Physical Therapy Faculty Research and Publications Copyright (c) 2013 Marquette University All rights reserved. http://epublications.marquette.edu/phys_therapy_fac Recent documents in Physical Therapy Faculty Research and Publications en-us Sat, 25 May 2013 01:41:15 PDT 3600 Wrist and Forearm Posture From Typing on Split and Vertically Inclined Computer Keyboards http://epublications.marquette.edu/phys_therapy_fac/34 http://epublications.marquette.edu/phys_therapy_fac/34 Thu, 23 May 2013 14:04:44 PDT A study was conducted on 90 experienced office workers to determine how commercially available alternative computer keyboards affected wrist and forearm posture. The alternative keyboards tested had the QWERTY layout of keys and were of three designs: split fixed angle, split adjustable angle, and vertically inclined (tilted or tented). When set up correctly, commercially available split keyboards reduced mean ulnar deviation of the right and left wrists from 12° to within 5° of a neutral position compared with a conventional keyboard. The finding that split keyboards place the wrist closer to a neutral posture in the radial/ulnar plane substantially reduces one occupational risk factor of workrelated musculoskeletal disorders (WMSDs): ulnar deviation of the wrist. Applications of this research include commercially available computer keyboard designs that typists can use and ergonomists can recommend to their clients in order to minimize wrist ulnar deviation from typing.

]]> Richard W. Marklin et al. Biomechanical Effects of Mobile Computer Location in a Vehicle Cab http://epublications.marquette.edu/phys_therapy_fac/33 http://epublications.marquette.edu/phys_therapy_fac/33 Wed, 22 May 2013 14:07:11 PDT

Objective: The objective of this research is to determine the best location to place a conventional mobile computer supported by a commercially available mount in a light truck cab.

Background: U.S. and Canadian electric utility companies are in the process of integrating mobile computers into their fleet vehicle cabs. There are no publications on the effect of mobile computer location in a vehicle cab on biomechanical loading, performance, and subjective assessment.

Method: The authors tested four locations of mobile computers in a light truck cab in a laboratory study to determine how location affected muscle activity of the lower back and shoulders; joint angles of the shoulders, elbows, and wrist; user performance; and subjective assessment. A total of 22 participants were tested in this study.

Results: Placing the mobile computer closer to the steering wheel reduced low back and shoulder muscle activity. Joint angles of the shoulders, elbows, and wrists were also closer to neutral angle. Biomechanical modeling revealed substantially less spinal compression and trunk muscle force. In general, there were no practical differences in performance between the locations. Subjective assessment indicated that users preferred the mobile computer to be as close as possible to the steering wheel.

Conclusion: Locating the mobile computer close to the steering wheel reduces risk of injuries, such as low back pain and shoulder tendonitis.

Application: Results from the study can guide electric utility companies in the installation of mobile computers into vehicle cabs. Results may also be generalized to other industries that use trucklike vehicles, such as construction.

]]> Kyle Saginus et al. Focal Acidosis in the Pre-Bötzinger Complex Area of Awake Goats Induces a Mild Tachypnea http://epublications.marquette.edu/phys_therapy_fac/32 http://epublications.marquette.edu/phys_therapy_fac/32 Thu, 16 May 2013 13:19:28 PDT There are widespread chemosensitive areas in the brain with varying effects on breathing. In the awake goat, microdialyzing (MD) 50% CO(2) at multiple sites within the medullary raphe increases pulmonary ventilation (Vi), blood pressure, heart rate, and metabolic rate (Vo(2)) (11), while MD in the rostral and caudal cerebellar fastigial nucleus has a stimulating and depressant effect, respectively, on these variables (17). In the anesthetized cat, the pre-Bötzinger complex (preBötzC), a hypothesized respiratory rhythm generator, increases phrenic nerve activity after an acetazolamide-induced acidosis (31, 32). To gain insight into the effects of focal acidosis (FA) within the preBötzC during physiological conditions, we tested the hypothesis that FA in the preBötzC during wakefulness would stimulate breathing, by increasing respiratory frequency (f). Microtubules were bilaterally implanted into the preBötzC of 10 goats. Unilateral MD of mock cerebral spinal fluid equilibrated with 6.4% CO(2) did not affect Vi, tidal volume (Vt), or f. Unilateral MD of 25 and 50% CO(2) significantly increased Vi and f by 10% (P < 0.05, n = 10, 17 trials), but Vt was unaffected. Bilateral MD of 6.4, 25, or 50% CO(2) did not significantly affect Vi, Vt, or f (P > 0.05, n = 6, 6 trials). MD of 80% CO(2) caused a 180% increase in f and severe disruptions in airflow (n = 2). MD of any level of CO(2) did not result in any significant changes in mean arterial blood pressure, heart rate, or Vo(2). Thus the data suggest that the preBötzC area is chemosensitive, but the responses to FA at this site are unique compared with other chemosensitive sites.

]]> Lawrence Pan et al. Wrist and Forearm Posture From Typing on Split and Vertically Inclined Computer Keyboards http://epublications.marquette.edu/phys_therapy_fac/31 http://epublications.marquette.edu/phys_therapy_fac/31 Thu, 16 May 2013 11:50:35 PDT A study was conducted on 90 experienced office workers to determine how commercially available alternative computer keyboards affected wrist and forearm posture. The alternative keyboards tested had the QWERTY layout of keys and were of three designs: split fixed angle, split adjustable angle, and vertically inclined (tilted or tented). When set up correctly, commercially available split keyboards reduced mean ulnar deviation of the right and left wrists from 12° to within 5° of a neutral position compared with a conventional keyboard. The finding that split keyboards place the wrist closer to a neutral posture in the radial/ulnar plane substantially reduces one occupational risk factor of workrelated musculoskeletal disorders (WMSDs): ulnar deviation of the wrist. Applications of this research include commercially available computer keyboard designs that typists can use and ergonomists can recommend to their clients in order to minimize wrist ulnar deviation from typing.

]]> Richard W. Marklin et al. Biomechanics of Elastic Resistance in Therapeutic Exercise Programs http://epublications.marquette.edu/phys_therapy_fac/30 http://epublications.marquette.edu/phys_therapy_fac/30 Thu, 16 May 2013 11:31:07 PDT Resistive materials in the form of elastic bands and tubing are inexpensive and highly versatile tools that are often used in therapeutic exercise programs. Companies that manufacture elastic bands and tubing provide a line of products that cover a wide range of resistance levels, which are typically distinguished by color. Theoretically, the spectrum of resistance levels makes it possible for rehabilitation personnel to give a patient the band or tubing that best corresponds to the suitable degree of exercise resistance for that patient. Unlike a set of clearly labeled hand-held weights, however, elastic bands and tubing provide no quantitative information on their actual or relative resistance. Therefore, the selection and progression of resistance levels when elastic bands or tubing are used is relatively subjective and often is dependent upon the perceived effort of the patient. To our knowledge, only 2 of the several manufacturers of elastic bands and tubing used in rehabilitation (The Hygenic Corporation, Akron, OH, and Lifeline International, Inc, Madison, WI), provide users with information (limited) on the physical characteristics of their elastic material. The goals of our report were to establish the stress-strain relationship of representative samples of elastic bands and tubing used in the clinical setting, establish the fatigue characteristics of representative samples of elastic bands and tubing, and increase the awareness of rehabilitation professionals of the kinesiological concepts of resistive exercises, especially as they relate to the use of elastic-type resistive material.

]]> Guy G. Simoneau et al. Influence of Knee Flexion Angle and Age on Triceps Surae Muscle Fatigue During Heel Raises http://epublications.marquette.edu/phys_therapy_fac/29 http://epublications.marquette.edu/phys_therapy_fac/29 Fri, 12 Apr 2013 12:33:19 PDT Hébert-Losier, K, Schneiders, AG, García, JA, Sullivan, SJ, and Simoneau, GG. Influence of knee flexion angle and age on triceps surae muscle fatigue during heel raises. J Strength Cond Res 26(11): 3134–3147, 2012—The triceps surae (TS) muscle-tendon unit is 1 of the most commonly injured in elite and recreational athletes, with a high prevalence in middle-aged adults. The performance of maximal numbers of unilateral heel raises is used to assess, train, and rehabilitate TS endurance and conventionally prescribed in 0° knee flexion (KF) for the gastrocnemius and 45° for the soleus (SOL). However, the extent of muscle selectivity conferred through the change in the knee angle is lacking for heel raises performed to volitional fatigue. This study investigated the influence of knee angle on TS muscle fatigue during heel raises and determined whether fatigue differed between middle-aged and younger-aged adults. Forty-eight healthy individuals aged 18–25 and 35–45 years performed maximal numbers of unilateral heel raises in 0° and 45° KF. Median frequencies and linear regression slopes were calculated from the SOL, gastrocnemius medialis (GM), and gastrocnemius lateralis (GL) surface electromyographic signals. Stepwise mixed-effect regressions were used for analysis. The subjects completed an average of 45 and 48 heel raises in 0° and 45° KF, respectively. The results indicated that the 3 muscles fatigued during testing as all median frequencies decreased, and regression slopes were negative. Consistent with muscle physiology and fiber typing, fatigue was greater in the GM and GL than in the SOL (p < 0.001). However, knee angle did not influence TS muscle fatigue parameters (p = 0.814), with similar SOL, GM, and GL fatigue in 0° and 45° KF. These findings are in contrast with the traditionally described clinical use of heel raises in select knee angles for the gastrocnemius and the SOL. Furthermore, no difference in TS fatigue between the 2 age groups was able to be determined, despite the reported higher prevalence of injury in middle-aged individuals.

]]> Kim Hébert-Losier et al. Whole Body Momentum During Gait: A Preliminary Study of Non-Fallers and Frequent Fallers http://epublications.marquette.edu/phys_therapy_fac/28 http://epublications.marquette.edu/phys_therapy_fac/28 Wed, 06 Mar 2013 08:59:54 PST The imponance of momentum in compens:Hing for elderly individua ls ' strength deficits to achieve activities of daily li ving. such as rising from a cha ir ha.!o been demonstrated in earlier studies. Here we present a case·conlrol study of three hcallhy "noll-faJl ers" and two "frequ ent fall ers," AI l S c iders were community-li ving and were tested in the gai l laboratory. A four-camera Sclspot system was used to obtain whole-body momentum from an II-segmcnl kinemalic model. Ground reaction forces and kinematics were used 10 calculate lower extremity join! moments. With the exception of the whole-body's angular momentum about the vertical axis, linear and angular Illomenta during gail were minimum during mid-single limb support and maximum near heel cOnlact Whole-body momentum values for individuals wi th a hi story of falls were similar to those measured in non-fallers. However. subjects wi th a history of falls had between 17 and 37% smaller maximum ankle and knee torque values th an the subjccts without a history of falls duri ng ambulation. A comprehensive description of whole-body linear and angular momenta during steady-stale gait in older individuals is presented. While whole-body momentum characteristics and magnitude were similar between fa lle rs and non-fall ers. the consequences of the lesser torque values in the fallers ' knees and ankles 10 generate and control this momentum warrant fu rther investigation.

]]> Guy G. Simoneau et al. Effect of Computer Keyboard Slope on Wrist Position and Forearm Electromyography of Typists Without Musculoskeletal Disorders http://epublications.marquette.edu/phys_therapy_fac/27 http://epublications.marquette.edu/phys_therapy_fac/27 Mon, 25 Feb 2013 07:40:20 PST Positioning a computer keyboard with a downward slope reduces wrist extension needed to use the keyboard and has been shown to decrease pressure in the carpal tunnel. However, whether a downward slope of the keyboard reduces electromyographic (EMG) activity of the forearm muscles, in particular the wrist extensors, is not known. Subjects and Methods. Sixteen experienced typists participated in this study and typed on a conventional keyboard that was placed on slopes. Electromyographic activity of the extensor carpi ulnaris (ECU), flexor carpi ulnaris (FCU), and flexor carpi radialis (FCR) muscles was measured with surface electrodes, while the extension and ulnar deviation angles of the right and left wrists were measured with electrogoniometers. Results. Wrist extension angle decreased from approximately 12 degrees of extension while typing on a keyboard with a 7.5-degree slope to 3 degrees of flexion with the keyboard at a slope of –15 degrees. Although the differences were in the range of 1% to 3% of maximum voluntary contraction (MVC), amplitude probability distribution function (APDF) of root-mean-square EMG data points from the ECU, FCU, and FCR muscles varied across keyboard slopes. Discussion and Conclusion. Wrist extension decreased as the keyboard slope decreased. Furthermore, a slight decrease in percentage of MVC of the ECU muscle was noted as the keyboard slope decreased. Based on biomechanical modeling and published work on carpal tunnel pressure, both of these findings appear to be positive with respect to comfort and fatigue, but the exact consequences of these findings on the reduction or prevention of injuries have yet to be determined. The results may aid physical therapists and ergonomists in their evaluations of computer keyboard workstations and in making recommendations for interventions with regard to keyboard slope angle. [Simoneau GG, Marklin RW, Berman JE. Effect of computer keyboard slope on wrist position and forearm electromyography of typists without musculoskeletal disorders. Phys Ther. 2003;83:816–830.]

]]> Guy G. Simoneau et al. Effect of Setup Configurations of Split Computer Keyboards on Wrist Angle http://epublications.marquette.edu/phys_therapy_fac/26 http://epublications.marquette.edu/phys_therapy_fac/26 Mon, 25 Feb 2013 07:31:00 PST Alternative computer keyboards whose halves can be slanted toward each other can reduce a risk factor (ulnar deviation) for work-related musculoskeletal disorders (WMSDs) affecting the upper limbs. Two questions that computer keyboard operators face when using keyboards that can be separated into halves (split keyboards) are: (1) At what angle should the keyboard halves be opened? and (2) At what distance apart should the keyboard halves be placed? The objective of this study was to investigate the effects of the opening angle and separation distance between halves of a split keyboard on wrist ulnar deviation and typing efficiency. Methods. Eleven experienced computer keyboard operators participated in this study and used a split keyboard that was set up in a conventional (nonsplit) format and also in 3 alternative configurations: (1) centers of keyboard halves were separated at 20-cm distance, (2) keyboard halves were separated half of the distance of shoulder width, and (3) keyboard halves were separated at shoulder width distance. Results. The 3 alternative configurations resulted in ulnar deviation of both wrists that were less than ulnar deviation from typing on a conventional setup. There were no differences in ulnar deviations among the 3 alternative configurations. Discussion and Conclusion. The results of this research provide physical therapists and ergonomists with a set of configurations of a split keyboard that they can recommend to their patients or clients. All of the alternative configurations of the split keyboard are beneficial in promoting a neutral wrist position, which theoretically would decrease exposure to WMSDs such as tenosynovitis in the wrist and carpal tunnel syndrome. [Marklin RW, Simoneau GG. Effect of setup configurations of split computer keyboards on wrist angle. Phys Ther. 2001;81:1038 –1048.]

]]> Richard W. Marklin et al. Posture and Gait in Patients with Diabetic Distal Symmetrical Polyneuropathy http://epublications.marquette.edu/phys_therapy_fac/25 http://epublications.marquette.edu/phys_therapy_fac/25 Fri, 22 Feb 2013 09:11:09 PST Guy G. Simoneau et al. The Convex-Concave Rules of Arthrokinematics: Flawed or Perhaps Just Misinterpreted? http://epublications.marquette.edu/phys_therapy_fac/24 http://epublications.marquette.edu/phys_therapy_fac/24 Fri, 25 Jan 2013 08:49:53 PST The convex-concave rules purportedly help describe the roll-and-slide relationships that naturally occur between moving articular surfaces. There are 2 components of this rule, depending on whether the convex or concave articular member of the joint is considered the moving segment. As a teacher of kinesiology and a physical therapist, I have always respected these rules, primarily because of their ability to assist with the mental imaging of joint motion. Recently, I have been perplexed by questions from experienced physical therapists as to why the convex-concave rules are still being taught in college or continuing education venues, when research has shown that they are flawed. Perhaps I am so hopelessly infatuated with, and blinded by, the educational charm and utility of the convex-concave rules that I fail to realize they are flawed. Are they? I don’t think so, which is the topic of this editorial.

]]> Donald A. Neumann Neuromagnetic Activity in the Cerebral Cortex is Modulated by Locomotor-Like Movements Produced during Pedaling http://epublications.marquette.edu/phys_therapy_fac/23 http://epublications.marquette.edu/phys_therapy_fac/23 Wed, 16 Jan 2013 07:56:35 PST Sheila M. Schindler-Ivens et al. Inflammatory Markers in Pediatric Obesity: Health and Physical Activity Implications http://epublications.marquette.edu/phys_therapy_fac/22 http://epublications.marquette.edu/phys_therapy_fac/22 Wed, 12 Dec 2012 14:42:21 PST The prevalence of childhood obesity has recently peaked in the USA with ~17% of children considered obese. With the increase in adiposity that occurs with weight gain, a persistent low-grade inflammatory state is created. The most commonly studied inflammatory markers associated with obesity are the cytokines, tumor necrosis factor α and interleukin-6, and the acute-phase reactant, C-reactive protein. Understanding the relation between adiposity and inflammation is an important concept because these inflammatory markers influence insulin sensitivity, glucose metabolism, and atherosclerosis, ultimately leading to impaired health. In addition to obesity, physical inactivity is associated with elevated inflammatory markers. The literature, however, is inconsistent as to whether the association between physical activity and inflammation is independent of adiposity. In some obese children, physical fitness appears to circumvent the increase in inflammatory markers that are associated with obesity. The purpose of this review is to examine the relation between adiposity and inflammatory markers, including potential health implications and the impact of physical activity. We exposed a dearth of literature in understanding the interaction between obesity and physical activity on inflammatory markers, especially in children because their anthropometrics change. This review highlights the necessity for further research to better understand the complexity of the chronic inflammatory state associated with obesity.

]]> Stacy Stolzman et al. Changes in Ankle Joint Proprioception Resulting From Strips of Athletic Tape Applied Over the Skin http://epublications.marquette.edu/phys_therapy_fac/21 http://epublications.marquette.edu/phys_therapy_fac/21 Wed, 12 Dec 2012 14:06:17 PST Athletic trainers, physical therapists, and other rehabilitation professionals stress the importance of proprioceptive reeducation during the rehabilitation process following an injury." 2 It is believed that an injury such as an inversion ankle sprain, for example, results in a reduction of proprioceptive function that may lead to future reinjuries. 3 One suggested palliative method to supplement a deficit in proprioceptive function at the ankle is the use of external support such as taping and braces.47 The tape or brace is believed to provide increased mechanical support as well as increased proprioception.

]]> Guy G. Simoneau et al. Reciprocal Inhibition Post-stroke is Related to Reflex Excitability and Movement Ability http://epublications.marquette.edu/phys_therapy_fac/20 http://epublications.marquette.edu/phys_therapy_fac/20 Tue, 04 Sep 2012 07:55:36 PDT Objective Decreased reciprocal inhibition (RI) of motor neurons may contribute to spasticity after stroke. However, decreased RI is not a uniform observation among stroke survivors, suggesting that this spinal circuit may be influenced by other stroke-related characteristics. The purpose of this study was to measure RI post-stroke and to examine the relationship between RI and other features of stroke. Methods RI was examined in 15 stroke survivors (PAR) and 10 control subjects by quantifying the effect of peroneal nerve stimulation on soleus H-reflex amplitude. The relationship between RI and age, time post-stroke, lesion side, walking velocity, Fugl-Meyer, Ashworth, and Achilles reflex scores was examined. Results RI was absent and replaced by reciprocal facilitation in 10 of 15 PAR individuals. Reciprocal facilitation was associated with low Fugl-Meyer scores and slow walking velocities but not with hyperactive Achilles tendon reflexes. There was no relationship between RI or reciprocal facilitation and time post-stroke, lesion side, or Ashworth score. Conclusions Decreased RI is not a uniform finding post-stroke and is more closely related to walking ability and movement impairment than to spasticity. Significance Phenomena other than decreased RI may contribute to post-stroke spasticity.

]]> Neha Bhagchandani et al. Restoring Functional Status: A Long-Term Case Report of Severe Lung and Ventilatory Muscle Pump Dysfunction Involving Recurrent Bacterial Pneumonias http://epublications.marquette.edu/phys_therapy_fac/19 http://epublications.marquette.edu/phys_therapy_fac/19 Mon, 06 Aug 2012 08:12:49 PDT Background and Purpose: Prolonged mechanical ventilation contributes to immobility and deconditioning making efforts to safely discontinue ventilator support desirable. This case report documents how implementing physical therapy treatment interventions, based on the Guide to Physical Therapist Practice, can help to restore a person’s functional status even after multiple years of mechanical ventilation dependency. Case Description: A patient (female; aged 63 years) with severe restrictive and obstructive ventilatory impairment has survived 34 recurrent pneumonias involving 6 bacterial pathogens while being mechanically ventilated at home. A 3-year study was approved and informed consent obtained for a home exercise program of resistive extremity and inspiratory muscle training along with exercise reconditioning. Tolerable distances walked, maximal inspiratory and expiratory pressures, hours spent on versus off mechanical ventilation, activities performed within and around her home, and community excursions taken were charted. Outcomes: Daily time tolerated off the ventilator improved from less than one to 12 hours, distance walked in 6 minutes increased 33%, and maximal inspiratory and expiratory pressures improved 62% and 9.6% respectively. These improvements made out-of-home social excursions possible. Discussion and Conclusions: This patient’s functional status improved following multiple physical therapy interventions dictated by the evaluation of initial physical therapy examination findings according to the Guide to Physical Therapist Practice. Long term mechanical ventilator dependency in the home environment did not exclude this patient from achieving clinically significant gains in functional status even when having severe restrictive and obstructive ventilator impairment.

]]> Dennis Sobush et al. E-Stimulation: An Effective Modality to Facilitate Wound Healing http://epublications.marquette.edu/phys_therapy_fac/18 http://epublications.marquette.edu/phys_therapy_fac/18 Fri, 03 Aug 2012 12:34:37 PDT Pamela Scarborough et al. The Effect of Movement Rate and Complexity on Functional Magnetic Resonance Signal Change During Pedaling http://epublications.marquette.edu/phys_therapy_fac/17 http://epublications.marquette.edu/phys_therapy_fac/17 Mon, 23 Jul 2012 17:19:13 PDT We used functional magnetic resonance imaging (fMRI) to record human brain activity during slow (30 RPM), fast (60 RPM), passive (30 RPM), and variable rate pedaling. Ten healthy adults participated. After identifying regions of interest, the intensity and volume of brain activation in each region was calculated and compared across conditions (p < .05). Results showed that the primary sensory and motor cortices (S1, M1), supplementary motor area (SMA), and cerebellum (Cb) were active during pedaling. The intensity of activity in these areas increased with increasing pedaling rate and complexity. The Cb was the only brain region that showed significantly lower activity during passive as compared with active pedaling. We conclude that M1, S1, SMA, and Cb have a role in modifying continuous, bilateral, multijoint lower extremity movements. Much of this brain activity may be driven by sensory signals from the moving limbs.

]]> Jay P. Mehta et al. Perspective Paper: Assessing Air Quality as Part of a Physical Therapy Plan of Care http://epublications.marquette.edu/phys_therapy_fac/16 http://epublications.marquette.edu/phys_therapy_fac/16 Fri, 20 Jul 2012 14:01:09 PDT Purpose: The purposes of this clinical perspective paper are (1) to expand physical therapists’ awareness to the topic of air quality as a health priority when providing professional services; and (2) to provide templates for screening the indoor clinical environments and patient profiles to avert respiratory exacerbations, especially in persons with asthma. Summary of Key Points: The location where a physical therapist practices determines the air quality indices to which a person is exposed. Poor indoor air quality can expose a person to even greater compromise of respiration (ie, Sick Building Syndrome) than outdoor air quality secondary to an array of factors like building materials, the ventilation exchange rate of an enclosed space, chemicals used in cleaning, and humidity. Statement of Conclusions: Extrinsic (ie, environmental) and intrinsic (eg, pre-disposition to airway hypersensitivity) factors must be accounted for by physical therapists to safeguard their patients and themselves from experiencing respiratory compromise and/or distress as a result of a treatment session or their place of employment. Recommendations: Efforts to screen indoor environments for potential triggers and patient risk profiles for abnormal airway reactivity should routinely be undertaken. Individualized Action Plans should be prospectively prepared and readied for implementation when warranted.

]]> Dennis Sobush et al. Wound Healing : Evidence-Based Management, 4th Edition http://epublications.marquette.edu/phys_therapy_fac/15 http://epublications.marquette.edu/phys_therapy_fac/15 Mon, 16 Jul 2012 14:22:11 PDT This most complete resource is back in a full-color, thoroughly revised, updated, and significantly expanded 4th Edition that incorporates all of the many scientific and technological advances that are changing the scope of practice in this multidisciplinary field. Learned authors Joseph McCulloch and Luther Kloth have gathered world renown experts in wound management to present a comprehensive text that is evidence based, clinically focused and practical. Responding to the ever-changing field of wound management, the 4th Edition is far from a simple update; it is virtually a brand-new text. The committed and respected teams of authors and contributors have broadened the scope of this text and expanded it from 14 to 35 chapters.

]]> Joseph M. McCulloch et al.