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By U. Fraser. Touro College.

Monopolization of authority by bureaucrats led to the creation o f an official elite buy discount plendil 2.5mg line, which in turn discrim inated against those less entrenched in the bureaucracy or those outside buy 5mg plendil with visa. T he same kind of rigidities and discriminations m ight appear in the United States as it changes from an industrial to a service economy. If so, change from a subsistence to a well-being society will be accompanied by a struggle against different injustices. Service sectors often pursue internal objectives in derogation o f the public in­ terest. T he slow strangulation of New York City by those in control o f vital services—fire, police, sanitation—is a good example. And if all of this is so, a series of severe social, political, and organizational problems may erupt. Well-being services are produced by the great provider institutions: law, m ed­ icine, government, and so on. However, all these systems are in severe disarray and under strong pressure to change. At the very time we are moving from a m anufacturing to a service economy, the m ajor service systems are in a state of crisis analogous to that suffered by m anufacturing industries in the 1920s and 1930s. A rem edy for the crisis in medical services is being sought through federal financing—a na­ tional health insurance plan. T he assum ption is that gov­ ernm ental absorption o f the costs of care will redress access and distributional inequities. If a national health insurance plan is enacted, some o f the inequities may be curbed or modulated. T he underlying prem ­ ise of medical care financing reform is that medicine pro­ duces enough health to justify the enorm ous expenditure. A larger governm ental role, particularly through fi­ nancing, will strengthen and intensify professionalism in medicine, not weaken it as many providers have argued. A national health insurance plan will specify that only professional services can be bought. Con­ sumers with cash can buy virtually any service from any person or agency willing to sell it, subject only to the loose strictures of state licensing and certification laws. But with federal assumption o f the costs o f care, the care that can be bought will inevitably be the care that is already provided. This might not be an unhappy result if professionalization in medicine were an unvarnished good. But the goals o f pro­ fessionals are rarely the same as the goals of those whom they serve. The Crisis in Service Institutions 131 Professionalized service bureaucracies—health, education, police, fire, transport, and so forth—are not as responsive as most o f us think they should be. As services become profes­ sionalized, as most have, the service bureaucracy becomes less sensitive to social needs and m ore impervious to social controls. Few have questioned the need for each judge to have a private bathroom in chambers, nor the physician’s “right” to work when and how he or she wishes. More will question the sanitary workers when they allow garbage to pile up on the streets. T he m ore the public becomes subser­ vient to the professional, and the less the consum er gets for m ore money, the m ore will the public’s sense of helplessness grow. As governm ent assumes the responsibility for the fi­ nancing of medical care, it will necessarily install a large bureaucracy to police the flow of public funds into private hands. Concomitantly, it will expand its regulatory ap­ paratus to scrutinize the quality o f the product it is buying, the means by which it is provided, and the distribution o f the resources it is creating. If these bureaucracies behave as other service bureaucracies have—and there is no reason to assume otherwise—they will im pede rather than facilitate the flow of benefits from providers to consumers. But paradoxically, they will also seek to preserve the flow of benefits from providers to consumers. T he en­ trenchm ent o f a bureaucracy that feeds off a service by serving as an interm ediary between provider and consum er will then frustrate if not prevent change in the service sys­ tem of the future. As the governm ent assumes larger obligations for services and as the economy gradually shifts to a service economy, bureaucracies will swell in power as well as size. In the past, a key problem has been the rapacity of the private sector which controlled the resources necessary for a decent life. But in the future, control over the flow o f resources will rest m ore with 132 Medicine: a. Evidence is available that medical care has less impact on health than a variety of other factors. T he growth and strength of service bureaucracies will frustrate attem pts to reallocate resources—to shift re­ sources from services to other program s with a potentially greater impact on health. Today’s com puters are already deployed in medical care; scores o f software salesmen visit doctors’ offices and hospital corridors. T he com puter, one example of high medical technology, can improve medical care, but there are hazards as well. Decisions regarding the kind and the am ount of medical care are made by the physician, but also to an increasing extent by government.

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To Hence purchase 2.5 mg plendil visa, the focus should not be on the symptomology buy plendil 2.5mg visa, prevent the body from telescoping in on itself, a rigid but on a return to function. This takes the focus away from the dimensions is not optimally controlled across the 4th symptomology and concentrates it on the etiology dimension of time. This is clearly in line with ance or dysfunction in any of the three movement naturopathic principles as outlined in Chapter 1. While this approach may be time- effective and is not un-useful, it does mean that pre- Muscle imbalance physiology scription of treatment – corrective stretching, corrective mobilization, corrective exercises and other nutrition Muscle imbalance physiology was first described by and lifestyle advice – may be somewhat non-specific. Muscle imbalance was mainly embraced progress is difficult to gauge with such subjective by the physiotherapy community, though in recent approaches. Nevertheless, this pain patients, it is critical to provide a focus on return- author considers identification and correction of ing function as opposed to getting rid of dysfunction. This means that a patient can make great strides Perhaps one reason for the decline in interest in towards a return of function, yet may still have a muscle imbalance is that, as with nearly all clinical similar symptom profile. This phenomenon may be entities, to find a ‘textbook’ case is less common than explained neurophysiologically through the process finding a partial case. When under stress, the body will migrate to its Fast twitch preponderance Slow twitch preponderance position of greatest strength – which is why Fatigue early Fatigue late dynamically loading the patient can help to identify dysfunctional postural patterns. This subjective assessment approach provides Mobilizer dominance Stabilizer dominance little incentive for the patient to perform prescribed corrective exercises – especially in Superficial Deep the absence of pain. Outer unit Inner unit In Chapter 4 there is some discussion of what con- Global stability Local stability stitutes ‘dysfunction’ of a somatic tissue and the point is made that pain does not have to present for a tissue Multi-articular Mono-articular to be dysfunctional. Hence, it is entirely possible that Lengthen/weaken Shorten/tighten a patient may attend with a muscle imbalance (which represents a biomechanical dysfunction) yet have no pain. Nevertheless, any muscle imbalance disrupts the optimal axis of joint motion (a spatial or three- we may be able to see improvement – even though dimensional dysfunction) which will, over time, result the patient may be able to feel little difference. The fore, the means to assess joint position, joint range of point at which the sufferer feels pain is the point at motion and length–tension relationships objectively is which the rate of damage exceeds the rate of repair critical, in order to manage patients effectively and (see Fig. Interestingly, even among these experts, there load it is useful to have, at the very least, a Swiss ball, was still some confusion regarding muscle classifica- but ideally a cable column and a squat rack with tion. So, under tradi- Cranz 2000, Janda 1978, Williams & Goldspink 1973, tional practice, we are only left with observationally 1978). After stretching the facilitated lumbar erector assessing the condition then treating and making (thereby inhibiting it), it would no longer fire with the exercise recommendations to the client, which, in rectus abdominis during the sit-up maneuver (Janda itself, has some serious shortcomings. This approach depends on a very subjective it can create disrupted function at a range of joints (in assessment – which is wide open to bias. Chapter 9 • Rehabilitation and Re-education (Movement) Approaches 341 c b a d e Figure 9. It is not uncommon to hear that a those over 65 years of age (Chek 2004b); hence a therapist works with a mainly elderly population, naturopathic approach is surely to prevent such falls. Swiss ball training can condition the tilting reflex – In fact, the therapeutic truth is that, if a given individual something moving under the body. This is technically is unable to sit on a Swiss ball (with three bases of what happens when the interface between the ice and support) then, theoretically, they should not be able to sole of the shoe meet – the water on the surface of the stand (two bases of support) and certainly should not ice moves and the foot slips over it. Therefore, Swiss be able to walk (one base of support for 80% of the ball conditioning is ideal for training fall prevention in the gait cycle). To walk, therefore, is far more neurologically elderly in a slippery (tilting) environment, whereas a demanding than sitting on a Swiss ball. In fact, clinical experience suggests 342 Naturopathic Physical Medicine that it is extremely rare in the symptomatic popula- ment syndromes and/or capsular instabilities (see tion to find any patient that does not exhibit at least Fig. Upper crossed syndrome, like lower crossed syn- Lower crossed syndrome (see Chapter 6, drome, is essentially a gravity pattern. This is also known as Muscles that are commonly considered to be short a pronation pattern. At the • Supra- and infrahyoid group lumbar spine, lordosis is enhanced, meaning that the • Middle and lower fibers of trapezius low back is held in relative extension. Across time, this will lead to increased microtrauma, The classic osteokinematic coupling of an upper instability and pain in the hip joint, predisposing to crossed syndrome is a forward head posture (ventral degenerative change. Interestingly, lower crossed cranial glide), an increased 1st rib angle (dropped syndrome is more frequently observed in women – sternum), protracted shoulder girdle, flexed cer- which may help explain the higher incidence of hip vicothoracic junction and an increased thoracic problems in elderly women (Baechle & Earle 2000). Since lordosis is increased in the lumbar spine, greater Arthrokinematically, this means that the cervical loading is placed through the facet joints (see discus- lordosis tends to flatten with a compensatory hyper- sion below under ‘Neutral spine philosophy’), extension in the upper cervical spine to maintain the meaning that they are more prone to cumulative eyes on the optic plane (horizon). Spinal pathologies, such as spon- rib angle creates a flexion stress onto the 1st thoracic dylolysis, spondylolisthesis, foraminal stenosis and vertebra rotating it forward into sagittal flexion – with spinal stenosis, are more common in the extended the potential end result being a ‘dowager’s hump’. The dropped sternum means that the ribs are held in a flexed or ‘exhalation’ position.

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The lateral towel edges are folded up so as not to lie beyond There have been a number of preliminary investiga- the posterior axillary line discount 10 mg plendil mastercard. At the 5-minute mark (approx 30 minutes has been conducted at the National College of Natu- total) plendil 5 mg lowest price, replace the two towels with one fresh ropathic Medicine to investigate the blood count towel wrung from hot water. Quickly replace parameters and to identify if heat shock proteins are this towel with a towel well wrung from cold involved in any changes observed. The tigation has identified that post-treatment core tem- lateral towel edges are folded up so as not to perature is more likely to show a net increase than a lie beyond the posterior axillary line. At the 10-minute mark (approximately 40 peripheral temperatures likewise are more likely to minutes), check the center of the towel to see show a net increase (91% of patients) (Wickenheizer if the patient has warmed the towel to at least et al 1995). If the patient has warmed Unpublished research conducted at the Southwest the towel, then remove the towel and College of Naturopathic Medicine by Mark Carney proceed. Use a fresh dry towel to give a 5–20 second (triglycerides, high-density and low-density lipopro- dry friction rub to the patient’s back. Regardless of the a post-treatment increase in leukocyte circulation relatively high temperature of the constitutional towel that remained elevated for 2 hours (longest point application, the temperatures are usually well toler- of observation), particularly the monocyte levels. Appropriate knowledge of physio- Drs Carroll and Scott regularly observed a decreased therapy modality application is necessary. These two observational trends sug- Chapter 11 • Naturopathic Hydrotherapy 533 gest improved intestinal flora balance and improved • The Water Cure in America: Over 300 Cases of kidney function. It should be understood that during Various Diseases Treated with Water by a serial course of treatments, variations from the ‘stan- Wesselhoeft et al, published in 1856 by Fowlers dard’ are commonly employed on an as-indicated & Wells, New York, contains numerous cases basis. The cases include pneumonia, tuberculosis and Naturopathic perspectives various other acute and chronic diseases, including appendicitis, peritonitis and The constitutional hydrotherapy system is a uniquely salpingitis. The cases document the potential naturopathic approach to clinical physiotherapy usefulness of a simple yet effective treatments. There are also focused treatments for addressing regional functional Hyperthermia and pathological conditions. Intestinal putrefaction Indications/description by-products that are excreted via the kidneys are pre- Hyperthermia is the increase of body temperature sumably absorbed via intestinal circulation. Presumably liver detoxication mia treatments may be used in the prevention or treat- pathways are required for oxidation/reduction and ment of disease. The observation of improved ments may be applied locally, regionally or to the urinary indican levels and increased kidney concen- whole body. Hydropathic physicians of the 19th Further reading century, the early 20th century naturopathic physi- For more information on the system of constitutional cians, and doctors such as Dr Henry Lindlahr and hydrotherapy, see: Dr O. Carroll endorsed a similar tenet, even anti- cipating the evolution of a naturally occurring febrile 1. Blake E 2006 Constitutional hydrotherapy: a process (healing crisis or healing reaction) in the workbook of clinical lessons. Boyle W, Saine A 1988 Naturopathic There are many historical examples of the application hydrotherapy. It has been used in the treatment of both provide further clinical evidence for bacterial and viral infections and in cancer treatment hydrotherapy. Dr Kellogg’s main works on (Park et al 1990, Spire et al 1985, Toffoli et al 1989, hydrotherapy are Rational Hydrotherapy and Tyrrell et al 1989). This book provides further clinical 2003), hypertension (Biro et al 2003, Reaven et al case evidence of hydrotherapy. This method is difficult to control and runs a greater risk of doing harm to the patient. Alternatives It is not commonly (if ever) utilized by naturopathic While there are alternative methods for increasing physicians and will not be discussed in this section. Arrays of ultrasound or diathermy (shortwave/microwave) Physiological effects have been utilized with mixed results in clinical set- Hyperthermia produces a number of physiological tings. Hot air (sauna), steam, and immer- According to Guyton (1981), the metabolic rate would sion baths are common tools used in the production increase 100% for every 10°C rise in temperature. Safety issues Spire et al (1985) and Tyrrell et al (1989) describe the The most obvious safety issue with hyperthermia is thermal inactivation of viruses. In Toffoli et al (1989) discuss the effect of hyperthermia general, the ‘low and slow’ approach to hyperthermia on increased cell membrane permeability and the sub- treatment provides plenty of leeway for its safe appli- sequent intracellular uptake of drugs, while Konings cation and is much more appropriate clinically. These Thomas et al (2006) state that: ‘Hyperthermia is include persons with anemia, heart disease, hyperten- known to be synergistic or supra-additive with radia- sion and diabetes. It also increases intracellular drug accumula- whole-body hyperthermia at 41–42°C. Therefore, it is important that if a tub [would] simulate the effects of exercise? They found apy, their oncologist is aware of and approves the use that after 30 minutes of immersion to the shoulders, 6 of hyperthermia.

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