Chapter 6 Immediate Care of Acute Orthopedic Injuries

RICES • The prescription for immediate care • RICES – Rest – Ice –

Immediate Care Myths • Acute care and immediate care the same. • Ice decreases

What Is Immediate Care? • Care given immediately after an acute orthopedic injury •

Acute Orthopedic Injury Care Typically three stages • Acute (0– 4 days) • Subacute

Acute Orthopedic Injury Care (cont. ) Problems with the typical three stages • Range

Acute Orthopedic Injury Care (cont. ) New three stages • Acute (0– 4 days)

Why RICES? • To limit (decrease): – Total injury – Swelling – Pain –

RICES Theory • • • Rest Ice Compression Elevation Stabilization Copyright © 2013 Wolters

Rest: Why? Limits injury aggravation • Should be total during immediate care • Transition

Ice/Cold: Why? • Most think it’s to control swelling. – Important but only part

Ice/Cold: Why? (cont. ) • Two theories – Circulatory or decreased blood flow theory

Decreased Blood Flow Theory • Older, traditional theory • Cold decreases blood flow. •

Decreased Secondary Injury Theory • History • First proposed in 1976 – Refined in

Decreased Secondary Injury Theory (cont. ) • Cold decreases cellular metabolism in viable cells,

Decreased Secondary Injury Theory (cont. ) Copyright © 2013 Wolters Kluwer Health | Lippincott

Metabolism and Cooling • Direct relationship – More cooling means greater decrease in metabolism

Metabolism and Cooling (cont. ) • Heat increases metabolism. – Causes more secondary injury

Cryotherapy and Swelling • Decreased edema, not hemorrhage – Most occurs hours after injury,

Compression: Why? • Controls edema beyond normal volume (i. e. , after tissue spaces

Compression: Why? (cont. ) • Compression enhances cooling. Copyright © 2013 Wolters Kluwer Health

Elevation: Why? • Decreases capillary hydrostatic pressure Copyright © 2013 Wolters Kluwer Health |

Stabilization: Why? Controls neural inhibition • Process in which neural pathway is blocked so

Stabilization: Why? (cont. ) Allows muscles to relax, thus • Decreases pain–spasm–pain cycle •

RICES Theory: Revisited • • • Rest Ice Compression Elevation Stabilization Copyright © 2013

What Is the Goal of Cold? • • Decrease tissue metabolism! More cooling means

Does It Matter How You Apply Cold? • Yes – Great differences in tissue

Cryotherapy Physics and Physiology • Cold does not exist; it is not a physical

Physiology of Heat Transfer Conduction • Exchange of energy (heat) between two substances in

Rate of Conduction • • Temperature differential between body and modality Regeneration of body

Heat Storage Capacity • Specific heat • Latent heat of fusion Copyright © 2013

Heat Storage Capacity (cont. ) Specific heat • Amount of heat energy required to

Heat Storage Capacity (cont. ) • Latent heat of fusion – Amount of heat

Heat Storage Capacity (cont. ) Crushed ice pack better than gel pack • Gel

Heat Storage Capacity (cont. ) Crushed ice pack better than gel pack Copyright ©

Temperature Changes Resulting from Cold Pack Application • Surface temperature – Repeated applications •

Temperature Changes Resulting from Cold Pack Application (cont. ) Copyright © 2013 Wolters Kluwer

Temperature Changes Resulting from Cold Pack Application (cont. ) • Tissue temperature – Depends

Temperature Changes Resulting from Cold Pack Application (cont. ) • Tissue temperature – Amount

Temperature Changes Resulting from Cold Pack Application (cont. ) • Articular temperature – Similar

Temperature Changes Resulting from Cold Pack Application (cont. ) Rewarming after application • Depth

Cryotherapy: Application Principles • Tissue cooling depends on – Cold modality used – How

Factors That Affect Tissue Cooling • Type of cold pack – Heat of fusion

Factors That Affect Tissue Cooling (cont. ) • Depth of target tissue – Deeper

Types of Cold Packs Four general types: • Crushed ice • Gel (Chattanooga, Cramer)

Types of Cold Packs (cont. ) Crushed ice • Most effective because of heat

Types of Cold Packs (cont. ) Gel • • pack Water, alcohol, and gel

Types of Cold Packs (cont. ) Gel pack • Dangerous if applied directly on

Types of Cold Packs (cont. ) Artificial ice • Water in vinyl pouches, surrounded

Types of Cold Packs (cont. ) Chemical: double bags, crushable • • • Chemical

Types of Cold Packs (cont. ) Frozen Peas • • • Popular; cheap and

Cold: Application Protocol • Apply directly to skin, not over a towel or elastic

Cold: Application Protocol (cont. ) • Insulation decreases effectiveness Copyright © 2013 Wolters Kluwer

Cold: Length of Application • Intermittent, 30– 60 min every 2 h • Depth

Cold: Length of Application Effect of Adipose Tissue on Tissue Cooling at 1 cm

Cold: Duration of Therapy • Severity of injury • Transition from RICES to cryotherapy

Preventing vs. Removing Swelling • Preventing secondary injury versus removing free protein from extracellular

Preventing vs. Removing Swelling (cont. ) • Removing free protein from extracellular spaces –

Compression: Application Principles • Elastic wraps preferred – Plastic wraps not as effective Copyright

Compression: Application Principles (cont. ) • Apply elastic wraps over ice pack – Compression

Compression: Application Principles (cont. ) • Stretch elastic wraps ~75% as they are applied.

Cryotherapy: Contraindications and Precautions Cold is dangerous if • Too cold or too long

Five-Step Application for Immediate Care • • • Foundation Preapplication tasks Application parameters Postapplication

Step 1. Foundation • • Definition Effects Advantages Disadvantages Indications Contraindications Precautions Copyright ©

Effects • Ice decreases metabolism in the injured tissue. – Decreases the need for

Effects (cont. ) Compression and elevation • Counteract edema and result in a decrease

Effects (cont. ) Stabilization • Allows musculature around the injury to relax • Along

Advantages • • Less total tissue damage means less healing needed. Decreased swelling means

Disadvantages • Effectiveness diminishes with time. • Full effects only if applied within 5–

Indications • Acute orthopedic or soft tissue injury Copyright © 2013 Wolters Kluwer Health

Contraindications Do not use with a person who is • Hypersensitive to cold •

Precautions • • Ice packs not directly on skin continuously for >60 min Cold

Step 2. Preapplication Tasks • • Selecting the proper modality Preparing the patient physically

Selecting the Proper Modality • • Evaluate the injury or problem. Determine the treatment

Preparing the Patient Physically • • • Remove overlying clothing. Remove braces and bandages,

Preparing the Patient Psychologically • • • Pain and frustration from the injury are

Preparing the Equipment • Prepare the ice pack – Crushed ice in a plastic

Preparing the Equipment (cont. ) • • , Elastic wraps – Prefer 6 in.

Step 3. Application Parameters • Procedures – Ice bag – Elastic wrap – Stabilize

Ice Bag • • • Place directly on skin Center over middle of injury

Elastic Wrap • • • Apply snugly, but not too tightly (stretch to ~75%

Stabilize • • Splint, sling, or brace Goal is total muscle relaxation. Sling for

Elevate • Six inches or so above heart , Copyright © 2013 Wolters Kluwer

Dosage • • Ice pack extends 2– 3 in. beyond injury. Compression extends 2–

Length of Application • • • , Ice bag, intermittently – 20– 60 min

Frequency of Application • • , Ice – 5– 10 min after injury –

Step 4. Postapplication Tasks • • • Replace equipment/clean up area – Drain water

Step 5. Maintenance • • Keep ice machine in good repair. Replace elastic wraps

Crutch Use Who? • Any patient unable to walk without a limp Why? •

Crutch Use (cont. ) Proper use requires • Proper fitting of crutches • Selecting

Crutch Use (cont. ) Crutch fitting • • • Adjust length so 2– 3

Crutch Use (cont. ) Select gait • Swing, if all weight off • Three-point

Crutch Use (cont. ) Walking instructions • Proper gait • Amount of weight on

Crutch Use (cont. ) Observe patient walking • Proper gait • Adjust if necessary

Medicated Ice Cups • For skin abrasions – Clean wound – Apply antiseptic –

Medicated Ice Cups (cont. ) Materials • Four 2 -oz disposable cups • 1

Medicated Ice Cups (cont. ) Medicated ice massage • Seek physician advice and approval

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Immediate Care Myths • Acute care and immediate care the same. • Ice decreases swelling. • The goal of immediate care is to decrease inflammation. • The purpose of ice is to decrease hemorrhaging. • Inflammation and swelling are the same. • Ice should be applied for 20 min during immediate care. • All injuries should be treated for the same amount of time. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Acute Orthopedic Injury Care (cont. ) Problems with the typical three stages • Range of acute care too wide – Treatment 10 min after injury is not the same as that needed 3 days after the injury. – Acute care, therefore, must be subdivided. • Injuries heal at different rates. – Type and severity of injury – Individual patient differences • Care dictated by patient progress, not by specific time frames Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Acute Orthopedic Injury Care (cont. ) New three stages • Acute (0– 4 days) – Emergency care (e. g. , CPR, if needed) – Immediate care (0– 12 h) – Transition care (12 h to 4 days) • Subacute (5– 14 days) • Postacute (>14 days) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Rest: Why? Limits injury aggravation • Should be total during immediate care • Transition to “relative” rest • Different from, but related to, stabilization Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Ice/Cold: Why? • Most think it’s to control swelling. – Important but only part of immediate care • Limiting secondary injury and neural inhibition are more important than controlling swelling. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Decreased Blood Flow Theory • Older, traditional theory • Cold decreases blood flow. • Logic of theory – Cold causes vasoconstriction – Which decreases blood flow and therefore – Decreases hemorrhaging and therefore – Swelling is reduced • Flaw: Clotting occurs before tissue is cooled enough to substantially decrease blood flow. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Decreased Secondary Injury Theory • History • First proposed in 1976 – Refined in 1985 – Tweaked in 2002 • Flaw: – Cold application has little effect on hemorrhaging. • Limits amount of secondary injury and, therefore, edema. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Decreased Secondary Injury Theory (cont. ) • Cold decreases cellular metabolism in viable cells, thus – Reduces oxygen demand (consumption) – Less secondary hypoxic injury – Less total injury – Less free protein generated by phagocytosis – Less edema Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Cryotherapy and Swelling • Decreased edema, not hemorrhage – Most occurs hours after injury, as free protein accumulates from phagocytosis • Cold reduces edema formation. – By preventing secondary injury and thus less free protein accumulation Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Compression: Why? • Controls edema beyond normal volume (i. e. , after tissue spaces are filled) • Apply constantly until swelling is over. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Stabilization: Why? Controls neural inhibition • Process in which neural pathway is blocked so impulses cannot pass – Intended function does not occur. • Can be partial so function is diminished or total so function is abolished temporarily Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Stabilization: Why? (cont. ) Allows muscles to relax, thus • Decreases pain–spasm–pain cycle • Numerous braces and splints for stabilization Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Physiology of Heat Transfer Conduction • Exchange of energy (heat) between two substances in contact with each other • Heat moves from body of higher energy to body of lower energy. • Causes warmer body to cool and cooler body to warm, until they reach equilibrium Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Rate of Conduction • • Temperature differential between body and modality Regeneration of body heat and modality cooling Heat storage capacity of cold modality Size of the cold modality Amount of tissue in contact with pack Length of application Individual variability Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Heat Storage Capacity (cont. ) Specific heat • Amount of heat energy required to raise 1 kg of a substance 1°C – Ice = 0. 5 cal/g – Water = 1 cal/g Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Heat Storage Capacity (cont. ) • Latent heat of fusion – Amount of heat energy needed to convert a substance from a solid state to a liquid state without changing its temperature – Phase change – Ice to water = 80 cal/kg Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Heat Storage Capacity (cont. ) Crushed ice pack better than gel pack • Gel pack ~22 kcal – Water from − 17°C to 5°C • Crushed ice pack ~86 kcal – Ice from − 1°C to 0°C, – Heat of fusion – Water from 0°C to 5°C Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Temperature Changes Resulting from Cold Pack Application • Surface temperature – Repeated applications • Time ratio • Activity between applications (shower) – Compression wrap over cold pack Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Temperature Changes Resulting from Cold Pack Application (cont. ) • Tissue temperature – Depends on depth and type of tissue – Delayed response – Continues to decrease after application Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Temperature Changes Resulting from Cold Pack Application (cont. ) • Tissue temperature – Amount of adipose tissue – Rewarming takes hours Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Temperature Changes Resulting from Cold Pack Application (cont. ) • Articular temperature – Similar to tissue temperature – Delayed response – Continues to decrease after application – Amount of adipose tissue Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Temperature Changes Resulting from Cold Pack Application (cont. ) Rewarming after application • Depth of tissue • Amount of heat available to rewarm area: function of circulation and environmental temperature. • Activity level before cryotherapy and palmer • Amount of heat removed from body during application (i. e. , magnitude and duration of cold exposure) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Cryotherapy: Application Principles • Tissue cooling depends on – Cold modality used – How modality is applied • Many protocols suggest – Length – Frequency – Duration Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Factors That Affect Tissue Cooling • Type of cold pack – Heat of fusion • Duration of application – Longer the application • More cooling • Slower rewarming • Size of cold pack – Larger cold pack, more cooling • Amount of tissue in contact with pack – More tissue contact, more cooling Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Factors That Affect Tissue Cooling (cont. ) • Depth of target tissue – Deeper target, less cooling • Type of cold pack • Method of application – On skin or over a towel or wrap – Compression over pack (per Merrick) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Types of Cold Packs Four general types: • Crushed ice • Gel (Chattanooga, Cramer) • Artificial ice – Water in vinyl (Dura*Kold) • Chemical – Double bags, crushable – Powder types Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Types of Cold Packs (cont. ) Crushed ice • Most effective because of heat of fusion • Excellent for on-the-field use because they don’t melt for hours stored if in insulated cooler • Should not be used if kept in a freezer (too cold) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Types of Cold Packs (cont. ) Gel • • pack Water, alcohol, and gel substance Cooled to ~1°F (− 17°C), so dangerous Not as effective as crushed ice packs (no heat of fusion) Even less effective if wrapped in towel Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Types of Cold Packs (cont. ) Artificial ice • Water in vinyl pouches, surrounded by nylon cover (Dura*Kold) • Better than gel because of heat of fusion • Not as good crushed ice because of insulation from nylon cover • Good for home use Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Types of Cold Packs (cont. ) Chemical: double bags, crushable • • • Chemical reaction when inner bag is crushed and contents react with outer chemicals Least cooling Not recommended Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Types of Cold Packs (cont. ) Frozen Peas • • • Popular; cheap and convenient Effective – Better than nothing and gel packs – Worse than crushed ice packs or ice water immersion – Little phase change with peas Avoid if possible Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Cold: Application Protocol • Apply directly to skin, not over a towel or elastic wrap – Except for gel packs – Except for crushed ice from freezer Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Cold: Length of Application Effect of Adipose Tissue on Tissue Cooling at 1 cm below the Adipose Tissue in the Thigh Skinfold Thickness (mm) 0– 10 Time to Decrease Tissue Temperature 44. 6°F (7°C) 8. 0 ± 3. 4 min 11– 20 23. 3 ± 6. 7 min 21– 30 37. 8 ± 9. 6 min 31– 40 58. 6 ± 11. 7 min Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Preventing vs. Removing Swelling • Preventing secondary injury versus removing free protein from extracellular spaces • Prevent: decrease metabolism – Cold effective • Remove: stimulate lymph flow – Cold is a waste of time. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Preventing vs. Removing Swelling (cont. ) • Removing free protein from extracellular spaces – Must stimulate lymph flow – Requires intermittent compression • Massage • Lymphedema pump • Active exercise (muscle pump) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Cryotherapy: Contraindications and Precautions Cold is dangerous if • Too cold or too long • Under excessive compression • Patient suffers from some specific diseases, such as – Raynaud – Cold hypersensitivity – Cold urticaria Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Five-Step Application for Immediate Care • • • Foundation Preapplication tasks Application parameters Postapplication tasks Maintenance Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Advantages • • Less total tissue damage means less healing needed. Decreased swelling means less pain. Decreased pain means less neural inhibition. Ice is relatively inexpensive. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Precautions • • Ice packs not directly on skin continuously for >60 min Cold packs cooled to or less than − 17°C (0°F) should not be applied directly to the skin. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Selecting the Proper Modality • • Evaluate the injury or problem. Determine the treatment goals. Check for contraindications. Hypersensitive to cold? Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Preparing the Patient Physically • • • Remove overlying clothing. Remove braces and bandages, as necessary. Place patient in a comfortable position and so that the injured area is elevated. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Preparing the Patient Psychologically • • • Pain and frustration from the injury are usually the biggest problems. Reassure the athlete. Warn about precautions. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Preparing the Equipment • Prepare the ice pack – Crushed ice in a plastic bag • Big enough to extend 2– 3 in. beyond injury – Evacuate as much air as possible from the bag. – Tie a knot in bag. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Preparing the Equipment (cont. ) • • , Elastic wraps – Prefer 6 in. , never <4 in. – Double length or multiple for large areas Splint or sling Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Step 3. Application Parameters • Procedures – Ice bag – Elastic wrap – Stabilize – Elevate – Dosage – Duration – Frequency of application Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Elastic Wrap • • • Apply snugly, but not too tightly (stretch to ~75% of length). Cover the entire area. Secure with clips, tape, or tuck. Wear constantly for 20– 24 h, except when changing ice bag. No Flexi-Wrap, no compression , Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Stabilize • • Splint, sling, or brace Goal is total muscle relaxation. Sling for upper extremity injuries, if muscle guarding occurs Crutches for lower extremity injuries, if walking causes pain and/or limping Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Length of Application • • • , Ice bag, intermittently – 20– 60 min depends on injury and skinfold • 20 min, finger • 30 min ankle, arm • 45 min, thigh • +1 min per millimeter of skinfold Compression and elevation constantly Rest and stabilization until pain free Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Frequency of Application • • , Ice – 5– 10 min after injury – Second application 30– 60 min later, after shower and go home – Every 2 h thereafter (don’t stay up into night) Rest, compression, elevation, and stabilization constantly Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Step 4. Postapplication Tasks • • • Replace equipment/clean up area – Drain water and ice from ice pack (save the plastic bag for another use). – Return cold pack to refrigeration unit. Give patient written instructions – Time of next appointment – Rest injury – Time for reapplication of ice – Phone number for emergency Record treatment and unique patient response to treatment Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Crutch Use Who? • Any patient unable to walk without a limp Why? • Crutches facilitate proper gait by using arms to substitute for, or supplement, leg power. • Failure to use crutches may result in: – Delayed healing – Permanent abnormal gait Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Crutch Use (cont. ) Proper use requires • Proper fitting of crutches • Selecting the appropriate gait • Instructing patient to walk properly • Observing the patient practice the gait • Periodic reevaluating to make sure patient is using crutches properly Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Crutch Use (cont. ) Crutch fitting • • • Adjust length so 2– 3 in. between top and axilla Adjust hand piece so that elbow is flexed to 30°. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Crutch Use (cont. ) Select gait • Swing, if all weight off • Three-point for partial weight bearing – Use this as much as possible – Gradually increase weight on foot Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Crutch Use (cont. ) Walking instructions • Proper gait • Amount of weight on foot • Up and down stairs – The phrase “the good go up to heaven, the bad down to hell” may help you remember which foot or leg goes first when walking up and down stairs. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Medicated Ice Cups (cont. ) Materials • Four 2 -oz disposable cups • 1 oz of 2% lidocaine • 3 oz of 10% povidine-iodine • 3 oz of distilled or boiled water • Plastic stir sticks (handle) • Adhesive tape (to secure stir sticks in the center of cup) Mix together and pour into cups. Secure sticks in center of each cup with tape. Label and freeze overnight. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Medicated Ice Cups (cont. ) Medicated ice massage • Seek physician advice and approval before using. • Hold by stir stick and roll the ice back and forth along lacerated skin ~10 min. • As ice melts, medicines flow into wound. • Debride the area (remove foreign materials). • Treat and protect the area as any open wound, emphasizing sterility. • Apply an ice pack for 20– 30 min each hour and compression constantly. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins