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MS Presentation 2010
MS Presentation 2010
Lecture Objectives
Identify areas of practice in womens health physical therapy Identify female abdominal anatomic structures Understand modifications to subjective and objective portions of patient evaluations Understand treatment options for various womens health dysfunctions Identify commonly used modality applications for various womens health dysfunctions Formulate wellness exercise programs for women with varying conditions
Topics of Discussion
Obstetrics and Complications Musculoskeletal Pain of Pregnancy Fibromyalgia Pelvic pain Incontinence
Cranial: peritoneum of the pelvic viscera Middle: Muscles, fibromuscular elements i.e. endo pelvic fascia Caudal: skin of the vulva, scrotum, perineum
Superficial
Bulbospongiosus, Ischiocavernousus, Superficial transverse perineal muscle Pubococcygeus, Pubovaginalis, Puborectalis, Illiococcygeus
Deep
Anatomy
Bony Pelvis
Anatomy
Levator Ani
Anatomy
External Sphincters
Anatomy
Pregnancy Complications
Gestational Diabetes Pregnancy Induced Hypertension HELLP Syndrome Anemia Preterm Labor Premature Rupture of Membranes Placenta Previa Placental Abruption
Gestational Diabetes
Review: Diabetes
Insulin is not produced or the body cannot use it properly Insulin is the hormone that allows glucose to enter cells of the body Glucose (unable to enter cells) builds in the blood stream, cells starve When a pregnant woman that does not have diabetes, develops a resistance to insulin because of the hormones of pregnancy. Hormones (estrogen, cortisol, human placental lactogen) can have blocking effect on insulin (generally occurs at 20-24 weeks) Usually the pancreas can respond and produce more insulin
Gestational Diabetes
Gestational Diabetes
Risk factors:
Family history Obesity Previous delivery of very large baby, stillborn, or child with a birth defect Mothers age >25 increases risk Glucose screening test performed at 24 and 28 weeks Diet, exercise, blood glucose monitoring, insulin injections
Diagnosis:
Treatment:
Gestational Diabetes
Macrosomia
excessive glucose in blood is turned into fat, resulting in a very large (fat) baby size of baby can make delivery difficult baby develops increased insulin production secondary to increased glucose from mother immediately post delivery, no glucose from mother, continues to have elevated insulin glucose levels drop rapidly and supplemental glucose may be administered excess glucose can delay fetal lung development
Birth injury
Hypoglycemia
Respiratory distress
HTN during pregnancy occurs in 5-8% of all pregnancies Most common in younger women during first pregnancy HTN >140/90 Protein in urine Edema Occurs 1 in 1,600 pregnancies Mostly near end of pregnancy, seizures
3 Primary Characteristics
Causes: Unknown
Risks
Pre-existing HTN Kidney disease PIH in previous pregnancies Mothers age: <20 or >40 Multiples
Symptoms
Elevated blood pressure Protein in the urine Edema Sudden weight gain Visual changes, blurred or double vision Nausea and/or vomiting R sided abdominal or stomach pain Urinating small amounts
Diagnosis
Blood pressure measurements Urine testing Edema assessments Frequent weight measurements Eye exams, looking for retinal changes Liver and kidney function tests Blood clotting testes
Treatment
Bedrest Hospitalization Magnesium sulfite (or other antihypertensive) Fetal monitoring Continue lab testing of urine and blood Corticosteroids to expedite fetal lung development Delivery
HELLP Syndrome
Serious complication of severe pregnancy induced hypertension (PIH) Occurrence: 2-12% of the women with PIH Usually develops prior to delivery, but may occur postpartum HELLP Consists of:
Hemolysis: red blood cell breakdown Elevated Liver enzymes: damage to liver Low Platelets: decreased clotting ability
HELLP Syndrome
Causes: unknown
Risk Factors
Concerns:
HTN risks: poor blood flow to organs, possible seizures, anemia, clotting difficulties Disseminated Intravascular Coagulation (DIC) is a serious clotting complication that can lead to severe bleeding, hemorrhage, placental abruption, and pulmonary edema May need to deliver early secondary to complications
HELLP Syndrome
Symptoms
Right sided upper abdominal pain Pain around the stomach Nausea and/or vomiting Headache Increased blood pressure Protein in the urine edema
HELLP Syndrome
Diagnosis
Blood pressure measurements Red blood cell count Bilirubin levels (breakdown of RBCs) Liver function tests Platelet counts Urine protein testing
HELLP Syndrome
Treatment options
Bedrest Hospitalization Blood transfusions (severe anemia, low platelets) Magnesium sulfate (prevent seizures) Antihypertensives Fetal monitoring Lab tests to continue to monitor progression of syndrome Corticosteroids to expedite fetal lung development Delivery
Anemia
Too few red blood cells, or a lowered ability of the red blood cells to carry oxygen or iron through the body Anemia can cause: poor fetal growth, preterm birth, low birth weight Common types of anemia associated with pregnancy: iron deficiency, Vitamin B12 deficiency, folate deficiency
Anemia
Pregnancy Anemia
Mothers blood volume can increase up to 50%, this can cause dilution of RBCs. Is considered normal unless RBC levels drop too low Occurs at delivery and postpartum
Vaginal birth: blood loss ~500 milliliters C-section birth: blood loss ~1000 milliliters
Anemia
Iron Deficiency
Most common Healthy mother has stored RBCs in her bone marrow prior to conception and this prevents anemia Iron is needed for hemoglobin Most common in Vegans B12 helps build RBCs and protein synthesis Folate/Folic acid is a B vitamin that with iron helps cell growth Associated with iron deficiency as they are found in the same foods Folic acid has been shown to decrease risk of birth defects of the brain and spinal cord if taken prior to conception and in early pregnancy
Folate Deficiency
Anemia
Symptoms
Pale skin, lips, nails, palms of hands, and underside of eyelids Fatigue Vertigo/dizziness Labored breathing Tachycardia Hemoglobin and hematocrit lab testing
Diagnosis
Anemia
Treatment
Meats, poultry, fish, leafy greens, legumes, yeast leavened whole wheat breads, iron-enriched white breads, pastas, cereal Leafy dark green vegetables, dried beans and peas, citrus fruits and juices, most berries, fortified breakfast cereals, enriched grain products
Sources of Folate
Preterm Labor
Causes: unknown
Preeclampsia, chronic medical illness, infection, drug use, abnormal uterine structure, cervical incompetence, previous preterm birth Abnormal or decreased function of placenta, placenta previa, placental abruption, premature rupture of membranes, hydramnios
Preganacy
Preterm Labor
Symptoms
Uterine contactions (more than 4 and hour) Menstrual type cramps Pelvic pressure Backache Intestinal upset Vaginal discharge of blood, mucus, or water Cervical examination, ultrasound, status of membranes, fetal fibronectin test
Diagnosis
Preterm Labor
Treatment
Bed rest Hospitalization Tocolytic medications - stop uterine contractions Corticosteroids - increase fetal lung maturity Cervical cerclage Antibiotics - infection Delivery Prenatal care, good mother health, education ***Progesterone
Prevention
Breaking of amniotic sac before labor begins PROM prior to 37 weeks PROM: 10% of pregnancies PPROM: 2% of pregnancies
Incidence
Causes
PPROM is often due to infection PROM caused by weakening of membranes or from force of contractions Other factors
Low socioeconomic status (prenatal care) STDs Previos preterm birth Vaginal bleeding Cigarette smoking during pregnancy
Symptoms:
Treatment
Bed rest Hospitalization Expectant management (self resolution of situation) Monitoring for signs of infection Corticosteroids - increase fetal lung maturity Tocolytic medications - stop uterine contractions Antibiotics - infection Delivery None Strong correlation with smoking during pregnancy
Prevention
Bleeding may or may not be a cause for alarm First Trimester bleeding is common
Miscarriage Ectopic pregnancy Implantation of placenta to uterus Infection Placenta Previa Placental Abruption
Placenta Previa
Condition in which the placenta is attached close to or covering the cervix 1 in every 200 live births
Placenta Previa
Symptoms: bright red vaginal bleeding without abdominal tenderness or pain Risks:
Slowed fetal growth Preterm birth Birth defects Infection after delivery
Placental Abruption
Placental Abruption
Direct trauma Increased risk: HTN, cigarettes, multiples Dark red vaginal bleeding with pain Non-relaxing uterine contractions Blood in amniotic fluid Nausea Thirst Decreased fetal movements Emergency delivery dependent on amount of blood loss and fetal distress
Symptoms:
No treatment
Hydramnios Oligohydramnios
Post Term Pregnancy (>42 weeks) Postpartum Hemorrhage Digestive and liver disorders
Back pain Constipation Dehydration Edema Gastroesophageal Reflux Disease Hemorrhoids Lower Abdominal Pain Urinary frequency Varicose Veins Diastasis Recti Pica Disorder
Pelvic pain Low back pain Nerve injury Upper extremity pain Lower extremity pain
25% have temporarily disability symptoms 50% report low back pain
Edema
~80%, most pronounced later in pregnancy relaxin hormone Begins during 10-12th week, relaxin 20% gain can increase joint force by 100%
Ligamentous laxaty
Weight gain
Lumbar hyperlordosis
Increased ligamentous laxity causes increased motion of the pubic symphysis Prevalence: ~20-28% Risk factors
Previous low back pain, trauma of the back or pelvis, multiparae, increased weight, high stress levels Mild cases respond well to rest and ice Sacroiliac belt
Treatment
Osteitis Pubis
Gradual onset of pubic symphysis pain Rapid progression to excruciating pain that can radiate to medial thighs
Bed rest followed by progressive mobility using walker, accupuncture, SI belt, stabilization exercises Post-delivery: Anti-inflammatory meds, intrasymphyseal injections of lidocaine and steroids
pain of the symphysis pubis with radiation to back or thighs Forceful descent of the fetal head against pelvic ring during delivery Forceful and excessive abduction of the thighs during delivery
Causes
Assessment
Palpable gap may be present Soft tissue swelling Bed rest in sidelying with pelvic binder Progress weightbearing with walker Severe cases may require ORIF
Treatment
Causes
Mechanical strain
Large gravid uterus and increased lumbar lordosis creates increased stress Relaxin hormone effecting pelvic and lumbar ligaments Referred pain Local compression causing decreased O2 saturation leading to hypoxemia of neural structures leading to pain Predisposition may lead to slippage or increase in slippage Uncommon, 1 in 10,000 back pain cases
Ligamentous laxity
Disk herniation
Hip pathology
Subjective
Pain in lumbar, pelvic or sacroiliac region, may radiate to posterior thigh or inguinal region Aggrivating factors: weight bearing or activity Relieving factors: rest, sitting, support pillows Observation, palpation, range-of-motion, muscle imbalance tests, neuro Posture, degree of lumbar lordosis Sacroiliac and lumbar paraspinal muscle tenderness is usually present Thorough hip assessment
Evaluation
Treatment
Rest
Elevated legs Reduce lumbar lordosis Sitting pelvic tilts Aquatic activity Stabilization
Exercise
Aspirin and nonsteroidal anti-inflammatorys are generally contraindicated, cause premature closure of ductus arteriosis Acetamenophen is the medication of choice Cyclobenzaprine, oxycodone and prednisone
Support Binder
Gabrialla
Target.com $32.99
Hand pain is the 2nd most common musculoskeletal pain Median nerve trapped between carpal bones and transverse carpal ligament Causes: swelling, awkward hand positioning Incidence: 2-25%
Evaluation
Pain is worst at night or with repetitive movements Splinting Education for proper body mechanics Severe cases require surgery 43-95% resolve within 2 weeks post delivery >80% women have some relief in symtoms with 2 weeks using night splints
Treatment
Prognosis
Meralgia Paresthetica
Pure sensory to anterior lateral thigh Injury causes burning pain or numbness Stretching and or compression of nerve during delivery (vaginal and c-section) Position changes during labor and delivery shortening pushing stages of delivery Smaller c-section incisions
Causes
Prevention
Femoral Neuropathy
Cause
Symptoms
Treatment
Temporary modification of mobility, Strengthening Good, recovery in <6 months with demyelinating injury
Prognosis
DeQuervains Tenosynovitis
Inflammatory condition of abductor pollicis longus and extensor pollicis brevis tendons Symptoms
Localized pain along the radial side of the wrist Fluid retention and hormonal status Overuse during childcare activities
Causes
DeQuervains Tenosynovitis
Assessment
Provocative maneuvers, Finkelsteins test Thumb spica splint Ice Activity modification Corticosteroid injections Post partum
Treatment
Rare 3rd trimester Pain with weight bearing Early protective weight bearing Good if osteoporosis is only associated c pregnancy
Treatment
Prognosis
Treatment
BREAK
Widespread pain >3 months Palpation pain 11/18 points Widespread pain >3 months Palpation pain 9/11 points
Fibromyalgia
Negative impact on work and social lives Sedentary, decreased cardiorespiratory fitness
Fibromyalgia
Symptoms
Widespread pain Decreased pain threshold Non restorative sleep patterns Fatigue Stiffness Mood disturbance Irritable bowel syndrome Headaches Paresthesia
Co-existing conditions
Chronic fatigue syndrome Depression Endometriosis Headaches Irritable bowel syndrome Lupus Osteoarthritis Post-traumatic stress disorder Restless leg syndrome Rheumatoid arthritis
Fibromyalgia
Multi-disciplinary approach
Medications
Analgesics, antidepressants, anti-epileptics Cognitive behavior modification, stress reduction Generalized exercise program Cardio and strength Treat any pressing joint pains Aquatic therapy
Counseling
Physical therapy
Pain on vaginal penetration Tenderness on local pressure in the vestibule Age 16-80 years, most common 20-50 years Burning, sharp stinging
Pain descriptors
Vulvodynia
Localized vs general
Provoked vs unprovoked
Primary vs secondary
Vulvodynia
Etiology
Central Sensitization
Diagnosis of exclusion
Vulvodynia
Vaginismus
Spasm of pelvic floor muscles with attempt to insert object into the introitis Dyspareunia sexual dysfunction
Vulvodynia
Treatment
Topical agents
Lidocaine Used as low level muscle relaxants Lidocaine, botox Muscle imbalances, dilators, biofeedback
Antidepressants
Injections
Physical Therapy
Vaginal Dilators
www.vaginismus.com
Various causes
Pelvic Pain
Evaluation
Subjective
Trauma, sexual abuse, obstetric and gynecologic history Postural screen Breathing assessment Spine, pelvis, hips Muscular assessment Pelvic floor muscles, abdominals, iliopsoas, glutes, hip adductors Carnetts Test
Objective
Pelvic Pain
Treatment
Postural modification Joint mobilization Muscle: stretching, massage, trigger point, strengthening Breathing modification Relaxation strategies Myofacial: scar and adhesion mobilizations
Up to 2/3 of women suffer from UI at some point in their lifetime General underestimation of the number of individuals with UI secondary to shame/embarrassment and lack of understanding of treatment Estimated 1 in 4 individuals that suffer from UI actually seek help Total annual cost to treat UI in the US is 19.5 billion dollars
Incontinence
Involuntary loss of urine, which is objectively demonstrable, with such a degree of severity that it is a social or hygienic problem Types
Stress Incontinence Urge Incontinence Mixed Incontinence Overflow Incontinence Functional Incontinence
Stress Incontinence
Definition: Involuntary loss of urine accompanying sudden increases in intraabdominal pressure Symptoms: Loss of small amount of urine with exertion (cough, sneeze, laugh, lifting heavy objects) Causes:
Weak pelvic floor Poor muscular timing Hyper-mobile Urethra Urethral Insufficiency
Urge Incontinence
Definition: Involuntary loss of urine associated with a strong desire to void Symptoms: loss of large amounts of urine associated with an irritant (walking by the bathroom, running water, putting a key in the door, nervousness Causes
Detrusor Overactivity
Mixed Incontinence
Definition: Combination of Stress and Urge Incontinence Symptoms: frequency, urgency, loss of urine with increase in intra-abdominal pressure Causes
Overflow Incontinence
Definition: The involuntary loss of urine associated with over distension of the bladder Symptoms: small loss of urine (similar to stress incontinence) occuring with full bladder Causes
Functional Incontinence
Definition: Urinary leakage associated with mental or physical impairments that may impede normal voiding
Symptoms: slow gait, difficulty with sit<>stand transfers, inability to remove clothing quickly Causes: muscle weakness, physical disability, deconditioning, poor environmental set up
Labor
Vacuum or forceps
Fetal weight Maternal age at delivery Time since delivery (Miller 2005)
Evaluation
Subjective
Establish history of specific symptoms Prior med Hx, social Hx Medications Screen for pre-existing musculoskeletal dysfunction Establish baseline to assist with goal setting Prioritize order of objective assessment
Gravada/Para Pelvic surgery DM Neurologic disease: Parkonsonism, CVA, MS, SCI, congenital defect CHF COPD Dementia Psychiatric disease
Increased bladder pressure, muscular effects (bethanechol, Increased bladder pressure, volume of urine (diuretics) Increased bladder pressure, impaired voiding (anticholinergics,
antiparkinsonism agents, -blockers, disopyramide)
Indirect effects: cough (angiotensin-converting-enzyme inhibitors), constipation (iron, narcotics), mental status changes (psychotropics)
Evaluation
Objective
Posture
Pelvic position Hips and spine determined from subjective portion of evaluation
Muscle length
General screens
Contraindications
Lack of patient consent Pregnancy Active pelvic infection (vagina or bladder) Active infectious lesions (genital herpes) Absence of previous pelvic exam (pediatric) Inadequate training on part of examiner Immediate Post partum (6-8 weeks)
Precautions
Severe pelvic pain Atrophic vaginitis History of sexual abuse be very cautious
Voluntary Contraction
Voluntary Relaxation
Involuntary Contraction
Absent or present
Involuntary Relaxation
Absent or present
Evaluation of Strength
Evaluation
Power: strength using mod Oxford Endurance: How long can pt hold contraction Repetitions; How many times can pt perform Flicks: Quick flicks, contract and relax in 10 sec
Result 4 number representation of pelvic floor strength, endurance and coordination Example 4/7/3/6
PFDI-20
Pelvic Floor Distress Inventory short form 20 Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire Pelvic Floor Impact Questionnaire short form 7 Urogenital Distress Inventory short form 6 Incontinence Impact Questionnaire
PISQ-12
PFIQ-7
UDI-6
IIQ
Absorptive Devices
Sanitary napkins
Less expensive No stigma surrounding purchase Can minimize odor For small amounts of leakage More expensive Designed for urine absorption Come in a variety of different absorptive amounts to fit patient needs
Panty liners
Continence pads
Behavioral
Caffeine, acidic juices Helps balance pH in bladder Reduction in 5-10% in baseline weight has been shown to reduce frequency of incontinent episodes by 50%
(Rogers 2008)
Weight loss
Devices
Tampons
Can be used to decrease urethral excursion during a stress maneuver (coughing, lifting) (Miller 2005)
(Roger 2008)
Pessaries
Intravaginal devices that support pelvic organs Incontinence pessaries are designed with knobs to provide increased urethral support Require regular upkeep and cleaning Must be fit for comfort and optimal management of symptoms Risks include: erosion of vaginal tissue, vaginal discharge
Examples of Pessaries
some research showing effectiveness, not permanent, unsure of cost vs outcome as compared to surgery (Smith
et al 2006)
Most common agent is glutaraldehyde cross linked collagen; injected in physician office under cystoscopic control (Miller 2005) Have low cure rates but low morbidity (Miller 2005)
Surgery options: retropubic operations, bladderneck slings, and tension free midurethral slings
(Smith et al 2006)
More than 100 surgical procedures Gold standards - designed to increase urethral support
Burch colposuspention Fascial sling Tension free vaginal taping success rate at 2 years was similar to Burch
Minimally invasive
Risks: overactive bladder, voiding dysfunction, increased risk of UTI, failure to treat incontinence symptoms
Goal: reduce undesired detrusor activity through reversible blockade of the muscularinic receptors and the detrusor NMJ (antimuscarinic) 2 types of muscularinic receptors in bladder
M3 is primarily responsible for detrusor contractility Drugs: oxybutynin, tolterodine, trospium chloride, solifenacin, darifenacin
Recent study 2496 pts: 36.9% had not refilled initial prescription in a 90 day period Additional study: 80% of patients c overactive bladder stopped meds within 6 months Side effects: dry mouth, constipation, blurred vision, etc
Behavioral Modification
Bladder diary (also an evaluation tool) Toileting posture/Voiding mechanics Timed voiding Fluid management Avoidance of bladder irritants Gradual exposure to bladder triggers Fiber intake guide
Diaphragmatic Breathing Pelvic floor strengthening, endurance training Pelvic floor coordination Vaginal cones and vaginal balls Manual techniques Biofeedback Electrical Stimulation
Insertion of fingertip into vagina or rectum Sitting on rolled hand towel Vaginal weights Mirror to observe movement of clitoris, introitus, anus Proper contraction: downward clitoris, inward introitus, tightening anus Improper contraction: movement of abdomen, glute squeezing, hip movements
Questions
References
Arnonen T, Fianu-Jonassen A, Tyni-Lynne R. Effectiveness of two conservative modes of physical therapy in women with urinary stress incontinence. Neurology and Urodynamics. (2001) 20: 591-599. Berghmans LCM, HendriksHJM, De Bie RA, et al. Conservative treatment of urge urinary incontinence in women: a systematic review of random clinical trials. BJU International. (2000) 85: 254-263. Bo K, Sherburn M. Evaluation of female pelvic floor muscle function and strength. Physical Therapy (2005) 85;3: 269-282. Dannecker C, Wolf V, Raab R, et al. EMG-biofeedback assisted pelvic floor muscle training is an effective therapy of stress urinary or mixed incontinence: a 7-year experience with 390 patients. Arch Gynecol Obst. (2005) 273: 93-97. Devreese AM, Nuyens G, Staes F, et al. Do posture and straining influence urinary-flow parameters in normal women? Neurology and Urodynamics. (2000) 19: 3-8 Dougherty MC. Current status of research on pelvic muscle strengthening techniques. J WOCN. (1998) 25: 75-83. Dumoulin C, Hay-Smith J. Pelvic floor muscle training versus no treatment for urinary incontinence in women. A Cochrane systematic review. Eur J Phys Rehabil Med (2008) 44: 47-63. Fitzgerald MP and Kotarinos R. Rehabilitation of the short pelvic floor I: Background and patient evaluation. Int Urogynecol J. (2003) 14: 261-268 Fitzgerald MP and Kotarinos R. Rehabilitation of the short pelvic floor II: Treatment of the patient with the short pelvic floor. Int Urogynecol J. (2003) 14: 269-275. Kafri R, Langer R, Dvir Z, et al. Rehabilitation vs drug therapy for urge urinary incontinence: long-term outcome. Int Urogynecol J. (2008) 19: 47-521. Kafri R, Langer R, Dvir Z, et al. Rehabilitation vs drug therapy for urge urinary incontinence: short-term outcome. Int Urogynecol J. (2007) 18: 407-411.
References
Leroi AM, Weber J, Menard JF, et al. Prevalence of anal incontinence in 409 patients investigated for stress incontinence. Neurology and Urodynamics. (1999) 18: 579-590. Messelink B, Benson T, Berghmans b, et al. Standardization of terminology of pelvic floor muscle function and dysfunction:report from the pelvic floor clinical assessment group of the International Continence Society. Neurology and Urodynamics. (2005) 24: 374-380. Miller KL. Stress urinary incontinence in women: review and update on neurological control. Journal of Womens Health. (2005) 14;7: 595-608 Neumann P, Blizzard L, grimmer K, et al. Expanded paper towel test: an objective test of urine loss for stress incontinence. Neurology and Urodynamics. (2004) 23: 649-655. Neumann PB, Grimmer KA, grant RE, et al. Physiotherapy for female stress urinary incontinence: a multicentre observational study. Austrailian and New Zealand Journal of Obstetrics and Gynaecology. (2005) 45: 226-232. Ostaszkiewicz J, Roe B, Johnston L. Effects of times voiding for the management of urinary incontinence in adults: systematic review. Journal of Advanced Nursing. (2005) 52(4): 420-431. Parkkinen A, Karjalainen E, Vartiainen M, et al. Physiotherapy for female stress urinary incontinence: individual therapy at the outpatient clinic versus home-based pelvic floor training: a 5-year follow-up study. Neurology and Urodynamics. (2004) 23: 643-648. Porru D, Campus G, Caria A, et al. Impact of early pelvic floor rehabilitation after transurethral resection of the prostate. Neurology and Urodynamics. (2001) 20: 53-59. Rogers RG. Urinary stress incontinence in women. N Engl J Med. (2008) 358;10: 1029-1036. Smith PP, McCrey RJ, Appell RA. Current trends in the evaluation and management of female incontinence. CMAJ. (2006) 175: 1233-1240.
References