Human balance and posture control during standing and walking

The common denominator in the assessment of human balance and posture is the inverted pendulum model. If we focus on appropriate versions of the model we can use it to identify the gravitational and acceleration perturbations and pinpoint the motor mechanisms that can defend against any perturbation.

We saw that in quiet standing an ankle strategy applies only in the A/P direction and that a separate hip load/unload strategy by the hip abd/adductors is the totally dominant defence in the M/L direction when standing with feet side by side. In other standing positions (tandem, or intermediate) the two mechanisms still work separately, but their roles reverse. In the tandem position M/L balance is an ankle mechanism (invertors/evertors) while in the A/P direction a hip load/unloading mechanism dominates.

During initiation and termination of gait these two separate mechanisms control the trajectory of the COP to ensure the desired acceleration and deceleration of the COM. During initiation the initial acceleration of the COM forward towards the stance limb is achieved by a posterior and lateral movement of the COP towards the swing limb. After this release phase there is a sudden loading of the stance limb which shifts the COP to the stance limb. The COM is now accelerated forward and laterally towards the future position of the swinging foot. Also M/L shifts of the COP were controlled by the hip abductors/adductors and all A/P shifts were under the control of the ankle plantar/dorsiflexors. During termination the trajectory of both COM and COP reverse. As the final weight-bearing on the stance foot takes place the COM is passing forward along the medial border of that foot. Hyperactivity of that foot's plantarflexors takes the COP forward and when the final foot begins to bear weight the COP moves rapidly across and suddenly stops at a position ahead of the future position of the COM. Then the plantarflexors of both feet release and allow the COP to move posteriorly and approach the COM and meet it as quiet stance is achieved. The inverted pendulum model permitted us to understand the separate roles of the two mechanisms during these critical unbalancing and rebalancing periods.

During walking the inverted pendulum model explained the dynamics of the balance of HAT in both the A/P and M/L directions. Here the model includes the couple due to the acceleration of the weight-bearing hip as well as gravitational perturbations. The exclusive control of A/P balance and posture are the hip extensors and flexors, while in the M/L direction the dominant control is with the hip abductors with very minor adductor involvement. At the ankle the inverted pendulum model sees the COM passing forward along the medial border to the weight-bearing foot. The model predicts that during single support the body is falling forward and being accelerated medially towards the future position of the swing foot. The model predicts an insignificant role of the ankle invertors/evertors in the M/L control. Rather, the future position of the swing foot is the critical variable or more specifically the lateral displacement from the COM at the start of single support. The position is actually under the control of the hip abd/adductors during the previous early swing phase.

The critical importance of the hip abductors/adductors in balance during all phases of standing and walking is now evident. This separate mechanism is important from a neural control perspective and clinically it focuses major attention on therapy and potential problems with some surgical procedures. On the other hand the minuscule role of the ankle invertors/evertors is important to note. Except for the tandem standing position these muscles have negligible involvement in balance control.     

Shared care: a review of the literature

This review examines broad issues of concern regarding the primary/secondarycare interface. The main purpose was to identify areas of goodpractice which could be adapted for more general use. One ofthe most fundamental aspects identified was communication, whichis discussed in some detail. Also covered are shared prescribingand disease management. The data suggest that the most effectivesystem(s) of shared care has yet to be established. Furtherqualitative and economic evaluations are required, taking intoaccount patient preferences. Although the literature does describecertain practice exemplars, it is clear that inter- and intra-professionalcommunication continues to be a problem. Whilst informationtechnology may provide some of the solutions, it is concludedthat a culture change, which compels health professionals tomake sharing of patient information a much higher priority,is reauired. Keywords. Shared care, seamless care, hospital, general practice, family practice.     

Asbestos-related focal lung masses: manifestations on conventional and high-resolution CT scans

In 260 asbestos-exposed individuals evaluated by means of computed tomography (CT), 43 unsuspected pulmonary masses were found in 27 individuals. The masses included fissural pleural plaques (n = 10), dense fibrotic bands (n = 3), round atelectasis (n = 11), carcinomas (n = 3), and other presumed benign masses (n = 16). The most helpful features in the diagnosis of rounded atelectasis with CT were (a) contiguity to areas of diffuse pleural thickening, (b) a lentiform or wedge-shaped outline, (c) evidence of volume loss in the adjacent lung, and (d) a characteristic "comet tail" of vessels and bronchi sweeping into the margins of the mass. Less advanced areas of focal atelectasis had fewer classic features. Intrafissural pleural plaques were readily identified with high-resolution CT. In asbestos-related masses, the demonstration of stability over time is necessary. Careful interpretation of CT and high-resolution CT features and close surveillance can obviate the need for biopsy in the majority of instances.     

The effect of dialysate on peritoneal phagocyte oxidative metabolism

The respiratory and oxidative responses of human peritoneal polymorphonuclear leukocytes (PMN) and peritoneal macrophages (PM phi) following exposure to unused continuous ambulatory peritoneal dialysis fluid (CAPD) and early dwell effluent were studied using an open oxygen (O2) electrode system and by measurement of oxygen radical-derived luminol-dependent chemiluminescence. Both cell types responded to stimulation by increasing O2 consumption and by generating chemiluminescence even at external O2 concentrations below 50 microM O2. Oxygen concentrations in the dialysate, as measured by blood gas analysis, were never lower than 118 +/- 8.3 microM O2 even during active peritonitis. Thus oxygen availability does not appear to be rate limiting for phagocyte oxidative metabolism in the peritoneal cavity. Preexposure of both inflammatory cell types to unused fluid or early dwell CAPD effluent significantly reduced both stimulated oxygen uptake and the subsequent ability of these cells to generate chemiluminescence without significantly affecting their viability. Further investigation of this down regulatory phenomenon using unused fluid and laboratory prepared dialysis fluid revealed that low pH (5.3) and high sodium lactate concentration in combination are directly responsible for the suppressive effect of unused fluid and early dwell effluent on cell function. These observations demonstrate that cellular host defense may be impaired early in the dialysis cycle as a result of lactate mediated "stunning" of resident phagocytes. The precise nature of the molecular species responsible for this suppressive effect remains to be identified.     

Fixed prosthodontics in the elderly population. Life expectancy of fixed restorations, failures, and retreatment methods.

The restorative needs of older dental patients challenge the ingenuity, anatomic knowledge, artistic skills, occlusal philosophies, and material knowledge of the clinician. Achieving the most secure foundation while simultaneously eliminating imperfections and incorporating a design that promotes good oral hygiene and a natural and attractive appearance are significant contributors to a patient's welfare. The treatment decision regarding fixed prosthodontics for elderly patients requires the balancing of two opposing arguments: 1. In patients who are older, and who are perhaps medically or physically compromised, and, in addition, who may be on a limited budget (or perceived limited budget), it is important to fabricate dental prostheses that are as good as possible to minimize the likelihood that the prosthesis will need to be remade in the future when the patient is likely to be even more compromised financially, medically, or physically, and also to minimize the stress on the patient of accommodating to something that is less than an optimal dental solution. 2. Patients in this age group often anticipate financial strain in the future, perhaps realistically in view of the increasing percent of older adults who are institutionalized (5% of persons 65 years old or older, 20% of persons 80 years old or older). Also, many are reluctant to invest large amounts of money in their teeth when they are already quite elderly and realize they may not live long enough to make the investment "worthwhile." Educating the patient regarding average life expectancy is sometimes helpful, but the experience of many clinical dentists is that many elderly persons either do not believe the numbers, require greater certainty in their "investments," or do not place as high a value on their dental health as they do other aspects of their lives (in a context in which there are more needs than resources to pay for them). Finally, many older adults, contrary to the popular bumper sticker, are trying to preserve as many resources for their children and grandchildren as possible. The final decision should be made with sensitivity to the overall needs of the patient, and with the assistance of a well-informed patient or other responsible party.     

Evidence for persistence of adenovirus in the tear film a decade following conjunctivitis

Chronic papillary conjunctivitis has been described following adenoviral conjunctivitis. It is unknown however, how long adenovirus is able to persist in the tear film and conjunctiva. To determine if adenovirus persists in the ocular surface following adenoviral conjunctivitis, 304 patients with a history of adenovirus conjunctivitis from whom an adenovirus had been isolated 10 years previously were sent a questionnaire regarding persistent or recurrent symptoms and were invited to attend. Patients were examined and samples of tears and conjunctival cells were collected from both eyes using tear film washes, filter paper, and swabs, the latter for virus isolation. Extracted DNA from the ocular samples was amplified using primers for herpes simplex virus (thymidine kinase) and adenovirus (hexon) genes. Adenovirus amplicons were sequenced and compared to original serotype. Thirty patients attended, 19 of whom had persistent papillary conjunctivitis. Evidence of adenovirus DNA was detected in 17 of 30 patients, 15 of whom also had evidence of a chronic papillary conjunctivitis. Adenovirus DNA was significantly associated with papillary conjunctivitis (P = 0.03). Adenovirus amplicons were successfully sequenced from six patients. Four patients harbored type 3 adenovirus, the same serotype with which they were infected originally 10 years previously. Two patients were infected originally with adenovirus serotype 3 but the current serotype was type 4. Infection of the ocular surface with adenovirus may predispose to the development of a persistent or recurrent conjunctivitis, the presence of which, appears to be associated with evidence of long term persistence of adenovirus DNA.