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In normal individuals, the heart rate will accelerate in response to inspiration and increased venous return to the right heart and decelerate in response to expiration (sinus arrhythmia) This response will diminish as a normal consequence of aging The afferent receptors for this re ex include pulmonary stretch receptors, cardiac mechanoreceptors, and possibly baroreceptors55 Sinus arrhythmia is a consequence of increased or decreased parasympathetic, cardiovagal tone There are numerous protocols that address both the performance and the measurement of heart rate variability Commonly the patient is positioned with the head up 30 from supine The patient is asked to breath slowly and steadily at a rate of 6/min (5-second inspirations and 5-second expirations), usually for a period of 1 minute Heart rate response to deep breathing can be measured either by the greatest difference between the fastest and slowest rate that occur during this interval or by the calculation of an E (expiration) to I (inspiration) ratio The latter is done my measuring the shortest (I ) and longest (E ) intervals between QRS complexes (R R interval) as singular, summed, or averaged values As the heart rate is the slowest during expiration, the R R interval increases accordingly resulting in an E :I ratio of >1 There are published, agematched normative data for both of these parameters The mean heart rate variation in heart rate in a teenager is 30 beats per minute (bpm) with the 5th to 95th percentile range being 14 to 41 bpm Between 60 69 years of age, the mean heart rate variation is closer to 18 with the 90% of normals being in the 7 27 bpm range45,46 The Valsalva maneuver is more complex The patient is asked to sustain a constant expiratory pressure of 40 mm Hg for approximately 15 seconds into a mouth piece attached to a manometer with a slow leak in the system Both heart rate and blood pressure responses are monitored during and in the immediate aftermath of this maneuver Four distinct phases are discernable, the rst and third and the rst part of the second phase (IIA) being mechanical in nature and phase IIB and IV resulting from autonomic nervous system responses During the rst phase, there is a transient increase in blood pressure resulting from strain and its effect of producing increased intrathoracic pressure resulting in compression on the aorta Phase IIA also takes place during strain and is de ned by a drop in blood pressure occurring from the reduced venous return also promoted by increased intrathoracic pressure Phase IIB is normally identi ed by rising blood pressure that approaches baseline This is promoted by increased vasomotor tone mediated by increased sympathetic and alpha adrenergic output During the entirety of phase II, there is an increasing heart rate as a result of cardiovagal withdrawal Phase III is initiated with glottic release and a resultant decline in intrathoracic pressures Blood pressure transiently declines as intrathoracic venous structures can now readily re ll During phase IV, blood pressure rises and pulse declines under normal circumstances and over- and.

if it s currently turned on (see the accompanying Hint) At the right end of the taskbar is the noti cation area often referred to as the system tray which displays the time and any number of small icons for system programs currently stored in RAM In the middle of the taskbar are buttons representing the user-started programs that are currently running

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SPECIFIC DISORDERS 150 Flanagan W, Webster GD, Brown MW, et al Lumbosacral plexus stretch injury following the use of the modi ed lithotomy position J Urol 1985;134:567 568 151 Stewart JD The piriformis syndrome is overdiagnosed Muscle Nerve 2003;28(5):644 646 152 Iverson DJ MRI detection of cysts of the knee causing common peroneal neuropathy Neurology 2005;65:1829 1831 153 Sotaniemi KA Slimmer s paralysis peroneal neuropathy during weight reduction J Neurol Neurosurg Psychiatry 1984;47:564 566 154 Campellone JV Peroneal neuropathy from antithrombotic stockings J Clin Neuromuscul Dis 1999;1:14 16 155 Uncini A, Di Muzio A, Awad J, Gambi D Compressive bilateral peroneal neuropathy: Serial electrophysiologic studies and pathophysiological remarks Acta Neurol Scand 1992;85:66 70 156 Adornato B, Carlini WG Pushing palsy: A case of selfinduced bilateral peroneal palsy during natural childbirth Neurology 1992;42(4):936 937 157 Crisci C, Baker MK, Wood MB, Litchy WJ, Dyck PJ Trochanteric sciatic neuropathy Neurology 1989;39:1539 1541 158 Jones HR, Felice KJ, Gross PT Pediatric peroneal mononeuropathy: A clinical and electromyographic study Muscle Nerve 1993;16:1167 1173 159 Drees C, Wilbourn AJ, Stevens GHJ Main trunk tibial neuropathies Neurology 2002;59:1082 1084 160 Delisa JA, Saeed MA The tarsal tunnel syndrome Muscle Nerve 1983;6:664 670 161 Goodgold J, Kopell HP, Spielholz NI The tarsal-tunnel syndrome: Objective diagnostic criteria N Engl J Med 1965;273(14):742 745 162 Oh SJ, Sarala PK, Kuba T, Elmore RS Tarsal tunnel syndrome: Electrophysiological study Ann Neurol 1979;5: 327 330 163 Smith HB, Litchy WJ Sural mononeuropathy: A clinical and electrophysiological study Neurology 1989; 39(Suppl 1):296 164 Stickler DE, Morley KN, Massey EW Sural neuropathy: Etiologies and predisposing factors Muscle Nerve 2006;34: 482 484 165 Robinson LR Traumatic injury to peripheral nerves Muscle Nerve 2000;23:863 873 166 Benezis I, Boutaud B, Leclerc J, Fabre T, Durandeau A Lateral femoral cutaneous neuropathy and its surgical treatment: A report of 167 cases Muscle Nerve 2007;36: 659 663 167 Lachance DH, Daube JR Acute peripheral arterial occlusion: Electrophysiologic study of 32 cases Muscle Nerve 1991;14(7):633 639 168 Levin KH AAEE case report #19: Ischemic monomelic neuropathy Muscle Nerve 1989;12:791 795 169 England JD, Ferguson MA, Hiatt WR, Regensteiner JG Progression of neuropathy in peripheral arterial disease Muscle Nerve 1995;18:380 387 170 Nukada H, van Rij AM, Packer SGK, McMorran PD Pathology of acute and chronic ischaemic neuropathy in atherosclerotic peripheral vascular disease Brain 1996; 119:1449 1460.

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Figure 7-5

If you don t see the Quick Launch area, point to an unused area of the taskbar, right-click, and select Properties Check the Show Quick Launch box and click OK You can now drag program icons or even folder shortcuts from the desktop onto the Quick Launch toolbar for quick access any time

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