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The pain of ilioinguinal neuralgia is made worse by extension of the lumbar spine depression definition meteorology purchase zoloft 50 mg fast delivery, which puts traction on the nerve. Untreated, progressive motor deficit consisting of bulging of the anterior abdominal wall muscles may occur. Physical findings include sensory deficit in the inner thigh, scrotum, or labia in the distribution of the ilioinguinal nerve. Plain radiographs of the hip and pelvis are indicated in all patients who present with ilioinguinal neuralgia, to rule out occult bony pathology. Magnetic resonance imaging scan of the lumbar plexus is indicated if tumor or hematoma is suspected. Differential Diagnosis It should be remembered that lesions of the lumbar plexus from trauma, hematoma, tumor, diabetic neuropathy, or inflammation can mimic the pain, numb- ness, and weakness of ilioinguinal neuralgia and must be included in the differential diagnosis. The ilioinguinal nerve is a branch of the L1 nerve root with contribution from T12 in some patients. The nerve may interconnect with the iliohypogastric nerve as it continues to pass along its course medially and inferiorly where it accompanies the spermatic cord through the inguinal ring and into the inguinal canal. The distribution of the sensory innervation of the ilioinguinal nerves varies from patient to patient as there may be considerable overlap with the iliohypogastric nerve. Chapter 178 Iliohypogastric Neuralgia 283 Treatment External oblique Iliohypogastric nerve Internal oblique Transverse abdominis Peritoneum Ilioinguinal nerve Anterior superior iliac spine Pharmacologic management of ilioinguinal neuralgia is generally disappointing, and general nerve block will be required to provide pain relief. Initial treatment of ilioinguinal neuralgia should consist of treatment with simple analgesics, nonsteroidal anti-inflammatory agents or cyclooxygenase-2 inhibitors. Avoidance of repetitive activities thought to exacerbate the symptoms of ilioinguinal neuralgia. If the patient fails to respond to these conservative measures, a next reasonable step is ilioinguinal nerve block with local anesthetic and steroid. The iliohypogastric nerve is a branch of the L1 nerve root with a contribution from T12 in some patients. The iliohypogastric nerve continues anteriorly to perforate the transverse abdominis muscle to lie between it and the external oblique muscle. The most common causes of compression of the iliohypogastric nerve at this anatomic location involve injury to the nerve induced by trauma, including direct blunt trauma to the nerve and damage during inguinal herniorrhaphy and pelvic surgery. Physical findings include sensory deficit of the abdominal skin above the pubis in the distribution of the iliohypogastric nerve. Testing Electromyography will help distinguish iliohypogastric nerve entrapment from lumbar plexopathy, lumbar radiculopathy, and diabetic polyneuropathy. Plain radiographs of the hip and pelvis are indicated in all patients who present with iliohypogastric neuralgia, to rule out occult bony pathology. Signs and Symptoms Iliohypogastric neuralgia presents as paresthesias, burning pain, and occasionally numbness of the abdominal skin above the pubis. The pain of iliohypogastric neuralgia is worsened by extension of the lumbar spine, which puts traction on the Differential Diagnosis It should be remembered that lesions of the lumbar plexus from trauma, hematoma, tumor, diabetic neuropathy, or inflammation can mimic the pain, numbness, and weakness of iliohypogastric neuralgia and must be included in the differential diagnosis.
Spinal cord dysfunction associated with multiple sclerosis will often manifest with the constellation of findings associated with transverse myelitis depression statistics zoloft 25 mg purchase line. Decreased joint proprioception and vibratory sense and, less commonly, abnormal pain and temperature perception can also be identified with careful neurologic examination. Testing in patients suspected of suffering from multiple sclerosis is required for three reasons: (1) to rule out other more treatable causes of neurologic dysfunction, such as stroke, epidural abscess, and hypoglycemia; (2) to identify other abnormalities due to the disability associated with multiple sclerosis, such as dehydration, urosepsis, and so on; and (3) to confirm the diagnosis of multiple sclerosis. To accomplish these three goals, basic screening laboratory testing, including complete blood count, chemistry profile, erythrocyte sedimentation rate, electrolytes, serum thyroxine, and antinuclear antibody testing, should be obtained. Note that largest normal-appearing tissue atrophy is in deep white matter where lesion probability map is largest. The color map (minimum dark blow) in the upper views corresponds to the percentage (maximum ~ 28% (bright red) in periventricular white matter and corpus callosum isthmus. The color map in the middle lower view corresponds to the percentage of patients with lesions. Treatment of patients with multiple sclerosis is based on the type of multiple sclerosis the patient is suffering from and variables including the severity of symptoms and rate of progression of the disease. For patients with more progressive forms of multiple sclerosis, the addition of corticosteroids, cyclophosphamide, and methotrexate may be indicated. The differential diagnosis of patients suspected of multiple sclerosis is a long one and is outlined in Table 212-4. Thus, although multiple sclerosis is not a diagnosis of exclusion, it should be thought of as a diagnosis that requires a thorough search of other diseases prior to confirming the final diagnosis of multiple sclerosis. It is estimated that between 30% and 50% of polio survivors will experience post-polio syndrome to a greater or lesser extent. Although the exact cause of post-polio syndrome is unknown, several pathophysiologic mechanisms have been proposed that either alone or together may be responsible for the signs and symptoms of post-polio syndrome. Many experts believe that post-polio syndrome is a combination of a gradual decompensation of the normal process of nerve denervation and reinnervation and the decrease in muscle strength that occurs as part of the normal aging process. Other experts have postulated that post-polio syndrome is due to the reactivation of a latent virus in a manner analogous to the varicella zoster/shingles mechanism. On physical examination, asymmetrical muscle weakness and atrophy may be observed in muscles that were affected initially by the poliovirus or in muscles that were not obviously affected at the time of initial infection. Fasciculations can sometimes be observed with careful examination of weakened and/or atrophied muscles.
Enterobius vermicularis (Linnaeus 1758) Introduction Enterobius vermicularis (pinworm) is the most prevalent nematode infection of humans great depression relief definition buy zoloft 100 mg cheap, its only host. In the United States, pinworm still occurs with one estimate indicating that it may affect up to 40 million individuals or more. In some communities in Europe, the prevalence rates may be as high as 50% in children, especially in the poorer countries of Eastern Europe and the Balkans. Life Cycle the lifecycle of pinworm is one of the simplest among parasites, and has a typical nematode pattern of development; four larval stages (L1-L4), and the adult stage. Adult worms live freely in the lumen of the transverse and descending colon, and in the rectum. The adult worms mate, and within 6 weeks, each female contains approximately 10,000 fertilized, non-embryonated eggs. The gravid female migrates out the anus onto the perianal skin at night, most likely stimulated to do so by the drop in body temperature of the host. There, she experiences a prolapse of the uterus, expels all her eggs, and then dies. The eggs rapidly embryonate and become infective within 6 hours of being laid, exhibiting one of most rapid embryological developmental cycles among all nematode species. An uncomfortable perianal pruritis develops, called pruritis ani, that may be severe enough to cause sleeping disturbance. Ingestion of these eggs can occur when a child places infective hands into their mouth. Once they reach the small intestine, they shed their cuticle (molt) becoming L2 larvae. L4 larvae feed and then molt, transforming into adults that travel to the large intestine, where they take up residence. Alternatively, eggs can hatch on the skin at the site of deposition, and the L2 larvae can crawl back through the anus into the rectum, and eventually the colon, where they develop into reproducing adults. In female patients, the larvae that hatch on the skin near the anus occasionally crawl into the vagina instead of the rectum, establishing an aberrant infection. Aberrant infections also include pelvic peritonitis, ovarian infection, granuloma of the liver, and the appendix. The parasite elicits a mild, local inflammatory 204 the Nematodes humans, but the reasons for this are not clear. It remains to be determined whether this difference in susceptibility has an immunological or physiological basis. Those few who are symptomatic experience intense itching of the perianal area, which in rare instances leads to cellulitis. Enuresis has been attributed to infection with pinworm, but no causal relation has been established.
In general mood disorder fact sheet discount zoloft 100 mg mastercard, total body immersion should be avoided in patients with multiple sclerosis to avoid the triggering of neurologic deficits that may become permanent. Fluidotherapy Fluidotherapy utilizes convection as its mechanism of heat transfer. In contrast to hydrotherapy, which relies on the high specific heat of water Chapter 339 the Physiologic Effects of Therapeutic Heat 569 delivered at lower temperatures, fluidotherapy relies on the substances with a low affinity for heat, such as glass beads, pulverized corn cobs, etc. The result is a dry semifluid mixture that is heated by thermostatically controlled hot air. The patient is able to immerse the affected hand, foot, or portion of an extremity into the mixture. As the affected body part is heated, sweating enhances heat transfer, producing superficial heating. This treatment modality is useful in the treatment of reflex sympathetic dystrophy in that the medium used, such as glass beads, provides gentle tactile desensitization. Deep Heating Modalities Modalities That Deliver Heat by Conversion the heat delivery modalities discussed earlier have in common their ability to produce superficial heating of affected tissues. When heating of the deep tissues is desired, the clinician has several modalities at his or her disposal. These include three modalities in common clinical use: (1) ultrasound, (2) shortwave diathermy, and (3) microwave diathermy. These modalities have in common their ability to safely heat deep tissues via the physical property of conversion of physical energy into heat when properly used. Variables affecting the amount of heat ultimately delivered to deep tissues for each of these modalities include (1) the pattern of relative heating, (2) the specific heat of the tissue being heated, and (3) the physiologic factors affecting the tissues being heated. Relative heating is the relative amount of energy that is converted into heat at any point in the tissue being heated. For sake of consistency, common reference points for the pattern of relative heating include the subcutaneous fat-muscle interface, the muscle-bone interface, and others. The pattern of relative heating is different for each of the deep heat modalities currently in common clinical use. The specific heat of the tissue also influences how deep heat is distributed through affected tissues. As each of these tissues is heated, the thermal conductivity of the tissue changes as the relative temperatures of each type of tissue reach equilibrium, thus affecting the heat exchange between warmer and cooler tissues. The physiologic changes induced by deep heating also influence the heat distribution of these deep heating modalities.
A short course of conservative therapy consisting of simple analgesics depression symptoms husband buy discount zoloft 25 mg on-line, nonsteroidal anti-inflammatory agents, or cyclooxygenase-2 inhibitors is a reasonable first step in the treatment of patients suffering from meralgia paresthetica. If the patient does not experience rapid improvement, the injection of the lateral femoral cutaneous nerve is a reasonable next step. Magnetic resonance imaging of the back is indicated if herniated disk, spinal stenosis, or a space-occupying lesion is suspected. Differential Diagnosis Meralgia paresthetica is often misdiagnosed as lumbar radiculopathy or trochanteric bursitis or attributed to primary hip pathology. Clinically, the pain of spinal stenosis usually manifests in a characteristic manner as pain and weakness in the legs and calves when walking. These symptoms are usually accompanied with lower extremity pain emanating from the lumbar nerve roots. In addition to the pain, the patient with spinal stenosis may experience associated numbness, weakness, and loss of reflexes. The causes of spinal stenosis include bulging or herniated disk, facet arthropathy, and thickening and bucking of the interlaminar ligaments. Signs and Symptoms the patient suffering from spinal stenosis will complain of calf and leg pain and fatigue with walking, standing, or lying supine. Patients will also complain of pain, numbness, tingling, and paresthesias in the distribution of the affected nerve root or roots. Muscle spasms and back pain, as well as pain referred into the trapezius and intrascapular region, are common. Occasionally, a patient suffering from spinal stenosis will experience compression of the lumbar spinal nerve roots and cauda equina resulting in myelopathy or cauda equina syndrome. This represents a neurosurgical emergency and should be treated as such, although often the onset of symptoms is insidious. Pain syndromes that may mimic spinal stenosis include low back strain, lumbar bursitis, lumbar fibromyositis, inflammatory arthritis, and disorders of the lumbar spinal cord, roots, plexus, and nerves including diabetic femoral neuropathy. Radionuclide bone scanning and plain radiographs are indicated if coexistent fracture or bony abnormality such as metastatic disease is being considered. Screening laboratory testing consisting of complete blood count, erythrocyte sedimentation rate, and automated blood chemistry testing should be performed if the diagnosis of spinal stenosis is in question. Caudal epidural blocks with local anesthetic and steroid have been shown to be extremely effective in the treatment of spinal stenosis. These abnormalities may be self-limited or may lead to compression of the nerve roots and spinal cord. In addition to pain, the patient with arachnoiditis may experience associated numbness, weakness, loss of reflexes, and bowel and bladder symptomatology. The cause of arachnoiditis is unknown but may occur following a herniated disc, infection, tumor, myelography, spine surgery, or intrathecal administration of drugs.
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Syphacia oblevata is a pinworm species that infects mice only mood disorder brochure 25 mg zoloft purchase mastercard, and reaches much larger numbers in nude (athymic) mice than it does in the same mice into which a subcutaneous implant of thymic tissue from syngeneic donors was introduced. These female worms are 8-13mm long and very thin having the appearance of small white pieces of thread. Adult pinworms can be readily identified when they are seen on histologic sections because of bilateral cuticular projections known as alae. In patients with abdominal pain or other gastrointestinal symptoms, a fecal examination may be necessary to rule out co-infection with other infectious agents. None of these drugs kills the eggs or developing larvae, therefore, "blind" re-treatment is the reason for a second treatment 2 weeks after the original therapy. This second round of therapy destroys worms that have hatched from eggs ingested after the first treatment. Since eggs can survive 2 to 3 weeks before being ingested, the timing of exposure for an infected patient is 1 to 2 months prior to appearance of adult female worms capable of producing infective eggs. Treatment of exposed contacts, all household members, and source patients, if not household members, is recommended and has been successful in both households and institutions. The groups showing highest prevalence of infection are school children and institutionalized individuals. Compounding the problem is the fact that the eggs can survive for several days under conditions of high humidity and intermediate to low temperatures. Thorough washing of hands with soap and water after using the toilet, changing diapers, or caring for school age children should help to reduce transmission. In institutions, daycare centers, schools, or other areas with pinworm infections, mass treatment during outbreaks can be successful. Journal of hygiene, epidemiology, microbiology, and immunology 1972, 16 (2), 213-21. Comparative efficacy of thienpydin, pyrantel pamoate, mebendazole and albendazole in treating ascariasis and enterobiasis. Working with Henry Shortt, and a host of other colleagues, the group discovered the hypnozoite, the stage responsible for relapses of infection with Plasmodium vivax. Garnham also produced a wealth of publications on non-primate and non-human primate malarias, in addition to those infecting humans. His book, Malaria Parasites and Other Haemosporidia, remains a classic in the field of malariology. The prevalence of trichuriasis is approximately 477 million worldwide, with the largest numbers of infections in Asia, Sub-Saharan Africa, and the tropical regions of the Americas.
Syndromes
C and D depression symptoms cure zoloft 50 mg purchase fast delivery, Ganglion of Walther appearing as a filling defect in a pool of contrast medium after precise needle placement. The proximity of the ganglion of Walther to the rectum makes perforation and tracking of contaminants back through the needle track during needle removal a distinct possibility. Infection and fistula formation, especially in those patients who are immunocompromised or have received radiation therapy to the perineum, can represent a devastating and potentially life-threatening complication to this block. The relationship of the cauda equina and exiting sacral nerve roots makes it imperative that this procedure be carried out only by those well versed in the regional anatomy and experienced in performing interventional pain management techniques. The use of fluoroscopy, computerized tomography, and/or ultrasound imaging may help decrease the complications and aid in accurate needle placement. After careful aspiration for blood, cerebrospinal fluid, and urine, 1 mL of water-soluble iodinated contrast medium is slowly injected. After proper needle position and spread of contrast in the precoccygeal space is confirmed on both posteroanterior and lateral fluoroscopic views, 3 mL of 1. The midline is also identified, and the skin that overlies the anococcygeal ligament is prepared with antiseptic solution. Transcoccygeal Technique Fluoroscopic-Guided Technique the patient is placed in the jackknife position to facilitate access to the inferior margin of the gluteal cleft. The midline is identified, and the skin overlying the coccyx is prepared with antiseptic solution. Note the ossification at the sacrococcygeal joint (black arrow) and the conserved space between the first and second coccygeal bones (Co1 and Co2) (white arrow). Along with the pudendal vessels, the pudendal nerve leaves the pelvis via the greater sciatic foramen. It then passes around the medial portion of the ischial spine to reenter the pelvis through the lesser sciatic foramen. The pudendal nerve is amenable to blockade at this point via the transvaginal approach. The nerve then divides into three terminal branches: (1) the inferior rectal nerve, which provides innervation to the anal sphincter and perianal region; (2) the perineal nerve, which supplies the posterior two thirds of the scrotum or labia majora and muscles of the urogenital triangle; and (3) the dorsal nerve of the penis or clitoris, which supplies sensory innervation to the dorsum of the penis or clitoris. The needle guide is inserted between the fingers, and its tip is placed against the vaginal mucosa just in front of the ischial spine. An additional 3 to 4 mL of local anesthetic may be injected as the needle is withdrawn into the vagina to ensure blockade of the inferior rectal nerve. The ischial tuberosity is identified by palpation, and an area 1 inch lateral and 1 inch posterior to the tuberosity is then prepared with antiseptic solution.
This maneuver is repeated until the needle is walked off the posterior sacrum into the S4 foramen anxiety urination purchase zoloft 25 mg on-line. Again, the needle is placed and the injection carried out as with the technique described for S4 nerve block. Because of the potential for spread of drugs injected via the transsacral approach onto other sacral nerves, incremental dosing is crucial to avoid accidentally applying neurolytic solution to the wrong sacral nerve. This anatomic region is highly vascular; therefore, the possibility of intravascular uptake of local anesthetic is significant with this technique when multiple sacral nerves are blocked. The epidural venous plexus generally ends at S4 but may descend the entire length of the canal in some patients. Needle trauma to this plexus may result in bleeding, thus causing postprocedural pain. Subperiosteal injection of drugs may also result in bleeding and is associated with significant pain both during and after injection. Both of these complications, as well as the incidence of ecchymosis at the injection site, can be reduced by the use of short, small-gauge needles. The incidence of significant neurologic deficit secondary to hematoma after sacral block is exceedingly rare. The application of local anesthetic to the sacral nerve roots results in an increased incidence of urinary bladder dysfunction. This side effect of sacral nerve block is seen more commonly in elderly males and multiparous females and after inguinal and perineal surgery. Overflow incontinence or dribbling may occur in this patient population if they are unable to void or bladder catheterization is not used. It is advisable that all patients undergoing sacral nerve block void before discharge from the pain center. The preganglionic fibers of the hypogastric plexus find their origin primarily in the lower thoracic and upper lumbar region of the spinal cord. These preganglionic fibers interface with the lumbar sympathetic chain via the white communicantes. Postganglionic fibers exit the lumbar sympathetic chain and, together with fibers from the parasympathetic sacral ganglion, make up the superior hypogastric plexus. As these fibers descend, at a level of L5, they begin to divide into the hypogastric nerves following in close proximity the iliac vessels.
Treatment of post-polio syndrome is aimed primarily at maximizing function and the relief of symptoms anxiety 504 plan zoloft 100 mg buy line. Physical and occupational therapy to maintain and improve function is the cornerstone of the management of post-polio syndrome. Respiratory and speech therapy is indicated if swallowing, sleep, and/or breathing problems are present. The pain of post-polio syndrome is managed with simple analgesics, anti-inflammatory agents, topical analgesic balms, and moist heat. Weakness can be managed pharmacologically with anticholinesterase agents such as pyridostigmine (Mestinon). Failure to treat post-polio syndrome may result in loss of functional ability, an increased risk of falls due to muscle weakness, dehydration and malnutrition secondary to swallowing abnormalities, and recurrent respiratory infections due to diaphragmatic weakness. Inactivity associated with post-polio syndrome may increase the risk of osteoporosis. Diseases that need to be considered in the differential diagnosis of postpolio syndrome are outlined in Table 213-2. Given the implications of missing the diagnosis of many of the diseases listed in Table 213-2, postpolio syndrome must be considered a diagnosis of exclusion. As the weakness and sensory dysfunction ascend, respiratory difficulties combined with paralysis of the lower cranial nerves may occur. The evolution phase is the period of time from onset of symptoms to the nadir of symptoms. The plateau phase begins at the nadir of symptoms and continues until the clinical recovery phase begins. The plateau phase on average can last for 2 to 4 weeks before the clinical recovery phase begins. The clinical recovery phase takes place over a period of many weeks, with most patients experiencing significant recovery within 25 to 30 weeks. The remaining 15% may suffer from permanent residual neurologic defects including footdrop, weakness, and the like. Bacteria that have been implicated include Campylobacter, Haemophilus influenzae, and Borrelia burgdorferi, among others. Mycoplasma pneumoniae and Epstein-Barr virus, cytomegalovirus, and Zika virus have also been implicated. Finding on cerebrospinal fluid analysis includes elevated protein with normal cerebrospinal fluid cell counts. Aggressive management of impending respiratory insufficiency with endotracheal intubation and mechanical intubation should be considered sooner rather than later given the progressive nature of the disease. Aggressive physical and occupational therapy to maintain function should be an integral part of the treatment plan.
Marlo, 28 years: Neoplasia, literally meaning "new growth," is a term derived from the Greek words neos ("new") and plasia ("growth"). This modality can be modified to nurse-controlled analgesia in the younger patient population. To ensure adequate block of these nerves, drugs must be injected in each quadrant to place medication in proximity to each of these nerves. In contrast to alveolar pneumonia, which is usually caused by bacteria, interstitial pneumonias are caused by viruses or M.
Deckard, 57 years: Munchausen syndrome by proxy has been recognized as a potential cause of elder and child abuse. Serious idiosyncratic and hypersensitive hepatocellular injury may occur that may be fulminant and fatal. Dip a wooden applicator stick into the Solution Time specimen to coat the tip of it with stool. He established that infection occurs through ingestion of water contaminated with infected copepods, and not through direct contact between the skin and contaminated water.
Dimitar, 47 years: The face is highly vascular, and the pain specialist should carefully calculate the total milligram dosage of local anesthetic that may be safely given, especially if bilateral nerve blocks are being performed. In patients with abdominal pain or other gastrointestinal symptoms, a fecal examination may be necessary to rule out co-infection with other infectious agents. Central pooling of blood in the abdominal organs and the lungs is accompanied by pallor of skin, which is clammy and cold. Our pressure reading of 120 over 80 mmHg is equivalent to 16 over 10 kPa (16/10kPa).
Gunock, 63 years: For patients who do not respond to these treatment modalities, injection of the Achilles tendon with local anesthetic and steroid may be a reasonable next step. This probably is the best course in the elderly and others with predisposing factors for constipation. Historical Information Humans have evolved with these "lair" parasites of domestic animals and fellow cave dwellers. The injury may be caused by chemical agents, physical forces, living microbes, or many other physiologic or pathologic (exogenous or endoge nous) stimuli that disturb the normal steady state.
Larson, 39 years: This includes preoperative use of anthelminthic drugs and the use of protoscolicidal compounds such as 95% ethanol, hypertonic saline and cetrimide. The use of night splints to slow the progression of ulnar drift should be considered early in the course of the disease. Salt marsh habitats can be drained or channeled and other breeding sites modified, but treatment of breeding sites with insecticides remains the most effective short-term control measure. Dengue, another flavivirus, is an acute, usually non-fatal viral disease characterized by high fever, severe headache, backache, and arthralgia.
Kerth, 26 years: In many regions it is given in a dose tions has been identified as a critical treatof 6 mg/kg/day for 12 consecutive days for a ment modality for worsening lymphedema total of 72 mg/kg body weight. Most commonly, they live in the lymFilaria bancrofti in honor of Joseph Bancroft, phatics of the lower and upper extremities and the surgeon who had investigated the causes male genitalia. Beetle to beetle transmission may be even more significant than cycles involving vertebrate intermediates, and may serve to free this parasite from reliance on the presence of an additional host to complete its life cycle. Continuous infections cause dilation of bronchi (bronchiectasis) and pulmonary fibrosis with destruction of the lung parenchyma ("honeycomb lung").
Grompel, 27 years: While slowly injecting, the needle is advanced from the dorsal surface of the foot toward the plantar surface. To avoid burning the patient, care must be taken to allow excess water to drain from the pack prior to use. The patient is placed in the supine position with the cervical spine in the neutral position. The main side effect of tibial nerve block at the ankle is postblock ecchymosis and hematoma.
Grimboll, 53 years: It then digests them, using acid hydrolases to Eukaryotic Parasites 5 do so, and in the process induces bloody diarrhea (dysentery). It should be noted that percutaneous vertebroplasty is indicated for stabilization of weakened vertebra whether or not pain is present. Juvenile Tapeworm Infections of Humans 383 released free-swimming coracidia are eaten by copepods. This action can irritate the trochanteric bursa, as can repeated trauma from repetitive activity, including jogging on soft or uneven surfaces or overuse of exercise equipment for lower extremity strengthening.
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