnants. They type a single layer of cells which might be} cuboidal or columnar in shape and possess microvilli and cilia. The cilia are sometimes motile, and their movements contribute to the move of the cerebrospinal fluid. Ependymocytes, which line the ventricles of the brain and the central canal of the spinal cord and are involved with the cerebrospinal fluid. Their adjacent surfaces have gap junctions, however the cerebrospinal fluid is in free communication with the intercellular areas of the central nervous system. Tanycytes, which line the floor of the third ventricle overlying the median eminence of the hypothalamus. These cells have lengthy basal processes that move between the cells of the median eminence and place finish ft on blood capillaries. The sides and bases of those cells are thrown into folds, and close to their luminal surfaces, the cells are held collectively by tight junctions that encircle the cells. The presence of tight junctions prevents the leakage of cerebrospinal fluid into the underlying tissues. Functions of Ependymal Cells Ependymocytes help within the circulation of the cerebrospinal fluid within the cavities of the brain and the central canal of the spinal cord by the movements of the cilia. The microvilli on the free surfaces of the ependymocytes would point out that they also have an absorptive operate. Tanycytes are thought to transport chemical substances Extracellular Space 59 Nucleus of microglial cell Neuron Golgi apparatus Lipofuscin granules Cytoplasm of microglial cell Figure 2-31 Dr. In this fashion,they might play a component within the management of the hormone production by the anterior lobe of the pituitary. Choroidal epithelial cells are concerned within the production and secretion of cerebrospinal fluid from the choroid plexuses. The extracellular area is in virtually direct continuity with the cerebrospinal fluid within the subarachnoid area externally and with the cerebrospinal fluid within the ventricles of the brain and the central canal of the spinal cord internally. The extracellular area additionally surrounds the blood capillaries within the brain and spinal cord. The plasma membrane of the endothelial cells of most capillaries is impermeable to many chemical substances, and this varieties the blood-brain barrier. B: Electron micrograph of ependymal cells lining the cavity of the third ventricle. The neuron consists of the cell body and its processes, the axons, and the dendrites. This would clarify the need for the transport of macromolecules down the axon from the cell body and likewise emphasizes the dependence of the axon on the cell body. The price of axoplasmic transport is inadequate to satisfy the release of transmitter substances on the nerve terminals. First, enzymes are current within the nerve terminals so as to to} synthesize the transmitters from amino acids derived from the extracellular fluid, and second, at some terminals, the transmitter is reabsorbed again into the terminal following its launch. The nerve cell becomes rounded off and swollen, the nucleus swells and becomes eccentrically placed, and the Nissl granules become dispersed towards the periphery of the cytoplasm. In the peripheral nervous system, section of an axon is adopted by attempts at regeneration, and reparative adjustments take place within the cell body. If the corticospinal tracts, for example, are destroyed by illness,the nerve cells that give rise to these axons degenerate and disappear completely. There is a vital exception to the axonal response of nerve cells described above. This occurs within the nerve cells of the posterior root ganglia of the spinal nerves. If the peripheral axons are sectioned, the nerve cells show degenerative adjustments; if, nonetheless, the central axons are sectioned or destroyed by illness, similar to tabes dorsalis, the nerve cells show no degenerative adjustments. Axonal Transport and the Spread of Disease Rabies, which is an acute viral illness of the central nervous system,is transmitted by the chunk of an infected animal. The virus is current within the saliva of the infected animal and following a chunk travels to the central nervous system means of|by means of|by the use of} axonal transport in both sensory and motor nerves. Herpes simplex and herpes zoster are viral ailments that additionally involve axonal transport to spread to completely different elements of the body. Axonal transport believed to play a job within the spread of the poliomyelitis virus from the gastrointestinal tract to the motor cells of the anterior gray horns of the spinal cord and the brainstem. Reaction of a Neuron to Injury the first response of a nerve cell to damage is loss of operate.

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Clinical Approach Meningiomas Meningiomas are often benign tumors, of mesodermic origin, hooked up to the dura. They generally are located alongside the sagittal sinus, over the cerebral convexities, and in the cerebellar-pontine angle. Microscopically, the cells are uniform with round or elongated nuclei, and a attribute tendency to whorl around each other. The typical scientific presentation is the sluggish onset of a neurologic deficit or a focal seizure; an surprising finding on a mind imaging can also be|can be} a common presentation. For lesions not amenable to surgery, native or stereotactic radiotherapy can ameliorate signs. In its most typical presentation, facial paralysis happens as a sudden sporadic cranial mononeuropathy. Generally, a pointed historical past and detailed bodily examination will get rid of many of the differential diagnosis. Likewise, the assorted causes of hearing loss may be eradicated by a cautious bodily examination. Disease processes, corresponding to otitis media, cholesteatoma, and otosclerosis, may be eradicated by cautious historical past and bodily examination with tuning fork tests. Occasionally, sufferers have mixed hearing loss, or a combination of conductive and sensorineural losses in a single ear. Furthermore, the audiogram may give a clue relating to the presence of retrocochlear hearing loss or hearing loss attributable to diseases proximal to the cochlea. Tests that might point out retrocochlear pathology embody speech discrimination, acoustic reflexes, and reflex decay. This take a look at measures the electrical exercise throughout the auditory pathway; and as such, this take a look at helps to evaluate retrocochlear causes of hearing loss. Waves which are be} absent or delayed are indicative of pathology at that time in the auditory pathway. Additionally, newer know-how, corresponding to fat suppression and diffusion weighted imaging may help to determine pathology. Current Diagnosis and Treatment in Otolaryngology Head & Neck Surgery, New York: McGraw-Hill; 2004, p 158. Often, both imaging modalities are mixed to understand the full extent of the disease process throughout the skull base. Treatment A therapy plan have to be created as soon as} a tumor in the cerebellopontine angle is recognized. The varied obtainable therapy choices have to be mentioned with the affected person; the ultimate decision of therapy course have to be determined between the affected person and the doctor. At least three choices should be considered in managing tumors in the posterior fossa: remark and serial imaging, stereotactic radiosurgery, or typical surgery. Some of these choices could be unavailable or unwise for sure tumor types or tumor dimension. Removal of tumor permits for final pathologic diagnosis, may right neurologic deficits, and may prevent further complications attributable to continued tumor development. A relatively new (although greater than 20 years experience) sort of remedy involves using of} directed, focus radiation beam to the tumor. Several different proprietary units have been developed to destroy or minimal of|no less than} prevent development of tumors. The expertise with stereotactic radiotherapy is probably greatest with acoustic neuroma, because of|as a end result of} that tumor is the most typical mass found in the cerebellopontine angle. Stereotactic radiotherapy has been found to be very effective at managing small to medium sized tumors (up to three cm). The drawback with stereotactic radiotherapy is the potential for continued development, and this development does happen in a big number of sufferers. Unfortunately, surgery following stereotactic radiotherapy is technically harder, and surgical outcomes are not as good as good} as|inferior to|not so good as} from surgery alone. By far, the most typical tumor in the cerebellopontine angle is the acoustic neuroma. Detailed bodily examination is a vital prerequisite before any diagnostic tests are ordered. Recent proof means that trigger of|the reason for} Bell palsy is probably recrudescence of herpes simplex virus. Every affected person should have a cautious examination to rule out different causes of facial paralysis, corresponding to those diagnoses listed. Bell palsy is a diagnosis of exclusion, and sufferers with facial paralysis require a cautious otologic and cranial nerve examination. Patients that current with a criticism associated to one cranial nerve require analysis of all cranial nerves. He describes the complications as occurring primarily over the right frontal temporal area and describes it as "dull" in nature. Additionally, he has had difficulty focusing and concentrating on tasks at hand, corresponding to reading the newspaper or half in} playing cards. His wife states that he has been extra irritable, moody, and "not himself" for 1 month. He is oriented to individual, time, location, and state of affairs, although he turns into upset during the examination. Motor energy testing is normal apart from questionable weak spot in the left finger extensors. The deep tendon reflexes are normal apart from a Babinski signal current on the left. His wife stories persona adjustments and the affected person himself acknowledges mood disturbances. His examination is notable for decreased arm swing on the left, questionable weak spot of the left finger extensors, and a left Babinski signal. Most probably diagnosis: Metastatic mind tumor affecting the right cerebral hemisphere. Next step in remedy: Corticosteroids and anticonvulsants are started immediately while ready for surgical analysis. Considerations this 59-year-old in any other case healthy man presents with unilateral dull complications related to nausea and persona adjustments. His bodily examination suggests delicate left-sided weak spot most likely from a proper hemispheric lesion given the left Babinski signal. Based on the historical past and examination the most likely diagnosis is a proper hemispheric mass lesion. Taking it one step further the historical past of weight loss and cough are regarding for a lung cancer. A chest x-ray will reveal that he has a big proper upper-lobe mass lesion highly suggestive of lung cancer. Corticosteroids corresponding to dexamethasone should be started as this reduces edema and capillary permeability. Approximately 40% of sufferers with metastatic mind tumors will expertise a seizure. In this explicit case the affected person has a hemorrhage, which is thought to be epileptogenic. Babinski signal: Extension of the massive toe adopted by abduction of the other toes when the lateral sole of the foot is stimulated. Midline shift: Movement of a cerebral hemisphere to the opposite aspect secondary to intracranial swelling. This may cause compression of the lateral ventricles and contribute to further elevated intracranial pressure. Herniation: Downward displacement of the cerebral hemisphere from increased intracranial pressure. Clinical Approach Metastatic mind tumors can arise from primary systemic cancers that spread to the leptomeninges, mind parenchyma, calvaria, or dura. In the United States roughly a hundred and fifty,000 new instances per 12 months of metastatic mind tumors are reported. Approximately 66% of metastatic mind tumors go to the parenchyma with almost 50% of these being a solitary lesion.

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Intellectualization: this refers to the act of transferring emotional concern in to the intellectual sphere: for example, a younger man could use intellectualization as methodology of avoiding confrontation with his fiancй if she modified her thoughts about wishing to marry him. In abstract, protection mechanisms are categorized in numerous methods: from wholesome to unhealthy, refined to primitive, most frequent to least incessantly used. Such lists of protection mechanisms have been developed after in depth analysis of several of} psychological sociological and psychiatric nursing texts and are based mostly on the diploma of persona disintegration and actuality distortion that may happen when the mechanisms are used incessantly. Defense mechanisms are categorized in numerous methods, health to unhealthy, refined to primitive; most incessantly used to least incessantly use. After in depth and several of|various|a variety of} other|and several of} other} psychological, sociological and psychiatric nursing analysis. In basic persona is the sum of all somatic process plus psychological phenomena. Psychological phenomena equate to psychological high quality combined with psychological process 149 Psychiatric Nursing Psychological high quality Psychological high quality contains the following options: Character Interest Habit Skills Attitudes Ability Knowledge Motives, and so on. Psychological process Psychological processes embrace Sensation Attention Feelings Memory Thinking Will Cognition, and so on. Personality disorder Personality disorder is described as a non-psychotic sickness characterized by maladaptive behavior, which the individual utilizes to fulfill his or her needs and produce satisfaction to self. The individual denies the maladaptive behavior s/he displays; such behavior has turn out to be a lifestyle for him. Minor stress is poorly tolerated, leading to increased inability to address anxiety 4. Ego functioning is unbroken but could also be} defective due to this fact, it could not control impulsive actions of the id 5. The individual is in contact with actuality though s/he has problem dealing with it 6. Psychiatric help hardly ever is sought end result of|as a result of} the individual is unaware or denies that his or her behavior is maladaptive. Biological predisposition could result from improper diet neurological defects, and genetic predisposition 2. A weak superego could result within the incomplete growth of or lack of a conscience. A individual with immature superego will feel no guilt or regret for socially unacceptable behavior 151 Psychiatric Nursing 5. The drive for prestige, energy and possession exploitative manipulative behavior 6. Urban societies such as internal cities are characterized by a low diploma of social interplay, thereby fostering the development of deviant behavior. Clusters of Personality Disorders Cluster A Paranoid persona disorder the defining trait of paranoid persona disorder is suspiciousness. Suspiciousness is some thing that we all feel in sure situations and with sure people, usually for good reasons. However, paranoid personalities feel suspiciousness in almost all situations and with almost all people, often for very flimsy reasons. Schizoid persona disorder Schizoid persona disorder is outlined by a basic eccentricity, a desire for social isolation. According to present considering, schizoids are poor within the capacity to expertise social warmth or any deep emotions and unable to form attachments. Schizoid personalities hardly ever marry, have few friends (if any), appear detached to praise or criticism from others, and prefer to be alone. They could also be} fairly successful of their work, if it is an occupation that calls for little social contact. Schizotypal persona disorder can also present magical considering, claiming that they inform the future run}, read the thoughts of others, and so on. The disorder is more common within the households of identified schizophrenics than within the inhabitants at massive. A history of illegal or socially disapproved activity, starting earlier than the age of fifteen and persevering with into maturity 2. Failure to present consistency and responsibility in work, sexual relationships, parenthood or financial obligations 3. Irritability and aggressiveness, together with not simply avenue brawls but usually abuse of spouse and youngsters 4. Instead, they tend to operate in an aimless, thrill-seeking fashion touring from city to city with no goal in thoughts, falling into mattress with anybody out there, stealing a pack of cigarette or a car, depending on what seems easiest and most gratifying in the meanwhile 5. Additionally, experiences an unfulfilled want for intimacy is liable to develop the disorder. Impulsive, unpredictable behavior that may involve playing, shoplifting, and intercourse. Unstable have an effect on} that shifts from regular moods to durations of depression, dysphoria (unpleasant mood), or anxiety 6. Histrionic persona disorder the essential function of histrionic persona disorder is selfdramatization: the exaggerated show of emotion. Such emotional a hundred and fifty five Psychiatric Nursing shows are often clearly manipulative, geared toward attracting consideration and sympathy. Initially, upon assembly a new new} individual, a person with this disorder will appear heat and affectionate. The histrionic persona resembles a caricature of the most sexist image of femininity: vain, shallow, self dramatizing, immature, over-dependent and egocentric. Narcissistic persona disorder the essential function of narcissistic persona disorder is a grandiose of self­importance, usually combined with periodic emotions of inferiority. In basic people with narcissistic persona disorder want fixed admiration, expect favors from others without reciprocating, and react to criticism with conceitedness and contempt. Cluster C Avoidant persona disorder Avoidant persona disorder is marked by social withdrawal. They typically feel depressed and indignant at themselves for their social failure, and these emotions further erode their self-esteem and create a vicious circle. Obsessive compulsive persona disorder Obsessive compulsive persona disorder is characterized by an extreme preoccupation with trivial particulars at price of|the price of} each spontaneity and effectiveness. Obsessive compulsive personalities are so taken up with the mechanics of effectivity: organizing, following rules, making lists and schedules that they stop to be environment friendly, for they by no means get something essential done. Passive aggressive persona disorder the essential attribute of passive aggressive persona disorder is an not directly expressed resistance to calls for made by others. Yet they by no means openly state their refusal; quite they covertly sabotage 157 Psychiatric Nursing the job by procrastinating dawdling, making errors or another means. Passive aggressive personalities most likely to|are inclined to} have troubled marriages and checkered job information. The diagnosis should be given to solely to those who present pervasive and longstanding passive-aggressive behavior, each on job and at house. Dependent Personal Disorder the dependent individual lacks self-confidence and is unable to operate in an impartial position. In an try to avoid any likelihood of changing into self sufficient, the individual permits others to turn out to be liable for his or her life, letting them make all their major choices. He or she avoids making calls for on others to avoid jeopardizing any existing dependent relationships that meet his or her needs. Social relationships and occupational functioning could also be} impaired dependent needs. Intense discomfort is skilled by a dependent one that is left alone for a while. Table 9: Examples of nursing diagnosis and nursing Interventions for persona disorder Nursing Diagnoses Ineffective particular person coping: hostility or performing out Nursing Interventions Recognize signs of increasing agitation. Attempt to enrich behavior by offering a safe environment for performing out hostility, offering distraction, or assigning constructive 159 Psychiatric Nursing tasks. Face but maintain a distance from the patient when talking, Avoid belong overly friendly. Be selective in utilization of} nonverbal gestures whereas talking with or near the patient. Ineffective particular person coping owing to increased stress or anxiety Provide a relaxed, quiet atmosphere to lower excitatory environmental stimuli. A non psychotic sickness characterized by maladaptive behavior, which the individual utilizes to fulfill his or her needs and produce satisfaction to self known as as} persona disorder.

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As faculty students, preservice educators have little alternative to see the adults in their lives as peers. This relationship presents them with the chance to have their concepts validated by professionals within the field. Working instantly with the intervention specialist, preservice art educators are supplied quick feedback for methods to enhance their instruction. For the intervention specialist new concepts presented by the preservice art academics invigorate even the more skilled educators. Often, concepts for engaging activities are a product of the dialogue between the pre-service educator and the intervention specialist. The preservice art educators design their instructing setting to meet the wants of the targeted students. By instantly meeting the wants of these students, their instructing is effective and significant. Organizing area for selection of|quite so much of|a wide selection of} classroom activities will increase the potential to turn out to be more active members in their very own studying (Guay, 2006). Importance of well-organized lesson plans, adaptive tools, and private flexibility. One of the most priceless lessons that the preservice academics learn is the necessity of being nicely organized with their plans. They learn to develop educational tools that might be effective in instructing their lessons. They learn to take the time to cut out aspects of the paintings to assist the scholars give attention to} the key thing} components of the piece. Adaptive tools are generally out there from the intervention specialist and generally are created by the preservice educators themselves. While traditional tools similar to adaptive scissors are sometimes out there within the classroom, the pre-service educator may need to make handles for paintbrushes or create different tools for painting similar to paint rollers. For some students, participation in art class is possible outcome of|as a outcome of} the preservice academics have recognized the need for some students to take a break. They perceive the desire and motivation of the scholars to return and finish their pieces. It can also be|can be} essential to retain good humor when situations within the classroom, or with a person scholar, make all these additional efforts ineffective. Benefits to the Students the introduction of art to the curriculum as taught by the preservice educators, supplies a number of} tangible benefits. Feedback supplied by the intervention specialists focuses on the next outcomes. Students frequently make impartial decisions related to their selection of colour, media, and the content material of their work when creating personal tales. Some of the notorious myths identifying people with autism as lacking individuality, and being unable to make eye contact and show emotion, are dispelled. Each scholar participates in his/her art expertise and creates with freedom, enthusiasm, and individuality. The capability of the scholars to remain attentive throughout art class is prolonged past what happens throughout different activities. Appropriate social abilities and positive conduct were displayed all through every lesson. Demonstrated personal communication connecting paintings creation to personal experiences. Memories, vacations, family relationships and interests present the fodder for private tales created in images. During one lesson, students were given a questionnaire to take house concerning current family travels. Inspired by her memories of this journey the student included a precise drawing of the Broadway theater her family attended. This paintings nonetheless hangs within the classroom and every so often the student will admire her work and provoke dialog about her journey with her family. In one other instance personal communication was pushed past what had occurred before. A pre-service educator asked her students to select their favorite animal using the signal for "favorite. Conclusion the job of a preservice art educator is to continue to work toward mastery. Essential in their growth and growth is the assist of skilled professionals to present guidance and an setting to practice their instructing. While all academics are very busy and have many calls for on their time, intervention specialists eagerly accepted the invitation to take part on this program. Art Partners particularly targets internal metropolis classrooms serving students with an array of special studying wants in intellectual, bodily, emotional, cultural, and social areas of growth. In this paper, the time period special studying wants refers to any scholar with unique studying traits and necessities that necessitate educational and curricular adaptations so as to to} maximize access to studying and guarantee scholar success. Each semester all through the academic 12 months, groups of students (referred to as "scholar academics") in collaboration with their course instructor/program founder (author) plan and facilitate weekly art experiences for kids and youths at the participating organizations. For instance, one group has applied the Art Partners program for a high school special training class, while one other worked with elementary school kids attending an internal metropolis school. Art Partners has recently expanded to embody service to a bunch of elementary and middle school students attending an after school program. In addressing the need for a field-based method to trainer training, the student trainer groups are accompanied by their instructor/program coordinator who, as an active member of every group, serves as model trainer, co-researcher, and mentor, providing on-the-spot guidance. With enter from the final and special training academics participating in Art Partners, scholar academics and their teacher collaborate to develop a curriculum of thematic items of examine with sequential lessons designed to promote art and general/special training targets and goals. Following every session with students, the student academics and their teacher meet to assess outcomes, determine issues, suggest solutions, and plan curriculum. This meeting additionally supplies scholar academics with an opportunity to specific their quick personal responses to working with students, an opportunity not usually out there on campus. A main objective of those occasions is to improve public awareness and appreciation for the exceptional abilities of urban students with special studying wants and the importance of supporting inclusive arts programming for all students. The Art Partners program has served students in self-contained and inclusive classrooms since 1994, and was initiated in response to recognized instructional and social wants in our urban group, notably categorised with disabilities and those thought of at risk. It operates underneath the assumption kids can learn, and kids can discover personal which means in art expertise. An equally essential premise upon which this system was founded is the concept of art as prevention. Regular participation in significant art experiences fosters the event of positive self-concepts and socialization abilities in kids (Sutherland, Waldman, & Collins, 2010; Coholic, Eys, & Lougheed, 2012). Thus, kids at risk and those with special studying wants can develop with greater confidence and objective, equipped to stand up to unfavorable pressures and make higher personal decisions when confronted with robust choices. The philosophical underpinnings and targets of this system are: · To promote greater collaboration amongst greater training and the group, faculty college and students, and academics and students in urban settings serving a diverse scholar inhabitants. Such an understanding must come from greater involvement between greater training and the urban group, particularly in our trainer training programs. In an exit survey of their scholar academics, Edwards, Carr and Seigel (2006) found that preservice students required a more in-depth expertise so as to to} more competently meet the wants of various learners, together with students with disabilities. Inclusion advocate Mara Sapon-Shavin takes the dialogue to one other stage, proposing that we eliminate boundaries between general training and special training, "changing such programs with inclusive trainer training fashions that worth range" (2001, p. Villa and Thousand (2003) indicated that trainer training candidates must learn to turn out to be collaborative group members and develop the mandatory abilities that will enable them to work with colleagues to develop diversified studying alternatives who vary in interests, studying types, and intelligences. Furthermore, these researchers found in a examine of 600 educators, that collaboration "emerged as the one variable that predicted positive attitudes toward inclusion on the half of} general and special educators" (p. This can occur on each personal and professional levels, from face to face interactions with students, academics and parents, to the establishment of urban classrooms serving various learners. These classrooms turn out to be living laboratories the place faculty students, college, and college academics can collaborate in motion research efforts to analyze behaviors and various classroom situations, determine issues, and suggest and implement solutions. Nationally, some forty-four p.c of students in elementary and secondary colleges right now are students of colour while our instructing force stays predominately white (Center for Public Education, 2007). Other forms of range in our colleges embody students who: are kids of immigrants, are biracial and multiracial, stay in poverty, and who determine themselves as gay, lesbian or bisexual (Center for Public Education, 2007). In addition, the inclusion movement has resulted in one other main shift within the current school inhabitants the place three out of 4 students recognized with disabilities spend half or all of their day in general training classes, studying alongside their peers without disabilities (National Education Association, 2012). These demographics are reflected in Buffalo the place the Art Partners program takes place.

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The axons of the third-order neurons within the ventral posterolateral nucleus of the thalamus now pass by way of the posterior limb of the interior capsule and the corona radiata to reach the somesthetic area within the postcentral gyrus of the cerebral cortex. The contralateral half of the body is represented as inverted,with the hand and mouth situated inferiorly and the leg situated superiorly, and with the foot and anogenital area on the medial surface of the hemisphere. The position of the cerebral cortex is decoding the quality of the sensory info at the degree of consciousness. Pain is a sensation that warns of potential injury and alerts the individual to keep away from or deal with it. Fast pain is described by the patient as sharp pain, acute pain, or pricking pain and is kind of|the sort of} pain felt after pricking the finger with a needle. Fast pain is experienced by mechanical or thermal types of stimuli, and gradual pain could also be} elicited by mechanical, thermal, and chemical stimuli. Many chemical substances have been found in extracts from damaged tissue that may excite free nerve endings. These embody serotonin; histamine; bradykinin; acids, such as lactic acid; and K ions. The individual ought to conscious of|concentrate on|pay consideration to} the existence of stimuli that, if allowed to persist, will result in tissue destruction; pain receptors have little or no adaptation. Functions of the Ascending Tracts 147 Conduction of Pain to the Central Nervous System Fast pain travels in peripheral nerves in large diameter A delta axons at velocities of between 6 and 30 msec. The fast pain impulses reach consciousness first to alert the individual to hazard so that an appropriate protecting response could happen. Conduction of Pain within the Central Nervous System the afferent pain fibers enter the spinal cord, for instance, within the posterior roots of a spinal nerve and terminate predominantly within the superficial layers of the posterior gray horn. The major excitatory neurotransmitter launched by the A delta fibers and the C fibers is the amino acid glutamate. Whereas glutamate is a fast-acting localized neurotransmitter, substance P has a gradual release and diffuses widely within the posterior horn and might influence many neurons. The preliminary sharp,pricking,fast-acting pain fibers stimulate the second-order neurons of the lateral spinothalamic tract. The burning, aching, slow-acting pain fibers additionally stimulate the secondorder neurons of the lateral spinal thalamic tract within the posterior gray horn and ascend with the axons of the fast-acting pain fibers. It is now believed, nonetheless, that many of the incoming gradual fibers to the spinal cord take part in further relays involving a number of} neurons within the posterior horn before ascending within the spinal cord. The repeated arrival of noxious stimuli by way of the C fibers within the posterior gray horn throughout severe injury ends in an increased response of the second-order neurons. This winding up phenomenon is attributed to the discharge of the neurotransmitter glutamate from the C fibers. For example, in a patient with osteoarthritis of the hip joint,the individual can solely vaguely localize the pain to the hip area and to not the precise web site of the illness. This could also be} explained by the fact that|the reality that} fast pain fibers directly ascend the spinal cord within the lateral spinothalamic tract, whereas the gradual pain fibers take part in quantity of} relays within the posterior gray horn before ascending to larger facilities. As the result of|the outcomes of} analysis using the positron emission tomography scan,the postcentral gyrus,the cingulate gyrus of the limbic system, and the insular gyrus are sites concerned with the reception and interpretation of the nociceptor info. The postcentral gyrus is answerable for the interpretation of pain in relation to past experiences. The cingulate gyrus is involved with the interpretation of the emotional facet of pain, whereas the insular gyrus is concerned with the interpretation of pain stimuli from the interior organs of the body and brings about an autonomic response. The reception of pain info by the central nervous system may be modulated first within the posterior gray horns of the spinal cord and at other sites at larger levels. Pain Control within the Central Nervous System the Gating Theory Massage and the application of liniments to painful areas within the body can relieve pain. The strategy of acupuncture, which was discovered a number of} thousand years ago in China, beneficial in relieving pain. Low-frequency electrical stimulation of the skin additionally relieves pain in sure circumstances. It was instructed that at the web site where the pain fiber enters the central nervous system,inhibition might happen by the use of connector neurons excited by large, myelinated afferent fibers carrying info of nonpainful touch and strain. The extra tactile stimulation produced by therapeutic massage, for instance,"closed the gate" for pain. Once the nonpainful tactile stimulation ceased,nonetheless,"the gate was opened," and knowledge on the painful stimuli ascended the lateral spinothalamic tract. Although the gate principle could partially explain the phenomena, the analgesia system might be involved with the liberation of enkephalins and endorphins within the posterior gray columns. The Analgesia System Stimulation of sure areas of the brainstem can cut back or block sensations of pain. These areas embody the periventricular area of the diencephalon, the periaqueductal gray matter of the midbrain,and midline nuclei of the brainstem. It is believed that fibers of the reticulospinal tract pass all the way down to} the spinal cord and synapse on cells concerned with pain sensation within the posterior gray column. The analgesic system can suppress both sharp pricking pain and burning pain sensations. Recently, two compounds with morphinelike actions, referred to as the enkephalins and the endorphins, have been isolated within the central nervous system. These compounds and serotonin serve as neurotransmitter substances within the analgesic system of the brain, and so they could inhibit the discharge of substance P within the posterior gray column. Other Terminations of the Lateral Spinothalamic Tract It is now typically agreed that the fast pain impulses travel directly up to as} the ventral posterolateral nucleus of the thalamus and are then relayed to the cerebral cortex. The majority of the gradual pain fibers within the lateral spinothalamic tract terminate within the reticular formation, which then prompts the complete nervous system. It is within the lower areas of the brain that the individual becomes conscious of the continual, nauseous, struggling sort of pain. These branches travel for a distance of 1 or two segments of the spinal cord, contributing to the posterolateral tract of Lissauer. It is believed that these fibers of the first-order neuron terminate by synapsing with cells within the substantia gelatinosa group within the posterior gray column. The axons of the second-order neuron now cross very obliquely to the alternative side within the anterior gray and white commissures within a number of} spinal segments and ascend within the reverse anterolateral white column because the anterior spinothalamic tract. As the anterior spinothalamic tract ascends by way of the spinal cord, new fibers are added to the medial facet of the tract. Thus, in Functions of the Ascending Tracts 149 the higher cervical segments of the cord,the sacral fibers are mostly lateral and the cervical segments are mostly medial. As the anterior spinothalamic tract ascends by way of the medulla oblongata, it accompanies the lateral spinothalamic tract and the spinotectal tract, all of which type the spinal lemniscus. The spinal lemniscus continues to ascend by way of the posterior a part of} the pons, and the tegmentum of the midbrain and the fibers of the anterior spinothalamic tract terminate by synapsing with the third-order neuron within the ventral posterolateral nucleus of the thalamus. The axons of the third-order neurons within the ventral posterolateral nucleus of the thalamus pass by way of the posterior limb of the interior capsule. The sensations may be solely crudely localized, and little or no discrimination of intensity is feasible. Discriminative Touch, Vibratory Sense, and Conscious Muscle Joint Sense Posterior White Column: Fasciculus Gracilis and Fasciculus Cuneatus the axons enter the spinal cord from the posterior root ganglion and pass on to the posterior white column of the identical side. The descending branches pass down a variable number of segments, giving off collateral branches that synapse with cells within the posterior gray horn, with internuncial neurons, and with anterior horn cells. It is obvious that these short descending fibers are involved with intersegmental reflexes. The lengthy ascending fibers may finish by synapsing with cells within the posterior gray horn, with internuncial neurons, and with anterior horn cells. Many of the lengthy ascending fibers travel upward within the posterior white column because the fasciculus gracilis and fasciculus cuneatus. The fasciculus gracilis is present throughout the length of the spinal cord and accommodates the lengthy ascending fibers from the sacral, lumbar, and lower six thoracic spinal nerves. The fasciculus cuneatus is situated laterally within the higher thoracic and cervical segments of the spinal cord and is separated from the fasciculus gracilis by a septum. The fasciculus cuneatus accommodates the lengthy ascending fibers from the higher six thoracic and all of the cervical spinal nerves.

References:

• https://www.mskcc.org/sites/default/files/node/4931/documents/osteoporosis.pdf
• https://hijamacups.com/books/4-investigation-effect-cupping-therapy-treatment-anterior-knee-pain.pdf
• https://www.aapd.org/globalassets/media/publications/archives/kupietzky-15-04.pdf