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Examiners of such imbalances) a variety of validated methods indicated whether leg length was equal zenegra 100mg visa, or if there have been described and assessed for accuracy best 100mg zenegra. Subjects were One relatively inaccurate method involved palpa- assessed with no heel insert and with heel inserts of tion of the iliac crests of the standing subject, in 0. Each insert interven- order to estimate the extent of the asymmetry (Clarke tion was examined twice on each subject by each 1972). In depend on examination findings, and only one of the study with higher reliability, the simulated leg- those on palpation. In the study with useful in predicting the efficacy of manipulation, they the poor reliability, the simulated leg-length differ- do not assist the practitioner in answering the ques- ences were 0. Aside from the differences already highlighted, this In contrast, Fritz et al (2004) have identified six vari- scenario provides good rationale for the use of multi- ables that predict non-response (negative outcome) to ple assessment methodologies in order to provide a manipulation in treatment of patients with low back comprehensive and accurate picture. Longer than 3 weeks’ duration of symptoms adjust for simulated leg-length discrepancy or uneven 2. No hypomobility on spinous process explanation as to why Gibbon’s study was apparently springing unfruitful. Reduced hip rotation range crest heights and shifts in the frontal plane, they may 5. A negative Gaenslen sign (pain provocation test with the patient supine, one hip taken Are there indicators that can suggest into full flexion and the other into successful palpation outcomes? The test is Is the focus on inter-examiner reliability the best way positive if pain is reported in the sacroiliac joint to evaluate the usefulness or otherwise of palpation (and/or thigh) on the side of the and assessment prior to treatment? Gemmell & Miller (2005) note that, in recent years, there has been a trend away from inter-examiner reli- Using such protocols would seem to offer useful ability studies towards a focus on outcome-based information as to who is more likely and who is less investigations (Borge et al 2001, Flynn et al 2002). For example, Flynn et al (2002) were able to identify However, as in the case of the positive predictors patients with low back pain that was more likely than above, they do not assist the practitioner in making a not to respond to manipulation. Duration of symptoms less than 16 days Such predictive methods should not result in 2. Hypomobility on lumbar spinous springing be applied with confidence once skills have been 5. Chapter 5 • Assessment and Palpation: Accuracy and Reliability Issues 117 The opinions of experts regarding the above three essential elements, as well as a deeper understanding of the problem that is As mentioned earlier, a team of experts were assem- inclusive of the patient’s perspective. While this model bled in 2002 to evaluate the problems highlighted of diagnosis is rapid, if employed too early there is a by studies that showed poor palpation outcomes chance that the pattern recognition model may be (Bullock-Saxton et al 2002). Poor inter-observer the conclusions drawn by the authors are confined to reliability of palpatory findings should not be consid- the limits of the study. Much research has been pub- ered as necessarily devaluing the use of palpation as lished that throws a negative light on clinical practice a diagnostic tool. This has resulted different ways to different palpatory cues, formulat- in ramifications that go far beyond clinical practice to ing their own manipulative prescription based upon stakeholders in the health care system whose agenda individual experience. I am not yet convinced that there Poor research design, use of inappropriate statistical is sufficient evidence in the current literature to methods and unsubstantiated conclusions have pre- condemn the use of some commonly taught palpation vented musculoskeletal medicine from drawing sub- techniques. Even where diagnosis is not predicated upon the use of palpatory cues, palpation is still criti- • Context specific, i. The authors would contend that highly refined pal- Conversely, experts in clinical practice tend to use a patory skills are essential for the development of the pattern recognition/inductive reasoning model that psychomotor skills necessary to perform manual has superseded the hypothetical deductive approach. From this, practitioners formed a motion will be constant from moment to moment for provisional diagnosis to explain their patient’s com- that individual. New diagnostic tests came 2000) in the pelvic girdle has shown that the stiffness to us in the 1980s with big hopes for the definitive value, directly related to range of motion (Buyruk answers to pain and suffering. The appropri- is under (at that moment) and therefore what the ately trained manual therapist, skilled in identifying available range of motion should be. To be • force closure (myofascial activation and meaningful in developing a treatment plan, these relaxation tests) methods all require subjective information from the • motor control (sequencing or timing of muscle patient and then subjective interpretation on the part activation) of the examiner. Such interpretation is clearly influ- • influence of the emotional state on resting enced by the level of experience and training of the muscle tone. The Nobel prize-winning Chapter 5 • Assessment and Palpation: Accuracy and Reliability Issues 119 microbiologist Rene Dubos said, ‘the measurable develop the sensitivity to detect differences in texture, drives out the useful’. To abandon a tool because it movement and muscle activity, in a stepwise fashion, is hard to measure does not make much sense when starting with simple tasks and gradually progressing we are in a field where over 85% of our patients are to more difficult tasks. There is some recent evidence labeled as having a ‘non-specific disorder’ (Bigos et al which suggests that starting with non-biological 1994, Erhard & Delitto 1994). If we were able to iden- materials may be an effective starting point for stu- tify, specifically, what was wrong with most back pain dents to be able to detect levels of stiffness in isolation patients with non-palpation tools and thereby deter- from the other nuances of biological tissue (Nicholson mine the most appropriate treatment, then it would et al 1997). However, in our field, we’re what I call the Three Essential Questions of Diagnosis just beginning to crawl. While we strive to establish (Murphy 2000): proof as our goal for creating a ‘best practice’ scenario, • Does this patient have a potentially serious or we are a long way from being able to reasonably life-threatening condition? The patient examination is too complex to measure with a gold standard instru- a multilevel process that begins when the practitioner ment, like seeing with photography or hearing with first lays eyes on the patient and continues through tape recorders, this does not make palpation useless.

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The specific focus of this chapter is on the type of language and the communicative resources employed by medical expert witnesses − professionals with a spe- cialized knowledge zenegra 100mg for sale, doctors and physicians – who are required to assist and provide their expertise in criminal trials discount zenegra 100 mg mastercard, for the admini- stration of justice. Due to their education and experience, expert wit- nesses can provide the court with assessments or opinions within their area of competence which would not be available or even accessible to other professionals in court, such as the lawyers and the judge, on the one hand, or to the jury and the public in general, on the other. Maci / Maurizio Gotti (covering a time span from 1900 to 1913), the chapter focuses on the narratives involving doctors, pathologists, physicians and practitioners with the specific purpose of finding out how items of the medical jargon are embedded in the legal discourse and used as a medical testimony giving a specialist and authoritative account of the physical examination of the victims and of the murderers themselves. The analysis stems from the assumption that the English versions of such sites − containing useful information about common infectious diseases or vaccination cam- paigns − are addressed to foreign-language-speaking users (mostly residents rather than tourists). From a discourse analytical perspective, and via a specific attention paid to how the language is used at a gram- matical and lexical level, this chapter examines, on the one hand, the type of information that is provided and the way it is linguistically represented, and, on the other, the way the targeted social groups are represented when English is used to translate or reformulate contents already expressed in the Italian version of the sites. The sample analysis presented here is intended to describe and provide insights as to how international communication is handled in such contexts, pro- viding also suggestions and possible guidelines for multilingual poli- cies in Web communication concerning public health. Closing remarks The topic of medical discourse is so vast that the authors do not claim to have been able to offer a complete, definitive account of the multi- farious discursive practices that are commonly employed in this com- plex field. However, we hope that the chapters in this volume will provide the opportunity for discussion and collaborative information- sharing, and stimulate debate among all those scholars and practitio- ners interested in the relationship between health issues and language. Introduction While phobias, such as arachnophobia or claustrophobia, are part of mankind’s make-up, no phobia has captured society’s attention and imagination over the centuries more grippingly than the fear of infection and death from pandemics. Boccaccio’s gruesome witticism that the victims of the Black Death often ate lunch with their friends and dinner in Paradise with their ancestors (see Section 2) is a testament to the fact that, far from being a figment of the imagination, pandemics have had a devastating impact on society for hundreds of years, seven being recorded between 1816 and 1975 for cholera alone. The Spanish flu pandemic killed an estimated 75 million people while th the 14 century Black Death pandemic is believed to have killed one third of the population of Europe. If medieval authors, such as Boccaccio and Chaucer, drew inspiration from the Black Death, it is because, together, fact and fiction pack a powerful punch when raising pandemic-linked fears. This has attracted several writers: from Virgil, with his description of an anthrax epizootic (Sternbach 2003: 463-4), to today’s epidemic- inspired and ominously-named novels, such as Follett’s 2007 World Without End and Cook’s Outbreak. Precisely because of their foundations in historical reality, the popular press (Gwyn 1999; Jen 2008), in particular, has engaged in fear-mongering that plays on these apprehensions. Special report: Inside the global race to avert a pandemic’ (September 2005) and ‘H1N1: As students head back to school this September, swine flu could infect millions. What concerns us in this chapter, however, is the fact that fears of being infected by plagues, and succumbing to them in a very short span of time, are mostly expressed indirectly, eschewing words such as fear, apprehension, scare, hysteria, panic or lexical equivalents. As a deliberate act of arousing public fear or alarm about a particular issue, fear-mongering is made more effective in terms of newsworthiness and reader impact through indirect reference to the unknown than through specific description of fears or reassuring positive messages. Compare Time’s positively- oriented ‘Polio’ cover (March 1954) about John Salk’s 1954 success- ful field trials of inactivated poliovirus vaccine with Newsweek’s negatively-oriented title ‘A back door for Ebola: smuggled bushmeat could spark a U. If, as the examples given above show, fear-raising, with its focus on the hypothetical and sensational, is indirect, then the techniques used to reconstruct the expression of fear in English-language texts also need to be indirect. This has long been recognised by specialists in The Language of Fear: Pandemics and their Cultural Impact 27 medical communication (Lakoff 2008, Schell 1997, Strassberg 2004, Strong 1990) but calls for models and techniques of text analysis, which, though focused on the contemporary world, are also diachronic in nature, i. This chapter thus reports on research designed to extend and consolidate our understanding of the language of fear as it pertains to epidemics and pandemics. The first, now completed stage, involved the construction of a model characterising the cultural evolution from the Elizabethan period to the current times in relation both to the changing interpretations of what epidemics and pandemics are, and to the changing nature of the fears they generate (Section 2). The tentative conclusion reached is that separating the different and some- times contradictory strands involved helps shed light on the ‘language of fear’ and the manipulation of these fears over the centuries by writers in many different English-language text types (Section 5). Developing a cultural model Given the factual and fictional intertwinings mentioned above, the term pandemic might be thought, in the tradition of folk etymology, to be a hybrid term derived from epidemic and pandemonium that blends their reference to the medical and the fearful. Although the latter word is a hybrid coined by Milton in 1667 for use in Paradise Lost (Allen 1962: 207), the term pandemic (Greek 28 Anna Loiacono pan- ‘all’ + demos ‘people’) is modelled on epidemic. Significantly, as a term, epidemic dates back to Hippocrates but has undergone semantic changes (Martin/Martin-Granel 2006: 976) as medicine, and social perception of it, has evolved: (1) For Hippocrates, an epidemic meant a collection of syndromes occurring at a given place over a given period, e. Much later, in the Middle Ages, the long and dramatic succession of waves of The Plague enabled physicians of the time to identify this disease with increasing precision and certainty; they began to recognize epidemics of the same, well-characterized disease. Then, with the historic contributions of Louis Pasteur and Robert Koch, epidemics of a characteristic disease could be attributed to the same microbe, which belonged to a given genus and species. The last stage in the semantic evolu- tion of the term epidemic was the progressive acquisition of the notion that most epidemics were due to the expansion of a clone or clonal complex of bacteria or viruses known as the epidemic strain. More recently, microevolu- tion of a clone of a bacterium (the epidemic strain) was shown to occur during an epidemic with person-to-person transmission. Despite having no etymological connection with panic or pandemo- nium, the term is vested with considerable ambiguity: a scientific term in the hands of, for example, epidemiologists and the statistics- oriented texts they produce, but also a fear-provoking term in other texts and contexts such as journalism, novels and films presenting pandemics as out-of-control global epidemics. Specifically, attitudes towards pandemics suggest that a diachronic pathway needs to be traced in terms of how different social layers perceive their fears of disease and communicate them (see Loiacono 2012b for a multi-tier approach to the analysis of medical communication). This ‘human ap- proach’ to fear of disease, and its interpretation, embraces a complex rational-to-irrational cline, implying various perspectives: the lay- man’s, the doctor’s, the politician’s, the reporter’s and so on (Loiaco- no 2012b: 83-86). Medicine, itself, straddles these layers and is subject to an uninterrupted cycle of separating and associating scienti- fic and social aspects; all of us, in our different ways, are caught up in the ensuing conflicts and fears that this cycle generates as the follow- ing webnews report (Mukpo 2014) dramatically highlights: The Language of Fear: Pandemics and their Cultural Impact 29 (2) According to Nyenswah [Liberia’s Assistant Minister of Health], rural belief in juju – West African magic – is also contributing to the challenges officials face.

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When resistance is felt discount zenegra 100 mg line, even a slight • This hand is then set into motion rhythmically 180 degrees out of phase with the motion of the pelvis cheap 100 mg zenegra amex, creating torsion of the torso. Reproduced with permission from by one of three strategies of application of rhythmic Blackburn J. Journal of Bodywork and Movement Therapies force: 2004;8(3):178–188 Chapter 7 • Modalities, Methods and Techniques 253 Box 7. In this application the intent would be to induce a relaxation pattern of baseline neuromuscular coordination and to entrain a more harmonic pattern. Comeaux (2004) makes clear: If a practitioner is applying these strategies to the spine, it is wise to begin with the patient in as gravity neutral a posture as possible, with access to the spine. Journal stimulation is reproduced that is equivalent to that of Bodywork and Movement Therapies 2004;9(2):88–98 during active walking, with its alternating pelvic rotation and counter torsion through the trunk. One strategy is to induce a stretch or articulation the strategies are assimilated, it is possible to mobilization with a rapid exaggeration of the transfer most of these strategies to the seated rotation of the segment in phase with the position. A second more forceful strategy is to add the trunk, with localization as is necessary. To diagnose exaggerated rotation out of phase with the in the pelvis and more particularly the sacrum, a developed rhythm. This applies a destructive reciprocal role of the two hands is used by rotating interference pattern to the established wave in the trunk to generate momentum, and letting the the tissue by introducing more energy. A third intervention strategy is to gently persist resonant tissue compliance, and to then making with the established wave pattern to soften tissue corrective suggestion. The tissues are then held in this of time (see below) offers restrictions a chance to position for variable periods (90 seconds is a ‘unlatch’, release, normalize. Functional approaches Safety therefore rely on a skilled palpation sense The nature of indirect approaches is essentially safe, (Johnstone 1997, Schiowitz 1990). Physical therapy has evolved methods such as are safe as well as being effective (Cislo et al 1991, ‘mobilization with movement’ and ‘unloading’ Ramirez 1989, Wong et al 2004a,b). Hospital studies involving treatment of recently sur- McKenzie exercise methods incorporate gically traumatized tissue validate the essential safety concepts of movement towards ‘ease’ that of positional release methods (Dickey 1989). In chiropractic, aspects of the use of sacro- numerous alternatives, and the overall approach of occipital technique’s ‘blocking’ methods indirect methodology offers an alternative to direct incorporate placing tissues into an methods of treatment. In craniosacral techniques much of the Proprioception treatment involves indirect pressure, taking Walther (1988) summarizes a ‘strain’ situation as distortions into a ‘crowded’ state, so allowing follows: change to take place spontaneously (Sergueef et al 2002). When proprioceptors send conflicting information there may be simultaneous contraction of the Upledger & Vredevoogd (1983) give a practical antagonists. The idea of moving reflex pattern develops which causes muscle or other a restricted area in the direction of ease is, they say, tissue to maintain this continuing strain. Often in order to dysfunction] often relates to the inappropriate open a latch we must first exaggerate its closure’. Chapter 7 • Modalities, Methods and Techniques 255 We can recognize such a pattern in an acute setting sis relates to the presumed effects of slackening fascial in torticollis, as well as in acute lumbago. This is a time of intense neurological and proprio- The reduction in tension on the collagenous cross- ceptive ‘confusion’, and is the moment of ‘strain’. Used appropriately there appear to be no contraindi- cations to use of positional release methods of Nociception treatment. Bailey & Dick (1992) suggest that strain dysfunction is far more complex than the simple proprioceptive example: Naturopathic perspectives In the realm of bodywork few if any methods would Probably few dysfunctional states result from a purely seem to be closer to basic naturopathic concepts than proprioceptive or nociceptive response. Nociceptive responses would occur (which are to have philosophical and practical similarities to more powerful than proprioceptive influences) and deep relaxation, therapeutic fasting, neutral (body these multisegmental reflexes would produce a flexor temperature) bathing, and various psychotherapeutic withdrawal, dramatically increasing tone in the flexor approaches such as emotional experiencing and group. Korr’s (1976b) explanation for the physiological In all these there is a ‘detachment from barriers’, normalization of tissues brought about through posi- provision of a ‘safe place’ (‘position of ease’), a virtual tional release is that: ‘granting of permission’ or offering of an opportunity for self-regulation to operate. D’Ambrogio K, Roth G 1997 Positional release physician has led the patient through a repetition of therapy. Churchill Livingstone, Edinburgh with gentle muscular forces, and second there have 3. American Academy of Other hypotheses Osteopathy, Indianapolis, Indiana Jacobson et al (1989) have suggested a circulatory 5. Locate an area of skin somewhere between your Horizontal reference elbow and wrist, on the flexor surface. Place two or three finger pads onto the skin and slide it 10˚ superiorly and then inferiorly on the underlying 36˚ 19. Slide the skin in that direction and, holding it there, test the preference of the skin to slide medially and laterally. Now introduce a slight clockwise and anticlockwise twist to these tissues which are already being held (‘stacked’) in two directions of 133˚ 8. Take it in that direction, so that you are now reference holding the skin in three positions of ease. Release the skin and retest; it should now display a far more symmetrical preference in all the Weightless neutral body position directions that were previously restricted or ‘tight’. You have demonstrated that moving tissues away called astronauts’ position or neutral body posture. Reproduced from their barriers or resistance, into ease, can with permission from Cranz G.

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The term ‘naturopathy’ was nothing less and nothing more than the first modern term to differen- Case management tiate the field of natural medicine – i 100mg zenegra free shipping. While The 1901 Kneipp Nature Cure Committee included homeopathy and Schussler cell salts as branches of 60 Naturopathic Physical Medicine ropathic physician centered around what was known as ‘physical-dietetic therapy’ (Lust 1909) purchase zenegra 100 mg. We can see from a perusal of the prospectus at Lust and Regeniter’s Naturopathic College, later renamed the American School of Naturopathy and the first school that provided a diploma as a naturopathic doctor, that the 10-subject program (see Figs 3. He writes that naturopathy is ‘the method of healing all diseases without medicines, drugs, poisons, and almost without any operations’ and that ‘Naturopathy’s materia medica consists of the principal elements derived from nature: light, air, water, heat, and clay, beside non-stimulating diet, exercise and rest, elec- tricity, magnetism and massage, calisthenics, physical culture, mental culture, etc. A European-trained physician practicing the nature cure, he arrived in what came to be called naturopathy. However, in the California and opened a practice in Los Angeles in Naturopath and Herald of Health, the primary profes- 1885 (Lust 1919a). He wrote and led the fight for the sional journal of the period, we are afforded insight into bill that became the first law to license naturopathic the actual case practices common at the time. The 1910 Naturo- cal application and case history the first two decades path and Herald of Health advertisement for the college of the naturopathic professional literature reflects a includes a more expansive curriculum: small focus on non-poisonous botanical remedies, a consistent position that homeopathy is a compatible yet. The early 20th century practice of the natu- Bacteriology, Hygiene, Dietetics, etc. The Naturopaths are legalized in California and in some other states, the rest will follow. We not only endeavor to make our students competent to pass any Medical or Osteopathic Board of Examiners, but make them competent and practical Physicians. While the college curriculum includes minor and orthopedic surgery and botany, the thrust of the adver- tisement for the services of Dr Carl Schultz’s Naturo- pathic Institute and Sanitarium, immediately above the college advertisement in the journal, involves various modalities of physical medicine (Schultz 1910): Figure 3. Electric Light, Hot Air, Vapor, Sun, Electric, Herbal, Needle, 62 Naturopathic Physical Medicine Figure 3. Osteopathy, fenugreek seed has potent antineoplastic activity (Sur Chiropractic, Orthopedic Surgery, and all Hydropathic et al 2001). In the interest of our current subject – the history of physical medicine in naturopathic practice – it Naturopathy and nature cure behooves us to consider our Dr Staden (Fig. In a 1902 article entitled ions in the profession, rather than attempting to ‘Naturopathy vs Nature Cure’, Dr Lust articulates that evaluate the relative merits of this perspective. For while the two are ‘distant relatives, it is true – so are example, when he states that naturopathy is the larger the pussy and tiger’. The thrust of the article is that branch of drugless healing he is using the terminology naturopathy is not a limited patent system of proscrip- of the period. Drugless healing was used to differenti- tive natural therapeutics – for example prescribing sitz ate a general category of practice, not only in relation baths and wet sheet packs for all patients. Instead, to non-allopathic systems of healing at the time but naturopathy individualizes treatment in an eclectic also to differentiate the category from homeopathic and progressively minded fashion. The approach of practice and from the botanical practices of the time universal prescription was an early trend derived from such as eclecticism. For example, Dr Staden sion of the therapeutic worldview of the naturopath describes two cases of cancer treated with topical beyond universally applied systems for all disease. Chapter 3 • History of Naturopathic Physical Medicine 63 Lust argued that naturopathy is a larger inclusive field The renaming of the title and Lust’s choice of this that expands beyond its nature cure foundations. So text as a textbook of practice indicates the early orien- what was naturopathic practice like during the first tation of the profession’s leadership. Other modalities such as sunlight, the legislature they declared that the practice of natu- breathing therapy and electricity play a supplemental ropathic therapeutics consists of: role, as do botanical teas, steam baths and injections. There is scant reference to naturopaths prescribing • Dietetics homeopathic or allopathic medications. Prior • Hydrotherapy scholarship was also used to demonstrate historical • Physical Culture antecedents. For example, in 1902 Lust republished • Dynamic Breathing an article from the first half of the 19th century, ‘The Sweating Cure for Hydrophobia’, in which • Massage Richard Metcalfe relates five successful case histories • Swedish Movements of rabies transmitted from animal to human that were • Structural Adjustments treated with Turkish steam cabinet baths (Metcalfe • Sun 1902). These include • Kneipp Cure a 10-month-old paralyzed boy originally diagnosed by allopathic doctors as a case of spinal meningitis, a • Just Cure case of acute peritonitis with a swollen abdomen, • Fasting cancer of the jaw, and pneumonia with ‘brain fever’ • And other simple natural agencies as Rest, (presumably meningitis). The Aside from the non-poisonous herbal remedies uti- cancer case also utilized electric light baths as part of lized in the Kneipp cure, the therapeutic means listed the therapy. The naturopathic treatment procedures in this period for various conditions such as gonorrhea, Eclectic naturopathy syphilis, diphtheria, infantile paralysis, meningitis While the early naturopathic profession included inter- and other infectious diseases detail what are primarily nal medication such as botanical medicine and homeo- physical methods of treatment allied with diet. In a pathic medicine in its larger conception of naturopathic 1909 article on spinal meningitis, Dr Lust refers to the practice, it would not be until the demise of the physi- naturopathic approach to treatment as ‘physical- cian level botanical (e. Originally entitled Physical Therapeutic viduals, professional groups and ideas would be Methods: A Handbook of Drugless Medical Practice when absorbed into the naturopathic profession. The profes- published in 1910, Lust republished the book in 1916 sional literature of the 1930s and 1940s documents the as A Treatise on Naturopathic Treatment: Based on the naturopathic professional absorption of those wither- Principles and Therapeutic Applications of the Physical ing professions with articles that focus more and more Modes and Methods of Treatment(Non-Medicinal Therapy).

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