E. Karlen. Azusa Pacific University.

Hemangiomas typically have reduced or normal initial blood flow with increased activity on delayed images cheap 3ml bimat with mastercard treatment shingles. Cavernous hemangiomas that are 3 cm or greater in size almost always demonstrate a markedly increased blood pool even on planar images 3ml bimat fast delivery symptoms joint pain and tiredness. A hepatoma usually shows increased early perfusion followed by a defect order bimat cheap treatment effect, whereas abscesses and cystic lesions are hypoactive in all phases of the study. The presence of extrahepatic subdiaphragmatic activity indicates that the catheter is not optimally positioned. When multiple lesions have been noted in other imaging studies, the presence or absence of an increased blood pool should be reported on a lesion- by-lesion basis when possible. Principle Hepatobiliary scintigraphy is a diagnostic imaging study that evaluates hepatocellular function and patency of the biliary system by tracing the production and flow of bile from the liver through the biliary system into the small intestine. Computer acquisition and analysis as well as pharmacological interventions are frequently employed. These two categories include investigation of: —Suspected acute cholecystitis; —Suspected chronic biliary tract disorders; —Common bile duct obstruction; —Bile extravasation; —Atresia of the biliary tree (differential diagnosis in neonatal jaundice); 274 5. Mebrofenin may be selected instead of disofenin in moderate to severe hyperbilirubinaemia due to its higher hepatic extraction. Whenever possible, continuous computer acquisition should be performed (1 frame/min for 30–60 min). Patient preparation To permit gall bladder visualization, the patient must have fasted for a minimum of two and preferably four hours prior to administration of the radiopharmaceutical. If the patient has fasted for longer than 24 hours or is on total parenteral nutrition, a false positive study for cholecystitis may occur. In those cases, especially with parenteral nutrition, the patient may be pre-treated with sincalide (Section 5. Interference by opioids can be minimized by delaying the study for four hours after the last dose. The digital data can be reformatted to 5–15 min images for display and hard copying. Cinematic display of the data may reveal additional information not readily apparent on the film. When acute cholecystitis is suspected and the gall bladder is not seen within 40–60 min, 3–4 hour delayed images should be obtained, or morphine augmentation may be employed in lieu of delayed imaging. If the patient is being studied for a biliary leak, imaging delayed by 3– 4 hours and patient positioning manoeuvers (e. Interventions A variety of pharmacological or physiological interventions may enhance the diagnostic value of the examination. Appropriate precautions should be taken to promptly detect and treat any adverse reactions caused by these manoeuvres. This may occur in patients who have fasted longer than 24 hours, are on parenteral hyperalimentation or have a severe intercurrent illness. Sincalide should be administered slowly (over 3–5 min) to prevent biliary spasm and abdominal cramps. If the cystic duct is patent, the flow of bile into the gall bladder will be facilitated by morphine induced temporary spasm of the sphincter of Oddi. A second injection of radiopharma- ceutical (a booster dose of approximately 1 mCi) may be necessary prior to morphine injection if the remaining liver and/or biliary tree activity appears insufficient to permit gall bladder visualization. Imaging is usually continued for another 30 min following morphine administration but may be extended if desired. Contraindications to the use of morphine include respiratory depression in non-ventilated patients (absolute), morphine allergy (absolute) and acute pancreatitis (relative). Numerous protocols can be employed, but when performing and interpreting this procedure, the physician must adhere to a specific technique (i. If visual assessment of gall bladder emptying is adequate, a fatty snack may be used. Interpretation (a) Normal A normal hepatobiliary scan is characterized by immediate demon- stration of hepatic parenchyma, followed sequentially by activity in the intra- extrahepatic biliary ductal system, gall bladder and upper small bowel. Gall bladder visualization implies a patent cystic duct and excludes acute cholecystitis with a high degree of accuracy. Some renal excretion of the tracer may be seen, and bladder activity should not be regarded as pathological. A pericholecystic hepatic band of increased activity (the rim sign) is often associated with severe phlegmonous and/or gangrenous acute cholecystitis, and constitutes a surgical emergency. In chronic cholecystitis, the gall bladder will usually be seen within 30 min of morphine administration or on 3– 4 hour delayed images, while true cystic duct obstruction (acute cholecystitis) will result in persistent gall bladder non-visualization. Visualization of the gall bladder after activity in the bowel has been observed has a significant correlation with chronic cholecystitis. Severely ill patients and those on total parenteral nutrition will have a high incidence of gall bladder non-visualization even after morphine despite a patent cystic duct, and a larger dose of morphine (0. This may be seen more easily using a cinematic display and when the patient is imaged in the decubitus position. However, no evidence of hepatobiliary excretion in a jaundiced neonate having received phenobarbital is probably due to biliary atresia. Urinary excretion of the tracer (especially into a diaper) may be confused with bowel activity and is a potential source of erroneous interpretation. This abnormal bile reflux is highly correlated with bile gastritis, a cause of epigastric discomfort. Reporting In addition to patient demographics, the report should include the following information: (a) The indication for the study (e. Since activity within the lumen of the bowel can move antegrade and retrograde, frequent images will increase the accuracy of localization of the bleeding site. Clinical indications Gastrointestinal bleeding can be either upper, originating above the ligament of Treitz, or lower, distal to the ligament of Treitz. Frequent causes of upper gastrointestinal bleeding include esophageal varices, gastric and duodenal ulcers, gastritis, esophagitis, Mallory–Weiss tears or neoplasms. Causes of lower gastrointestinal haemorrhage include angiodysplasia, diver- ticula, neoplasms and inflammation, and, in children and young adults, Meckel’s diverticulum. Endoscopy and angiography provide accurate locali- zation of bleeding sites and potential therapeutic control. This is a major advantage since most gastrointestinal bleeds are intermittent and therefore are frequently missed by other methods. The clinical picture for active gastrointestinal haemorrhage is often unreliable and misleading. There is frequently a marked temporal lag between the onset of bleeding and clinical presentation. While it may be clinically apparent that the patient has bled from the presence of melena or a haemor- rhage, the blood may pool in the colon for hours before being evacuated.

Elaborating on the “two-fold consi- deration” of plague order discount bimat symptoms thyroid, “the first Supernaturall buy bimat 3ml cheap symptoms quivering lips, the second Naturall” order bimat with american express medicine kit, Clapham interestingly equates “atheists” with “naturians”, suggesting that notions of the natural origin of plague entail ignorance and lack of faith: “Atheists, meere Naturians and other ignorant persons, do hold 7 A powerfully imaginative description of buboes as marks of divine punish- ment is found in Dekker: “the purple whip of vengeance” (1609: B). The syntactic coordination of “atheists”, “naturians” and “ignorant persons” is expressive of Clapham’s contempt of supporters of the natural or Galenic theory of plague. The opposition Galenist/Christian in Clapham’s warning that “To speake and act in such cases, as sole Naturians, is of Christian to become Galenists, and of spirituall to become carnall” (A3) points to his open challenge of the official stand of mainstream Anglicanism which stressed God’s blessing of medical practices. His contempt of medi- cine is conveyed by the verb to creepe in the following quotation: “we should not creepe on the earth herein with Galen, Hippocrates and v such” (B ). Clapham’s use of the verb to creepe, by evoking creatures from the lower section of the great chain of being, dehumanizes Galen, Hippocrates and their followers. While the repulsiveness generally associated with creeping creatures like worms and snakes is clearly implied, the verb is also suggestive, I think, of the serpentiform Satan of Genesis. The supporters of the providential notion of plague usually dared not challenge openly the official stand of the national Church on the divine sanction of medical practices. Instead, exploiting the universal awareness of extraordinary mortality rates during epide- mics, they often insinuated suspicion of medical regimens’ efficacy and suggested that survivors owed their lives to spiritual medicine and God’s inscrutable will since: “when God shoots these arrows […] none can pull them out but God himself”. Writings by people holding these views are characterized by frequent recourse to terms within the semantic field of inscrutable events and incurable or inescapable scourges. Some distinctive features of plague, like the rapidity of its spread and the swiftness of death after contagion, are also used in connection to discourses of medical impotence and 8 people’s helplessness. Hence variations of sudden and unexpected 8 As Boeckl (2000: 12) points out, the incubation period of septicemic and pneumonic forms of plague “lasts only a few hours. In his reminder that “the Plague usually killeth within a few daies; sometimes within a few hours after its first ap- proach”, Vincent admonishes: “suddenly the arrow is shot which woundeth unto the heart, so it gives little time of preparation before it brings to the Grave” (1667: 10-11). Pullein warns that the young and healthy should not feel out of danger, since it is for all to see “how men and Women, that were lusty and strong v are suddenly laide along in the dust of the earth” (1608: E3 ). Another rhetorical strategy employed to subtly criticize current policies for public health while avoiding open criticism is a highly emotional and suggestive rendering of the human cost and social consequences of the official strategies of containment of the epidemic through quarantine of the infected enforced by local authorities with 9 full backing by the Church. Vincent is perhaps the most gifted author of such narratives: his depiction of the despair of segregated people “crying and roaring at their windows” (1667: 38) is powerful. I think that the verb to roar, apart from being suggestive of anguish, in view of its relation to wild, dangerous beasts, performs two additional functions: it points to the dehumanizing character of a policy entailing segregation of human beings like beasts in cages and rejects medical notions of the life-threatening character of contact with the infected. Vincent adds to the current uses discussed above of the metaphor of war in connection to plague (humans versus disease and God versus sinners) by suggesting that quarantine sparks off a conflict between the healthy and the diseased: people cast a fearful look at infected can kill patients within a day, causing apparently healthy persons to collapse suddenly”. Ideological Uses of Medical Discourses in Early Modern English 61 houses marked by red crosses, “as if they had been lined with enemies in ambush, that waited to destroy them” (1667: 32). Alarm about disruption of affective and social ties because of fear of contagion ─ people “begin to fear whom they converse with and deal withall, […] least they should have come out of infected places” (Vincent 1667: 31) ─ and the segregation of whole families is often associated in the writings of critics of official policies with stern censure of another strategy of containment of epidemics: flight from infected areas. The issue of the ethical legitimacy and epidemiological efficacy of flight is a major topic in most plague writings which resonate with questions of this kind: since plague is a well deserved divine punishment, is it morally acceptable to evade it? Totaro (2005: 39) puts the moral dilemma into focus: No one could determine whether God wanted people to remain within a plague-infested city and have faith in his protection or whether God wanted people to care for their bodies and families by fleeing from the infection. The topic must have been in the forefront of people’s mind if physi- cians like Cogan often devote space in their widely read health ma- nuals to the debate on “whether it be lawefull to flie from the plague” (1584: 266); notably, the adjective lawful in this context is used with reference to ethics, not laws. One party endorsed Galen’s teaching re- garding the crucial role of miasma in plague epidemics and the effica- cy of flight to avoid infection, the other recalled Moses’ warning “flee whether thou wylte, in case thou take with thee the contempt of god and breache of his commaundement, god shall fynde thee out” (Hooper 1553: C1) and stressed providential and predestinarian views: “If it bee Gods will, you shall bee safe any where, if it be not Gods will, you shall be safe no where” (Pullein 1608: F2). Some texts aim to rouse sympathy for the abandoned diseased, as does the following passage which cen- sures the behaviour of those who flee infected areas. Fear of contagion 62 Paola Baseotto Hath rased out of their hearts, for the while, all affections of love and pity to their nearest Relations and dearest Friends; so that when the Disease hath first seized upon them, and they have had the greatest need of succour, they have left their friends in distress, and flown away from them, as if they had been their Enemies (Vincent 1667: 12). The official stand was that churchmen and magistrates should stay at their posts during epidemics, although they should not risk their lives by visiting the sick. Hooper’s warning that “bishops, vicars, curates” who abandon the sick “flee from goddes people into god’s high indig- nation” (1553: C2) seems reflective of the fact that clergymen in the Church of England very often fled (see Totaro 2005: 46). It is worth noting, as Wallis suggests (2006: 15), that on the occasion of out- breaks of plague many nonconformist clergymen who had been eject- ed from their parishes after the Restoration stayed in plague-infected areas to assist the diseased and preach, thus circumventing the statuto- ry prohibition of public preaching by the dissenting clergy. The tone of the many references to the stands of nonconforming preachers in official documents by the Privy Council and Church of England authorities seems to indicate a deep preoccupation with their impact on common people’s acceptance of medical care and com- pliance with government plague-control measures. The plague orders issued in 1603, which replicate those promulgated by Queen Elizabeth in 1578, are eloquent in this regard: If there be any person Ecclesiasticall or Lay, that shall hold and publish any opinions (as in some places report is made) that it is a vain thing to forbeare to resort to the Infected, or that it is not charitable to forbid the same, pretending that no person shall die but at their time prefixed, these persons shall be not only reprehended, but by order of the Bishop, if they be Ecclesiasticall, shall be forbidden to preach, and being Lay, shall also be enioyned to forbear to ut- ter such dangerous opinions upon pain of imprisonment. The correspondence between Bishop Grindal and Lord William Cecil, Queen Elizabeth’s Secretary of State, attests to a common worry and effort at opposing such views (1563: 270). While nonconformists tended to inflect passa- Ideological Uses of Medical Discourses in Early Modern English 63 ges of the Bible which seemed to endorse their predestinarian and providential views and laid great stress on extrapolations from Cal- vin’s wider teaching like “it is only in his hand to apoint lyfe or death: and therefore thys mater oght onely to be refferred to hys wil” (1561: F6), the mainstream Church of England clergy emphasized the abun- dant Scriptural evidence regarding the divine sanction of medical practices and recalled Calvin’s numerous and unambiguous references 10 to it. An obligatory element of their plague writings (as of those, it should be noted, by medical and lay authors) is a reminder of the reite- ration throughout the Bible of God’s blessing on healing plants and remedies used by physicians who thus function as instruments of divine mercy. All authors quoted from Ecclesiasticus (Book of Sirach) 38 which opens with the exhortation “Honour the physician for the need thou hast of him: for the most High hath created him” then speci- fies that “all healing is from God. Vehement attacks on preachers holding the opposite view are penned by influential churchmen like John Sanford who admonishes that those who trust only in “God’s protection” and “neglect the good meanes of [their] preseruation” become “homicides and willfull mur- therers” of themselves (1604: 50). The inclusion and prominence of such warnings in the various editions of official prayers for universal reading and repetition endow them with the quality of expressions of the official stand of the national Church. The tone of these pronounce- ments is often harsh and lapidary as in a reference to the attitude of those who refuse medicaments and stay in infected places trusting that their faith will save them: “this is not faith in God, but a grosse, igno- v rant, and foole-hardy presumption” (Church of England 1603: D1 ). While, as Slack notes (1985: 230), Nowell’s homily in the first edition of the official plague prayers urged godly submission to God’s will and endorsed ─ at least partly ─ providential interpretations of and attitudes to plague, the “Exhortation” in the third edition of 1603 stressed the role of contagion requiring containment measures and of- fered a particularly forceful statement of ecclesiastical energetic back- 10 On Calvin’s and more generally the Anglican Church’s endorsement of medi- cal practices see Harley (1993). A general reference to the efficacy and legitimacy of com- pliance with health regulations, “the good use of ordinarie meanes, and the wary and carefull carriage of our selues out of the danger of contagion” is followed by exposure of the ungodliness of opposite approaches: “the desperate securitie of those, that seeme neither to feare, nor to flie from this infection, is but a tempting and prouoking of the iudgement of God”. Their behaviour makes them guilty of “willfull murder both of themselues, their children, their families, and neighbours, which hatefull crueltie against their owne kind, Turkes and infidels would abhorre. Concluding remarks The synergic effort of the national Church and the English govern- ment in containment of plague seems to mark a turning point in the shaping of a mentality that prepared breeding ground for a new atten- tion to human nature in its relation to the physical world. Plague epi- demics in sixteenth- and seventeenth-century England sparked off a conflict of opposed ideological views regarding the efficacy and legi- timacy of human initiative on the occasion of medical emergencies. Faced with a universal, collective catastrophe of apocalyptic propor- tion, the vigorous endorsement of health regulations by the main- stream Anglican authorities and their inclusion of instruction for the preparation of plague medicaments in official prayers had a great impact on containment of the disease. It also produced a less easily documentable but no less crucial effect on developments of a new scientific understanding of the human body and its environment as a subject worth study and experiment not despite theology and its view Ideological Uses of Medical Discourses in Early Modern English 65 of the pre-eminence of the spiritual or immaterial component of hu- man nature, but in harmony with it. A Fourme to be Used in Common Prayer Twyse a Weke, and also an Order of Publique Fast, to be Used Euery Wednesday in the Weeke, Durynge this Tyme of Mortali- tie, and Other Afflictions, Wherewith the Realme at this Present is Visited. Certaine Prayers Collected out of a Forme of Godly Meditations, Set forth by his Maiesties Authoritie: And most Necessary to be Vsed at this Time in the Present Visitation of Gods Heauy Hand for our Manifold Sinnes. Orders thought Meete by his Maiestie and his Priuie Councell, to be Executed throughout the Counties of this Realme, in such Townes, Villages and other Places as are, or may be hereafter Infected with the Plague, for the Stay of Further Increase of the Same. Certain Necessary Directions, as well for the Cure of the Plague as for Preuenting the Infection; with many Easie Medicines of Small Charge, Very Profitable to His Maiesties Subiects; Set Downe by the Colledge of Physi- cians by the Kings Maiesties Speciall Command; with Sundry Orders Thought Meet by His Maiestie, and his Priuie Councell, to be Carefully Executed for Preuention of the Plague. Language user refers to the aspects related to the user that participates in a language event such as geographical, temporal, idiolectal, social aspects, etc. Our starting point is the general agreement on the part of several linguists (Firth 1935: 67; Gregory/Caroll 1978: 64; Halliday 1978:77; Biber/Finegan 1994: 33) regarding the importance of the co- relational nature of the situational characteristics (field, tenor and mode) and the linguistic expressions, so that recurrent situational characteristics may determine the selection of linguistic expressions and the latter may correspondingly shape the situation. This use- related framework for the description of language variation aims to uncover the general principles that lead to variation in situation types, so that it is possible to identify “what situational factors determine what linguistic features” (Halliday 1978: 32).

Treatment McKenzie has classified mechanical low back pain demands that motions which centralize are into three syndromes order 3 ml bimat with amex symptoms ketosis, each of which is defined by a performed and that motions which theoretical model of the underlying pathology purchase discount bimat on line medicine that makes you poop, plus peripheralize are not buy bimat now medicine 7 day box. This might include patient history, postural assessment and mechanical appropriate exercises (that centralize) and/or examination findings (Razmjou et al 2000): manual treatment, as well as application of appropriate ergonomics Patients whose 1. Postural: Examination findings include full and symptoms peripheralize during assessment pain-free active ranges of motion, with using positions and movements have a poor repetitive motions also pain-free. Sustained prognosis, and usually respond poorly to posture at normal end of range causes pain. Testing muscles for length Treatment involves primarily avoiding painful positions and maintaining correct posture. Janda (1983) suggests that to Dommerholt (2000), discussing enhancement of obtain a reliable evaluation of muscle shortness, the posture and function in musicians, has summarized following criteria be observed during passive an important concept: testing: In general, assessment and treatment of individual • The starting position, method of fixation and muscles must precede restoration of normal posture direction of movement must be observed and normal patterns of movement. Instead, muscle • If possible, the force exerted on the tested imbalances must be corrected through very specific muscle must not work over two joints. Once the musculoskeletal conditions of ‘good posture’ have been met, postural • The examiner should keep the stretch and the retraining can proceed. The functional tests described above offer evidence • Pressure or pull must always act in the of overactivity. Understanding ‘ease’ and ‘bind’ It is in shortened muscle fibers, as a rule, that reflex The concept and reality of tissues providing the pal- activity is noted. This takes the form of local dysfunc- pating hands or fingers with a sense of their relative tion variously called trigger points (Simons et al 1999), ‘bind’, as opposed to their state of ‘ease’, is one which hyperalgesic skin zones (Lewit 1999a), tender points needs to be literally felt to be appreciated. The examples of assessment of shortness in muscles, given here as exercises, are meant to encourage Why do we need to identify muscle acquisition and/or refinement of the skills required shortness? Greenman (1996) offers a summary of his clinical approach that demands knowledge of shortness: Hamstring notes: Should obviously tight After short tight muscles are stretched, muscles that hamstrings always be treated? The patient lies with the non-tested leg abducted • A sense of bind should be noted by the palpating slightly, heel over the end of the examination table. The leg to be tested should be close to the edge of • An observation sign can confirm this barrier. After the table, and you should ensure that it is in its it has been passed there will be movement of the anatomically correct position: knee in full extension, pelvis as a whole, laterally towards the tested and with no external rotation of the hip, which would side. Stand between the patient’s leg and the table, so passed (pelvis moves), repeat the process over and that control of the tested leg is achieved with your over until you learn to recognize the subtle lateral (non-tableside) arm/hand, while the tableside ‘tightening’ under your palpating hand on the inner hand can rest on, and palpate, the inner thigh thigh. Abduction of the tested leg is introduced passively reached, then no further testing of these muscles is until the first sign of resistance (first barrier) is noted required, as the degree of abduction is normal and (Fig. There are three indicators of this there is probably no shortness in the short or long resistance: adductors. A The practitioner’s perception of the transition point, where easy movement alters to demand some degree of effort, is regarded as the barrier. B The barrier is identified when the palpating hand notes a sense of bind in tissues which were relaxed (at ease) up to that point. Reproduced with permission from Chaitow (2001) Chapter 6 • Assessment/Palpation Section: Skills 159 Box 6. If, after knee flexion has been introduced, further a 45° angle is achieved (without effort, or a sense of abduction is now easily achieved to 45° when bind in the tissues), then a shortness restriction previously it was restricted, this indicates that any exists in either the medial hamstrings or the short previous limitation into abduction was the result of adductors of the thigh. After the short adductors have been appropriately treated/released it will still be necessary to retest 1. Precisely the same test is carried out; however, when abduction with the leg straight, as the fact that the the first resistance barrier is reached, flexion of the short adductors are short does not remove the knee is introduced, so that the lower leg hangs down possibility that the medial hamstrings (two-joint freely. Intrinsically, the influence is via the close anatomic • The quadratus lumborum stabilizes lumbar and physiological relationship between biceps femoris spinal movements (McGill et al 1996), while and the sacrotuberous ligament (they frequently tightening has also been described. If there is no hip flexor shortness, the non-tested leg should lie flat on the surface of the table. Reproduced with permission from Chaitow there is some shortening of the hamstrings and the (2001) muscles can be treated in this straight leg position. Tensor fascia lata notes Upper trapezius notes Rolf (1977) points out that persistent exercise such as Lewit (1999a) simplifies the need to assess for short- cycling will shorten and toughen the fascial iliotibial ness of this muscle, by stating: ‘The upper trapezius band ‘until it becomes reminiscent of a steel cable’. There is com- muscle can often be observed when it is very short, 162 Naturopathic Physical Medicine Box 6. Reproduced with permission from Chaitow (2001) (unless unusual hip width or a short thigh length prevents this). If the scapulohumeral rhythm test is positive, then, In these functional tests firing sequences may at by implication, upper trapezius (and levator scapu- times have differed from the proposed norm (Janda lae) will be overactive and so will have shortened, and 1983, Liebenson 2005), with implications for overac- will probably house trigger points (see discussions of tivity, and therefore shortness, in specific muscles postural and phasic muscles earlier in this chapter). Strength tests of these muscles allow them to be graded from virtually ‘no strength/no contraction’ to Assessing and grading muscle weakness ‘movement possible against resistance’. Note that stretching in this (or any of the alternative positions which access the middle and posterior fibers) is achieved following the isometric contraction by means of an easing of the shoulder away from the stabilized head, with no force being applied to the neck and head itself. For more detailed understanding of muscle strength evaluation, Janda’s Muscle Function Testing (1983) is recommended. For an understanding of en- durance features, Norris’s Back Stability (2000b) is recommended. Scale for evaluation of concentric contractions (Janda 1983) Grade 0 = no contraction/paralysis Grade 1 = no motion noted but contraction felt by Figure 6. Usually a lengthened muscle will demonstrate a loss of endurance when tested in a shortened position. This can be tested by the practitioner passively pre- positioning the muscle in a shortened position and assessing the duration of time that the patient can hold Figure 6. Reproduced with permission from Chaitow (2001) the muscle in the shortened position. There are various methods used, including: • Ten repetitions of the holding position for 10 seconds at a time • Alternatively, a single 30-second hold can be requested. Optimal endurance is indicated when the full inner If the patient cannot hold the position actively from range position can be held for 10 to 20 seconds. Chapter 6 • Assessment/Palpation Section: Skills 165 example, adding dorsiflexion during the straight leg Box 6. Comparison with the test findings on an opposite • Assess results based on criteria outlined above. Altered range of movement is another indicator of abnormality, whether this is noted during the initial These testing procedures can become treatment. These problems can be test regarded as mechanical in origin as far as the nerve restriction is concerned. Provocation tests that involve movement rather than Less well known is the fact that the tibial nerve, pure (passive) tension are most effective. There is no movement of zation’ of the neural structures, rather than simply the tibial nerve behind the knee itself, which is there- stretching them, and that these methods be reserved fore known as a ‘tension point’. Muller et al • ankle dorsiflexion (this stresses the tibial component (2003) studied over 300 patients with back pain, using of the sciatic nerve) among other methods Janda’s functional tests, and • ankle plantarflexion, plus inversion (this stresses the found that approximately one-third (112 patients, pre- common peroneal nerve, which may be useful with dominantly female) demonstrated constitutional anterior shin and dorsal foot symptoms) hypermobility compared with 13% of normal con- • passive neck flexion trols.