Heat stress associated with aerosol PPE and its impact.

BACKGROUND: Aerosol personal protective equipment (PPE) is subjectively reported to negatively impact healthcare workers' performance and well-being, but this has not been assessed objectively. AIMS: This randomized controlled crossover study aimed to quantify the heat stress associated with aerosol PPE and to investigate its impact upon mood, cognitive and motor function, and task performance. METHODS: Sixteen healthy, young, lean participants (eight males) undertook an exercise protocol, which simulated the metabolic expenditure of hospital work: once wearing aerosol PPE (PPE visit) and once wearing standard surgical attire (control visit). Participants walked on a treadmill for 2 h followed by 30-min rest. Core temperature, heart rate, urine specific gravity, weight, grip strength, mood (Bond-Lader scale) and task performance (Intubation of a Manikin) were recorded. Values are between-visit mean (standard deviation) differences. RESULTS: On the PPE visit core temperature (+0.2 (0.3)°C; P < 0.01), heart rate (+12 (13) bpm; P < 0.001), urine specific gravity (+0.003 (0.005); P < 0.05) and intubation task time (+50 (81) s; P < 0.01) were greater than on the control visit; and alertness (-14 (21) mm; P < 0.001), contentment (-14 (15) mm; P < 0.001) and grip strength (-4 (4) N; P < 0.01) were less. CONCLUSIONS: This study demonstrates that wearing aerosol PPE in a simulated hospital environment results in heat exhaustion and has a negative impact upon mood, motor function, and task performance. Whilst wearing PPE is important to prevent disease transmission, strategies should be developed to limit its impact upon healthcare workers' performance and well-being.

Biomechanical determinants of elite rowing technique and performance.

In rowing, the parameters of injury, performance, and technique are all interrelated and in dynamic equilibrium. Whilst rowing requires extreme physical strength and endurance, a high level of skill and technique is essential to enable an effective transfer of power through the rowing sequence. This study aimed to determine discrete aspects of rowing technique, which strongly influence foot force production and asymmetries at the foot-stretchers, as these are biomechanical parameters often associated with performance and injury risk. Twenty elite female rowers performed an incremental rowing test on an instrumented rowing ergometer, which measured force at the handle and foot-stretchers, while three-dimensional kinematic recordings of the ankle, knee, hip, and lumbar-pelvic joints were made. Multiple regression analyses identified hip kinematics as a key predictor of foot force output (R(2) = 0.48), whereas knee and lumbar-pelvic kinematics were the main determinants in optimizing the horizontal foot force component (R(2) = .41). Bilateral asymmetries of the foot-stretchers were also seen to significantly influence lumbar-pelvic kinematics (R(2) = 0.43) and pelvic twisting (R(2) = 0.32) during the rowing stroke. These results provide biomechanical evidence toward aspects of technique that can be modified to optimize force output and performance, which can be of direct benefit to coaches and athletes.

Patients' views on an education booklet following spinal surgery.

PURPOSE: This study evaluated an evidence-based education booklet developed for patients undergoing spinal surgery which was used as a treatment intervention in a multi-centre, factorial, randomised controlled trial (FASTER: Function after spinal treatment, exercise and rehabilitation) investigating the post-operative management of spinal surgery patients. This study sought to determine the acceptability and content of the booklet to patients. METHODS: Patients receiving the educational booklet before discharge from hospital as part of the FASTER study were asked to complete an evaluation, which rated the booklet "Your Back Operation" with regard to content, information, usability, etc. using forced and open questions. This assessment was conducted at the same time as the initial 6-week post-operative review performed as part of the larger study. RESULTS: Therefore, 97% of the 117 trial participants who returned their 6-week evaluation and randomised to receive a booklet returned their questionnaire. The booklet was highly rated receiving an overall rating of 7 or more out of 10 from 101/111 (91%), and high ratings for content, readability and information. The booklet's key messages were clear to the majority of patients; however, many patients highlighted deficiencies with respect to content particularly in relation to wound care and exercise. CONCLUSIONS: Patients valued the booklet and rated its content highly. Many suggested that the booklet be developed further and there was a clear desire for specific exercises to be included even though there is no evidence to support specific exercise prescription.

Predicting the lumbosacral joint centre location from palpable anatomical landmarks.

The kinematics of the lumbar spine have previously been described by considering the bearing of the pelvis and lower back. However earlier studies have not described an intersegmental angle measured about a single point; which is necessary for investigation into movement, posture and balance, and lower back pain and injury. This study used computed tomography (CT) scans of 16 pelves to determine the location of palpable bony landmarks, and the junction of the fifth lumbar and first sacral vertebrae within a pelvis axis system. Data were used to derive equations which express the three-dimensional location of the lumbosacral joint centre as an offset from palpable surface landmarks. The magnitude of X, Y, Z offsets was controlled using individual pelvic geometry, and robustness and repeatability of the method was assessed. Regression equations provided the location of the lumbosacral junction to within 8.2mm (+/- 3.4mm) of its true coordinate. Leave-one-out analyses calculated equation coefficients using 15 of the original pelves, with the 16th acting as a control; average errors increased by 6.7 per cent (+/- 0.1 percent). To the authors' knowledge the current method is the most accurate non-invasive means of locating the lumbosacral junction and may be useful for constructing biomechanical models.

An open-source musculoskeletal model of the lumbar spine and lower limbs: a validation for movements of the lumbar spine.

Musculoskeletal models of the lumbar spine have been developed with varying levels of detail for a wide range of clinical applications. Providing consistency is ensured throughout the modelling approach, these models can be combined with other computational models and be used in predictive modelling studies to investigate bone health deterioration and the associated fracture risk. To provide precise physiological loading conditions for such predictive modelling studies, a new full-body musculoskeletal model including a detailed and consistent representation of the lower limbs and the lumbar spine was developed. The model was assessed against in vivo measurements from the literature for a range of spine movements representative of daily living activities. Comparison between model estimations and electromyography recordings was also made for a range of lifting tasks. This new musculoskeletal model will provide a comprehensive physiological mechanical environment for future predictive finite element modelling studies on bone structural adaptation. It is freely available on https://simtk.org/projects/llsm/.

Function after spinal treatment, exercise and rehabilitation (FASTER): improving the functional outcome of spinal surgery.

BACKGROUND: The life-time incidence of low back pain is high and diagnoses of spinal stenosis and disc prolapse are increasing. Consequently, there is a steady rise in surgical interventions for these conditions. Current evidence suggests that while the success of surgery is incomplete, it is superior to conservative interventions. A recent survey indicates that there are large differences in the type and intensity of rehabilitation, if any, provided after spinal surgery as well as in the restrictions and advice given to patients in the post-operative period. This trial will test the hypothesis that functional outcome following two common spinal operations can be improved by a programme of post-operative rehabilitation that combines professional support and advice with graded active exercise and/or an educational booklet based on evidence-based messages and advice. METHODS/DESIGN: The study design is a multi-centre, factorial, randomised controlled trial with patients stratified by surgeon and operative procedure. The trial will compare the effectiveness and cost-effectiveness of a rehabilitation programme and an education booklet for the postoperative management of patients undergoing discectomy or lateral nerve root decompression, each compared with "usual care"using a 2 x 2 factorial design. The trial will create 4 sub-groups; rehabilitation-only, booklet-only, rehabilitation-plus-booklet, and usual care only. The trial aims to recruit 344 patients, which equates to 86 patients in each of the four sub-groups. All patients will be assessed for functional ability (through the Oswestry Disability Index - a disease specific functional questionnaire), pain (using visual analogue scales), and satisfaction pre-operatively and then at 6 weeks, 3, 6 and 9 months and 1 year post-operatively. This will be complemented by a formal analysis of cost-effectiveness. DISCUSSION: This trial will determine whether the outcome of spinal surgery can be enhanced by either a post-operative rehabilitation programme or an evidence-based advice booklet or a combination of the two and as such will contribute to our knowledge on how to manage spinal surgery patients in the post-operative period.

Reliability and minimal detectable change of the 'Imperial Spine' marker set for the evaluation of spinal and lower limb kinematics in adults.

OBJECTIVES: As a step towards the comprehensive evaluation of movement in patients with low back pain, the aim of this study is to design a marker set (three rigid segment spine, pelvic and lower limb model) and evaluate the reliability and minimal detectable change (MDC) of this marker set in healthy adults during gait and sit to stand (STS) tasks using three dimensional motion capture. RESULTS: The 'Imperial Spine' marker set was used to assess relative peak angles during gait and STS tasks using the minimum recommended sample size (n = 10) for reliability studies with minimum Intraclass Correlation Coefficient (ICC) of 0.70, optimum ICC 0.90 and 9 trials replicated per subject per task. Intra- and inter-tester reliability between an experienced and inexperienced user was examined. ICC, mean, standard error (SEM), Bland Altman 95% limits of agreement (LOA) and MDC were computed. ICC values demonstrated excellent intra- and inter-tester reliability in both tasks, particularly in the sagittal plane (majority ICCs > 0.80). SEM measurements were lower in gait (0.8-5.5°) than STS tasks (1°-12.6°) as were MDC values. LOA demonstrated good agreement. The 'Imperial Spine' marker set is reliable for use in healthy adults during functional tasks. Future evaluation in patients is required.

Establishment of a protocol to test fatigue of the trunk muscles.

BACKGROUND: Muscle fatigue has high relevance in human performance yet little research has evaluated how it should be assessed. OBJECTIVE: To perform a pilot study to identify suitable methods of generating and assessing fatigue of the trunk flexor and extensor muscles. METHODS: Sixteen university rugby players (mean (SEM) age 21.9 (0.2) years) were recruited and subjected to four protocols (A, B, C, D), separated by a week to allow recovery, with peak torque being recorded during each test: A, isokinetic measurements before and after fatigue, with a 10 repetition isokinetic fatigue period; B, isokinetic measurements before and after fatigue with a 45 second isometric fatigue period; C, isometric measurements before and after fatigue with a 10 repetition isokinetic fatigue period; D, isometric measurements before and after fatigue with a 45 second isometric fatigue period. All were conducted during flexion and extension of the trunk on the Cybex Norm Isokinetic Dynamometer trunk flexion-extension unit. RESULTS: All subjects completed all four protocols. Fatigue induction appeared more effective in flexion than extension. Significant differences in mean peak torque before and after fatigue were seen in protocols A, B, and D in flexion and only in protocol D for extension. In flexion, protocol D produced the greatest fatigue, peak torque being 16.2% less after than before fatigue, suggesting greatest sensitivity. CONCLUSIONS: Protocol D, which incorporates isometric testing and fatigue protocols, appears to be able to produce fatigue most effectively, and therefore may provide the most valid assessment of fatigue in the trunk flexor and extensor muscles.

Phenobarbitone-induced ploidy changes in liver occur independently of p53.

Liver polyploidisation, characterised by accumulation of tetraploid and octaploid cells, is found with increasing age and after administration of various drugs. The significance and mechanisms controlling polyploidisation are not understood but p53 is a candidate gene to be involved. We have investigated the effect of p53 on sodium phenobarbitone (PB)-induced liver proliferation and polyploidisation. Using p53 wild type (+/+), heterozygous (+/-) and homozygous (-/-) C57BL/6J mice, we measured ploidy and proliferation (BrdU incorporation) after 21 days oral administration of PB. Administration of PB caused a striking ploidy change compared with untreated controls, with an increase in 8n cells, and no difference noted comparing the p53 genotypes. BrdU positivity also increased significantly compared with controls, with the increase in BrdU positivity occurring in 8n cells. Our results confirm that PB is a hepatic mitogen that causes liver polyploidisation with a striking increase in 8n cells within the liver. p53 status does not appear to have any effect on this PB-induced ploidy change.

Motion characteristics of the lumbar spine in the normal population.

STUDY DESIGN: The present study investigated the dynamic motion characteristics of the lumbar spine in the normal population using a potentiometric analysis system. OBJECTIVES: To assess the ability of a triaxial potentiometric analysis system to measure dynamic motion in the lumbar spine, and to use this system to form a database of dynamic motion characteristics from which normal parameters of motion and the factors affecting this motion could be defined. SUMMARY OF BACKGROUND DATA: Spinal motion has been studied using a variety of different methods, the majority of which have been limited either in terms of reliability, accuracy, or invasiveness and many have been only of a static nature. There has been no previous study into the normal dynamic motion characteristics of the lumbar spine. METHODS: The accuracy of the system was determined by a series of tests against a calibrated engineering mill, and the reliability of the system was assessed on 10 subjects with repeated measurements over a 3-day period. Values of range of motion and angular velocity were obtained from 203 normal subjects during flexion and extension, lateral flexion, and rotation. RESULTS: The results of the calibration testing revealed excellent accuracy, and it was shown that the system was repeatable. Initial analysis of the results indicated that sex differences did exist with men having 58.4 degrees of flexion and women having 53.4 degrees. Age appeared to have an influence on motion, and a gradual reduction was seen with each decade (P < 0.001), with the 20-29-year age range having 59.5 degrees mean flexion, the 30-39-year group having 58.1 degrees, the 40-49-year group having 53.7 degrees, the 50-60-year group having 57.5 degrees, and the 60-70-year group having 45.9 degrees. Multiple regression techniques revealed that only a few factors are important with respect to motion and that these varied according to the characteristic being defined. CONCLUSIONS: Range of motion tended to be affected by age and sex, whereas velocity was only affected by distance moved, with occupation and body mass index having little or no influence on the motion. The factors identified could only account for a small proportion of the variation seen, suggesting that it is difficult to predict the motion characteristics with any degree of sensitivity.

Global spinal motion in subjects with lumbar spondylolysis and spondylolisthesis: does the grade or type of slip affect global spinal motion?

STUDY DESIGN: This was a prospective pilot study to investigate the global motion characteristics of the spondylolysis and spondylolisthesis populations. OBJECTIVES: The aim of this study is to determine the influence of a spondylolisthesis or a spondylolysis on global spinal motion and to establish whether this is dependent on the cause of the slip or the degree/grade of the slip. SUMMARY OF BACKGROUND DATA: The condition of spondylolisthesis has been extensively discussed in the literature with respect to its etiology and management. However, the mechanics and movement of the spine in relation to pathology and the effect of this condition on function have received scant attention. METHODS: The motion of the lumbar spine was investigated in 31 patients (19 men, 12 women, mean age 47.7 +/- 17.8 years) who were diagnosed as having either a lumbar spondylolysis or a spondylolisthesis. These patients were compared with a preexisting database of 203 normal subjects (100 men, 103 women, mean age 39.8 +/- 13.4 years). Patients were graded according to the type of spondylolisthesis or spondylolysis they had, and the extent of slip was rated using Meyerding's classification (1932) and measured directly using methods of Boxall et al (1979) and Wiltse et al (1983). RESULTS: Direct measurements of the extent of slip using Boxall et al (1979) and Wiltse et al (1983) methods were found to have no significant correlation with the resultant range of motion (ROM) or the speed of movement. This study suggests that motion parameters are influenced by the grade of slip in patients with spondylolisthesis, and the type of spondylolisthesis i.e., whether isthmic or degenerative. In the A-P flexion-extension plane, the results indicate that subjects with a defect only, i.e., a spondylolysis, and thus no slip present with a spinal hypermobility (P < 0.01). Subjects with an isthmic slip tend to be either slightly hypermobile or within the anticipated range of motion, whereas those subjects with a degenerative slip tend to be hypomobile (P < 0.05). Movements into lateral flexion were restricted in both the isthmic and degenerative spondylolisthesis patients, whereas rotation was only influenced by the level at which the defect occurred. In terms of degree of displacement, in higher grades of displacement, there was a trend towards hypermobility. CONCLUSIONS: The findings of this study suggest that the grade and type of spondylolisthesis do influence global motion parameters. This information may be useful in the clinical assessment of this patient group.

Spinal motion in lumbar degenerative disc disease.

We have measured the dynamic movement of the lumbar spine in 57 patients with degenerative lumbar disc disease. Each completed a questionnaire which recorded pain and subjective signs and symptoms. From plain lateral radiographs, the subjects were graded using the criteria of Kellgren and Lawrence and those of Lane et al, which are both based on the severity of degenerative changes. Measurements of the height of the disc space and the vertebral height were obtained and expressed as a ratio. We found no relationship between the characteristics of spinal movement and the overall grading of degenerative disc disease with either system. Both were influenced (p < 0.01) by age, walking distance, severity of symptoms, drug intake and frequency of pain. The present systems for grading degenerative disc disease from plain lateral radiographs have limited application.

Correlation of nerve root pain with dermatomal sensory threshold and back pain with spinal movement in single level lumbar spondylosis.

We studied 27 patients with low back pain and unilateral L5 or S1 spinal nerve root pain. Significant radiological changes were restricted to the symptomatic root level, when compared with controls. Low back and leg pain were graded on a visual analogue scale. Dermatomal quantitative sensory tests revealed significant elevations of warm, cool and touch perception thresholds in the affected dermatome, compared with controls. These elevations correlated with root pain (warm v L5 root pain; r = 0.88, p < 0.0001), but not with back pain. Low back pain correlated with restriction of anteroposterior spinal flexion (p = 0.02), but not with leg pain. A subset of 16 patients underwent decompressive surgery with improvement of pain scores, sensory thresholds and spinal mobility. A further 14 patients with back pain, multilevel nerve root symptoms and radiological changes were also studied. The only correlation found was of low back pain with spinal movement (p < 0.002). We conclude that, in patients with single level disease, dermatomal sensory threshold elevation and restriction of spinal movement are independent correlates of sciatica and low back pain.

The influence of initial resting posture on range of motion of the lumbar spine.

The aim of this study was to investigate the influence of initial resting posture on range of motion of the lumbar spine in 18 normal subjects. Subjects resting posture and active range of motion was measured using the CA-6000 Spinal Motion Analyser (OSI, USA) in five test positions, namely in flat standing and with a variety of heel raises. Analysis showed that there was no significant correlation between subject's normal resting posture and active range of motion. However, when subjects resting posture was artificially altered with heel raises, significant effects on the active range of motion were demonstrated. Increasing heel height significantly influenced resting posture in the sagittal plane only. As heel height increased, the lumbar lordosis decreased and a significant reduction in the range of lumbar spine flexion (P<0.001) was observed. Simulating pelvic asymmetry influenced resting posture in the frontal plane and significant effects on the range of lateral flexion (P<0.05) were observed. These results have important clinical implications in terms of using range of motion of the lumbar spine as an examination tool and suggest that studies using range of motion as an outcome measure should consider initial resting posture.

Measuring spinal motion in rowers: the use of an electromagnetic device.

OBJECTIVE: To determine whether a skin-mounted electromagnetic measurement device can be used to measure lumbar spinal motion in rowers and discriminate between variations in technique. DESIGN: The lumbar spinal kinematics of elite level rowers were assessed with an electromagnetic device (Flock of Birds) during ergometer training using five technique variants. The system was correlated with sagittal MRI imaging of the lumbar spine and pelvis. BACKGROUND: Rowing technique is related to performance and injury. This study sought to test a method to obtain quantitative data on the effect of changes in technique on lumbar spinal and pelvic motion. METHODS: Lumbar spinal and pelvic motion were measured in six elite level rowers on an ergometer using normal rowing technique, three common bad technique variants, and after a 10 min piece of rowing simulating fatigue. RESULTS: Significant differences were found between the different rowing techniques for femoral, thoraco-lumbar and lumbo-sacral flexion. CONCLUSIONS: Kinematic parameters of spinal motion of rowers can be measured dynamically and used to quantify and discriminate between good and bad rowing styles. Relevance There is a consistent style of "good" rowing technique on an ergometer. Deviations from this technique can be measured and this will allow studies to be conducted comparing rowing styles between rowers of different standards and between different boat houses. There is potential to develop a dynamic feedback system to the rower that will assist in training and eradicate bad technique variants.

Can interventional MRI provide an insight into the mechanics of a posterior-anterior mobilisation?

OBJECTIVES: A pilot study aimed to investigate if interventional MRI could detect changes in the spine and surrounding soft tissues as a result of a posteroanterior mobilisation, and to determine if such an effect was specific to the level of application. DESIGN: A prospective pilot study to investigate the kinematics of cervical spine mobilisation. BACKGROUND: Posteroanterior mobilisation is a manual physiotherapy technique that is commonly used as an examination tool and a form of conservative treatment. The efficacy of this technique is controversial and little is known regarding the underlying mechanisms. METHODS: Five control subjects were recruited and written informed consent obtained. Subjects were scanned, using a General Electric Signa SP10 Open Interventional MRI scanner, in the prone position with their necks in either a neutral or flexed position. In each position a posteroanterior mobilisation to the 2nd and 6th cervical vertebrae was performed. Sagittal images of the spine were obtained prior to, during and following the mobilisation. RESULTS: Clear images of vertebral position could be obtained during the application of a posteroanterior mobilisation. Measurements of intervertebral angulation and translation demonstrated little if any motion during the application of a posteroanterior mobilisation, in both a flexed and neutral position. Changes were seen in terms of soft tissue compression and in some instances overall angulation of the cervical spine. CONCLUSIONS: Interventional MRI can produce images of posteroanterior mobilisation. Dynamic imaging of the procedure produced images of unsuitable quality for analysis. The quasi-static images of suggested that the application of a posteroanterior mobilisation to the cervical spine produces minimal if any intervertebral motion, but significant soft tissue deformation of the overlying structures. RELEVANCE STATEMENT: Posteroanterior mobilisation is frequently used in the assessment and management of spinal problems, but the efficacy of the technique remains controversial. This is hampered by the fact that little is known about the mechanisms involved during such a procedure.

Liver death and regeneration in paracetamol toxicity.

Paracetamol overdose (POD) is a major clinical problem as the commonest cause of fulminant hepatic failure (FHF) in the UK and the USA. While the main loss of liver mass occurs following hepatocyte necrosis, hepatocyte apoptosis has also been reported to occur during paracetamol toxicity in murine liver. Hepatocyte apoptosis has not previously been identified in human liver and the significance of apoptosis in paracetamol toxicity is not known. In this study of paracetamol toxicity in human liver after POD, hepatocyte apoptosis was identified at time of liver transplantation or death and was associated with striking regenerative activity. The biological significance of apoptosis is unclear but the rates of apoptosis found (0.6%) could account for a significant loss of hepatic parenchyma. The stimulus for apoptosis is not known but it is unlikely to be induced directly by paracetamol since it is absent from serum at this time. The possibility that apoptosis may be induced by Kupffer cell activation with cytokine production is raised. Patients who develop FHF after POD have a poor prognosis, with few therapeutic options apart from liver transplantation; an understanding of the dynamics of liver regeneration and ongoing cell loss by apoptosis may allow the development of new therapies in these patients.

Are subjective clinical findings and objective clinical tests related to the motion characteristics of low back pain subjects?

Many authors have demonstrated that low back pain sufferers have impaired spinal motion. However, it is not known to what degree the patient's signs and symptoms influence this impairment in motion. The aim of this study was therefore to conduct an explorative study to investigate the relationship between low back pain patients' signs and presenting symptoms and objective measurements of motion. One hundred thirty-eight patients with low back pain completed a questionnaire detailing their signs and symptoms and underwent a full clinical examination. A potentiometric motion analysis system of known accuracy and repeatability was used to measure their spinal motion during a flexion-extension test. The effects of a variety of subjective and clinical findings on the motion characteristics were examined, which revealed that certain factors, such as diagnosis, pain characteristics, symptom severity, and level of disruption, were related to the resulting motion measurements. The strength of these relationships were not as strong as anticipated (accounting for 16-45% of the variability). This suggests that routine objective assessments cannot be used as a substitute for a thorough physical and subjective examination.

A technique for the measurement of patellar tracking during weight-bearing activities using ultrasound.

A new fixation device, the femoral clamp, was developed in this study for the ultrasound measurement of patellar medio-lateral motion during sitting and squatting knee flexion/extension. Seventeen subjects, 6 males, 11 females, aged between 18 and 40 years were recruited for the test. Results showed that the patella moved medially then laterally from extension to flexion when sitting. Weight-bearing knee motion produced a more laterally tracked patella without the presence of the initial medial patellar translation. The tracking patterns of the patellae were similar regardless of knee movement direction. The patellar lateral position was greatly affected by the movement task (p < 0.0005), and was also influenced by gender for maximum medial position (p < 0.05). The reproducibility of the measurement was between 0.29 and 0.90 for the intra-rater and 0.34-0.75 for the inter-rater reliability. The accuracy of the ultrasound measurement was validated by interventional magnetic resonance (iMR) imaging of the patella and the mean error of the measurement was 1.4 +/- 3.2 mm. Although further research is needed to improve the accuracy and reliability of this method, it has demonstrated the feasibility of obtaining patellar tracking data during load-bearing activities.

Initial assessment of back pain: an overview.

In any illness, the severity of symptoms and their effect on lifestyle are very important to the patient. Pain in the back may indicate simple backache which most people have at some time, a number of serious spinal diseases or low back disability. It is important to establish to which category a patient belongs, and this article will outline some of the methods by which this can be achieved.