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By Y. Potros. Knox College.

All these traditions and attitudes are still strongly supported not only by the men in these societies purchase levitra 20mg, but at least in public apparently also by the women themselves purchase levitra with paypal. For example cheap levitra 20mg on line, during a conference on women’s rights and domestic violence, held in Dar es Salaam, many Kenyan women agreed publicly that they needed to be periodically beaten by their husbands to become better and more obedient wives (Daily News (Tanzania), 19 April, 1999). In such a situation, a health care professional with a diVerent cultural background has a diYcult task in trying to improve women’s health and position within her community while simultaneously remaining sensitive to cultural diVerence. If medical and other interventions are seen as disrespect- ing the tradition of a particular community, the result may be that the old customs are even more strongly defended and the care needed is rejected as ‘foreign’ inXuence. Since talking about sex is still taboo in many communities, the information on the virus is not passed on properly and the real causes of the disease are misunderstood or merely disregarded (McFadden, 1992: pp. While it is often understood that too early, too late and, in general, too frequent pregnancies can cause serious health problems to mothers, many of whom often are children themselves (under 18 years), old habits die hard. Medical professionals who have to work with these issues may face a dilemma about how to approach the matter and how to educate not only women but also their husbands and/or male partners. In Musoma Rural District in Tanzania, for instance, 25 per cent of the young girls admitted having been forced or raped in their Wrst sexual intercourse. Globally, between 20 to 30 per cent of all women report having been physically assaulted by an intimate partner at least once in their life, accord- ing to the Washington-based Health and Development Policy Project. In 1993 the World Development Report of the World Bank estimated that gender violence causes more deaths and disability among women aged 15 to 44 than cancer, malaria, heart disease, traYc accidents or even war. These women may want to have children and/or carry their pregnancies to term, regardless how short or painful their own or their children’s lives might be. Since in many cases they do not want others to know about their pregnancy, unsafe Multicultural issues in maternal–fetal medicine 49 abortions and self-abortions are typical. A study conducted at the Muhimbili Medical Center in Dar es Salaam, for instance, has shown that 50 per cent of women between 15 and 24 years of age have been hospitalized because of abortion related complications. A further challenge for maternal–fetal medicine is the vicious circle that follows when young girls with unplanned pregnancies drop out of school, and thus miss out on the information they would need in order to improve their own and their children’s health and to plan the size of their family. After all, those who have the least access to information, to health services, to the right to make critical decisions and choices, are the easiest victims of any serious disease. At the same time, however, we need to acknowledge that the advice given or the methods of care suggested can sometimes lead the patient and her family to reject essential medical help, turning instead to self-help or the less professional and sometimes straight- forwardly harmful advice and treatment of traditional healers. In Mara Region in Tanzania, for instance, a high number of women seek help from traditional healers rather than professionals with modern (often Western) medical training. The result has been that many of them die annually from complications, such as prolonged labour pains, excessive bleeding and burst- ing of the womb when giving birth, because of the use of untested traditional medicine during labour (Howard, 1995: pp. Sometimes this rejec- tion of modern medicine occurs because the patient and/or her family and community feel oVended by the physician’s interference in their value or belief systems. Sometimes the cause lies in the particular treatment (family planning, abortion, Caesarean delivery, prenatal testing or blood transfusion) which in itself oVends against particular cultural norms. Feminist bioethics and respect for difference From a universalist point of view in maternal–fetal medicine and reproduc- tive health care, the immensity of women’s health problems in many socie- ties, particularly in the developing world, is related to the social constraints on women’s lives. In order to improve women’s health we not only need more health care and medical resources, we also need to improve women’s social position and promote women’s rights within their communities. However, controversial as it may sound, attempts to respect an individual’s rights and autonomy within some traditional and mainly patriarchal cultures 50 S. Let us take an example of how liberal promotion of the same standards everywhere and insensitivity to social inXuence can reinforce existing struc- tural discrimination and injustice. However, in order for this proposal to succeed, the society has to have already adopted the liberal concept of justice and to be committed to enhancing women’s rights. While the idea in itself promises more equality to women, importing it and applying it directly to a male-dominated culture may create serious problems in practice. The practical conclusion might easily be that it is better not to promote women’s rights in these societies, but to take an alternative approach in order to improve women’s health. So-called universalism often fails to take into account how much inXuence our personal diVerences as well as social circumstances have on our health, health care and medical practices. In its attempt to treat everybody equally, universalism may in reality disregard the diVerences between people (whether we talk about race, ethnicity or gender) that should be taken into account when we have to decide on medical advice or treatment for a particular person (Wolf, 1999: pp. Since our concept of equality is based on an illusionary, idealistic standard of normality, we may discrimi- nate against those who do not Wt this norm. Treating everybody exactly the same may mean failing to under- stand the special problems which particular groups of people, for instance African women, may encounter in their social circumstances and in their medical care. In many cases individual patients beneWt more from medical treatments in which the particularities in their personal situation are taken into consideration. Multicultural issues in maternal–fetal medicine 51 Second, the feminist criticism of the Western abstract form of liberalism shows that the same is true when it comes to the promotion of universal human rights standards. Thus they either inadvertently or deliberately ignore many human rights violations particular- ly relevant to women (such as domestic violence, rape and other forms of sexual and reproductive violence and coercion). Since human rights standards were originally set by men and justiWed by the idea of social contract which, even in the West, historically excluded women from equal participation as less rational and less human, there still appear to be problems in including women within the scope of human rights. As Catharine MacKinnon (1998) has pointed out, there is always a way to Wnd jurisdictional, evidentiary, substantive, customary or habitual reasons to overlook these violations and to disregard women’s special needs. Thus, those human rights violations that are done to women are actually sometimes defended by the very human rights standards that should be there to prevent these violations. Appeals to cultural identities, autonomy and tolerance can be used to justify women’s global subordination by men, not only by traditional communities but also in apparently democratic societies which claim to promote equality (MacKinnon, 1998: pp. Many human rights violations escape the human rights net, because women in general as a group (and particularly not as individuals) are still not seen as naturally meeting the standard of the ideal of humanity. In other worlds, the demand that everyone should be treated the same may eVectively ignore the special needs of women and disregard sexually based violence towards women. Talking about collective rights makes ‘women’s rights issues’ appear to be some kind of deviation from ‘universal human rights issues’, as any minority or cultural rights demand is. Womanhood then remains a deviation from the ideal of our ‘common humanity’, and women cannot meet the traditional standards for human rights (MacKinnon, 1998: pp. If we want to promote equality in practice and not merely as an abstract ideal, particularly in maternal–fetal medicine, we need to pay attention not only to diagnostic diVerences, but also to diVerences in socio-politico- cultural circumstance. Equality may sometimes require that we do not try to provide all the same services to everybody everywhere, but rather that we try to Wnd the most appropriate way to promote health in particular situations. It cannot merely mean some abstract ideal of common humanity, because such a concept of humanity is often interpreted in social and medical practice as the fundamental similarity of all human beings, without paying attention to the diVerences in their needs and special circumstances. It should be noted here also that while feminist bioethics provides import- ant criticism of abstract universalism, its own focus on diVerence is often questionable, again because of the danger of falling into relativist reasoning. Particularly if it is mainly gender diVerence that is emphasized, there is an evident danger that we may construct a distinct moral outlook, which cannot provide the normative basis for globally acceptable ethical guidelines. Thus, feminist bioethics should not give up on the ideals of common humanity for fear of losing the notion of universal human rights altogether – leaving instead only women’s rights, children’s rights, minority rights, disability rights and so on ad inWnitum. If that happens, the demand to protect women’s rights may plausibly be seen to conXict with a ‘competing’ demand to protect patriarchal cultural practices, instead of being properly taken to be a demand for protection of individual rights within not only a particular community, but in all communities. Its normative emphasis is on the incompatibility of diVerent value and belief systems – it claims that there are no universal principles of justice that would apply to all cultures.

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This sign consists of intense tracer uptake in two apposing end-plates with narrowed disc space purchase levitra in india. Pathologically cheap levitra 20 mg visa, bone tuberculosis is characterized by destruction with relatively mild reactive bone formation 10 mg levitra otc. A special form of tuberculosis, which involves the finger in infants, is known as spina ventosa. Planar bone scan findings are usually not specific, but pinhole scinti- graphy reveals findings of diagnostic value. The diseased bone shows a localized area of increased tracer uptake, occasionally with associated photopenic area(s). In the spine, as in acute infective spondylitis, tuberculosis involves two or more neighbouring vertebrae and intervertebral discs. Extended tracer uptake can be seen deep in the vertebral bodies, confirming that the chronic granulo- matous process spreads from the end-plate into the vertebral body. Each of these diseases manifests characteristic signs on pinhole images that are comparable to radiographic signs. Granulocytes avidly accumulate in acute infective foci while lymphocytes accumulate primarily in chronic foci. Gallium-67 scans are non-specific, accumulating in both inflammatory and neoplastic lesions. In contrast, pinhole scintigraphy precisely localizes tracer uptake to the synovia, which cover the femoral head and acetabular fossa. Such uptake is due to an increase in blood flow through the anastomotic vascular channels in the inflamed synovium. The tracer uptake may be prominent in the active stage but rapidly returns to normal with rest and conservative treatment. It is to be noted that in the early stage with large synovial effusion, tracer uptake may become reduced due to ischaemia of the femoral head created by capsular distension. However, bone scintigraphy reveals an increased blood flow and blood pool in septic joints, and intense tracer uptake in the subchondral bone on static images in the early stages. The intensity of subchondral tracer uptake in acute pyogenic arthritis has been described as roughly paral- lelling the intensity of infection. Dual head pinhole scintigraphy produces a pair of either the anterior and posterior, or the medial and lateral, images, permitting a three dimensional analysis of the disease. Histologically, it is characterized by the derangement and eventual destruction of the cartilage and subchondral bone without obvious inflammation. Bone scintigraphs may show discrete unifocal or multifocal tracer uptake in subchondral bones, and can be spotty, patchy or segmental in type. Whole body bone scans are the only way to portray symmetric polyarthritis panoramically; spot views can depict characteristic changes in both large and small joints in great detail. Pinhole scintigraphy is useful in delineating many scintigraphic signs of rheumatoid arthritis. Nuclear angiography provides information on lesional vascularity and on the activity of the pathological process. Ankylosing spondylitis is a non- specific inflammatory disease of the sacroiliac joints and the spine. The disease primarily involves the synovial components of the sacroiliac joints and the cartilaginous discovertebral junctions as well as the apophyseal, costovertebral and neurocentral joints of the vertebrae. Planar bone scintigraphy reveals symmetric intense tracer uptake in the sacroiliac joints and/or spine. Pinhole scintigraphy can portray the characteristic ribbon-like tracer uptake in the synovial joints of the spine, producing a ‘bamboo spine’ appearance. In the late stage, tracer uptake becomes reduced, reflecting a quiescent metabolic state. The disease mechanism is still obscure, but an interaction between several different infective organisms and a specific genetic background is currently being given serious consideration. Pathologically, the main alterations are present in the enthesis, which is the site of insertion of a tendon, ligament or articular capsule into the bone, creating characteristic inflammatory enthesopathy. Conspicuous involvement of entheses in this syndrome sharply contrasts with the dominant involvement of the synovium in rheumatoid arthritis. The whole body scan can panoramically reveal characteristic asymmetrical pauciarticular involvement of the spine and appen- dicular bones and joints. Pinhole scintigraphy often detects characteristic enthesopathy in the pre-radiographic stage, especially in the heel and knee. In addition, pinhole scintigraphy can show specific signs of Reiter’s syndrome, namely the ‘knuckle bone’ sign of the sausage digit, the ‘teardrop’ sign of paravertebral enthesopathy and the ‘whisker’ sign of periarticular hyperostosis. It is a rheumatic disorder of clinical importance and academic interest, often related to previous trauma. The pathogenesis has not yet been clarified, although the theory of the internuncial pool is widely accepted. The identification of the ‘sympathetic vasoactive intestinal peptide-containing nerve fibres’ at the cortical bone and the bone–periosteal junction has provided a biochemical basis for the theory. Three phase scintigraphy is useful, revealing increased blood flow and blood pooling, which denotes hyperperfusion. Involvement of periarticular structures of one or more joints of a limb is characteristic. The common causes include trauma, embolism, thrombosis, elevated bone marrow pressure, irradiation and vasculitis. Scintigraphically, avascular necrosis presents as a hot area on the planar image, especially in small bones. However, when magnified using pinhole scintigraphy, a photopenic area can be detected within the hot area. Typical examples are avascular osteonecrosis of the femoral head and of the internal femoral condile of the knee. Common clinical features include a predilection for actively growing bone, chronic exposure to trauma and local pain, and tenderness. Osteochondroses affect the capital femoral epiphysis (Legg–Calvé– Perthes disease), the tarsal navicular bone (Koehler’s disease), the metatarsal head (Freiberg’s disease), the medial clavicular end (Friedrich’s disease), the secondary ossification centres of the vertebrae (Scheuermann’s disease) and the tibial tubercle (Osgood–Schlatter’s disease). Large avascular osteonecrosis produces cold areas, whereas microfractures or bone infraction are represented by hot lesions. Scintigraphy can provide information regarding the size, shape, location, texture and osteochondral junction pattern, frequently leading to specific diagnosis. In elderly patients, it is useful for the study of contusion and fracture in osteoporotic ribs and spine. Bone scintigraphy is valuable for the detection and differential diagnosis of shin splints and stress fractures.

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The client experiences rhythmical rocking trauma to reverse the deformation of fibrin through motions much of the time during the tablework buy levitra line. Chapter 7 • Modalities generic levitra 10 mg with amex, Methods and Techniques 251 Pathway to organization Organization Possible outcome Figure 7 buy cheap levitra 20mg online. Reproduced with Psycho- General changes in motor permission from Lederman (2000) Sensory feedback response (proprioception) physiological General changes in pain perception General autonomic changes Sensory feedback Increased proprioception Harmonic (proprioception) Neurological technique Altered pain reflexes Effecting repair precesses Physical loading Local Mechanical changes tissue Fluid dynamic changes Lederman (2000) suggests that harmonic methods movement education. Trager Institute, Mill influence local tissue organization following trauma Valley, California (influencing mechanical in addition to fluid dynamic properties), as well as neurological (providing pro- Pilates methods prioceptive stimulation in addition to gating of pain) There is additional information in Chapter 9. Pilates-based exercises can be performed on the floor, termed ‘mat work’, or Cautions on equipment, termed ‘apparatus work’. A key piece None noted apart from caution regarding rate and of apparatus is the Reformer which comprises a single amplitude of rhythmic movements imposed on tissues bed frame equipped with a sliding carriage that uses under repair. Cables, bars, straps and pulleys are features of a variety of Naturopathic perspectives Pilates-based exercises, performed in multiple posi- There is something inherently naturopathic about tions. Strength, endurance and flexibility of the major bodily rhythms being employed to gently coax postural muscles involved in trunk (core) stability, enhanced circulatory and drainage efficiency as well particularly the abdominal group, receive focused as neurological coordination and integration in dis- attention (Mullhearn & George 1999). Comeaux Z 2002 Robert Fulford and the elderly (Hall et al 1999, Hutchinson et al 1998, Segal philosopher physician. Juhan D 1989 An introduction to Trager Pilates has also been described as a mind–body psychophysical integration and mentastics fitness program (Pilates 1934, 1945). The movements happen within the safe proceeds the practitioner adjusts the parameters of confines of conditioned reflexes, creating a playful movement in response to changes in resistance, sense of letting go and trust in the client. The rhythmical movement in Trager® creates a Comeaux (2004) suggests: lulling relaxation, like floating on the sea, or swaying The stretch, cyclic afferent input, and articulatory in a hammock. The practitioner can vary different movements associated with natural gait is a useful parameters: frequency, amplitude, direction, hand way of mobilizing restricted segments of the central contact, pattern, pause, position, stretch, or axis. The Facilitated Oscillatory Release approach to compression, while initiating movement from his/her the spine and sacrum attempts to replicate the gait feet, as the hands catch, nudge and anchor the cycle. Like a ballroom dancer, the practitioner can take advantage of gravity, momentum, tensegrity, and • Beginning with the patient in a prone position, tonus, while feeling for signs of impedance and flow. When resistance is felt, even a slight • This hand is then set into motion rhythmically 180 degrees out of phase with the motion of the pelvis, 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’.