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By H. Hamid. LeMoyne-Owen College.

I asked him to choose five simple items ("something so simple purchase epivir-hbv 100 mg line, a child could understand") for his "master" drawing and keep them a secret generic epivir-hbv 150mg amex. As we sat with our backs to one another discount epivir-hbv 150mg line, I directed him to draw four of the five items he had chosen and purchase epivir-hbv 100mg on line, as he compiled his drawing buy generic epivir-hbv 150mg on line, to give spe- cific verbal directions to me (the follower). However, before we matched our drawings I asked Dion how close in ap- pearance he imagined they would be. Beyond the clouds and sun, little else in my drawing resembles the "master" drawing. The mountains completely baffled me, as did the geometric shapes, which apparently represented lightning bolts. Although we processed the exercise based on its formal and structural qualities, it took little verbiage for Dion to appreciate that misunderstanding occurs even when we believe that our communication is clear and concise. In the months that followed, I instituted directives designed to promote enhanced communication and problem solving in the here-and-now. In the ensuing sessions I broke down the developmental stages of Erikson and at separate times instructed Dion to "draw yourself as an infant, child, adolescent, young adult, and mid-adult. A pic- nic, free of siblings, shows interaction between the figures; there is comfort in the symbiotic transparency of the infant Dion and his mother, with a sense of trust and strength in the father’s broad shoulders. However, as we move away from the family constellation, the environment becomes increas- ingly anxious. The apprehensive line quality coupled with short, sketchy strokes adds a sense of trepidation within the outer world. He rides his bike on a city street with a group of friends, a shared activity that widens his social circle and strength- ens his sense of competency and industry. In these three renderings, Dion has offered us a look within the debili- tating and enveloping illness of schizophrenia. In the second picture the only other person in Dion’s immediate world is his bunkmate, who is asleep on the cot (far right). He indi- cated that while he was incarcerated he frequently refused treatment be- cause "I didn’t want to be a bump on the log. As the drawings illustrate, he had not mastered the tasks necessary to move from a child’s sense of dependency to an adult’s sense of competency. The confu- sion that accompanies adolescence was exacerbated by an illness that gen- erates detachment over productiveness. Instead of finding success within his relationships, his work, and social interaction, he found success within his delusional beliefs. He could move houses by laying a hand on them—why would someone with that "power" desire the drudgery and responsibility that attended daily living? To prepare Dion for a future where responsibility, action, and reality is- sues outweighed the lure of an omnipotent delusional power (which he could call upon by refusing his medication), our focus centered on the growth of the self as a being separate from the dependency upon a "family unit" (his biological family, the hospital staff, etc. After months of art directives designed to strengthen his ego and expand his coping capacities, Dion announced, "I don’t really know how to do life. It was time to challenge the disease that had fixated him within adolescence for mastery. This is generally interpreted as a need to contain and delineate the ego boundaries. For this reason, the reinforcement of the body wall barriers parallels that of human functioning, as "the ego not only mediates between the individual and the environment but also mediates in- ternal conflict among various aspects of the personality" (Goldstein, 1984, p. It is in this image that Dion is able to reconcile unconscious feelings with determined statements and thoughts. In talking about his drawing he stated, "I know it’s good, but it’s hard and painful to learn new things. Individual sessions were no different: As we explored his early adolescence, withdrawal and retreat became his man- ner of coping with environmental stressors as outside support systems gave 226 Individual Therapy: Three Cases Revealed 5. Note that both the driver of the crane and the individual being flattened are projections of Dion. Throughout the discussion Dion processed the fig- ure under the ball as himself: "When I’m powerless I’m all curled up, shrunken. Utilizing this metaphor became an important re- minder for Dion both verbally and symbolically.

Statistics as impressive as mine are bound to evoke 88 Healing Back Pain skepticism in the medical community quality 150 mg epivir-hbv. There is reason to believe the statistics will remain favorable order epivir-hbv 150mg with visa, since I now interview patients prior to consultation in order to discourage those from coming who would not be receptive to the diagnosis buy generic epivir-hbv 150 mg line. The reality is that only a small proportion of the back pain population would be open to the diagnosis and it is a waste of time and effort to try to treat someone who could not accept the TMS diagnosis buy epivir-hbv 100 mg fast delivery. Some critics have said that I get such good results because I only accept patients who believe in my concepts purchase epivir-hbv 150mg without a prescription. But I can only work with patients who are reasonably receptive to the idea that their emotions are responsible for their pain. It is my job to convince them of the logic of the diagnosis, because only by acknowledging the role of emotions can we get the brain to stop doing what it is doing. Another common criticism by my peers, since we are talking about critics, is that I go too far in claiming that the majority of pain syndromes of the neck, shoulders and back are due to TMS. If 30 percent to 40 percent of back pain patients have TMS, why then do these critics never make the diagnosis themselves? The sad fact is that they cannot because it means repudiating long-held diagnostic biases and acknowledging the role of the emotions in these pain syndromes—something for which they have a “visceral incapacity,” to borrow a phrase from Senator Byrd of West Virginia. These treatment results are the only solid proof of the accuracy of the diagnosis and the efficacy of the therapeutic program. Indeed, many of the people who come know one or more successfully treated patients. The Treatment of TMS 89 It should be emphasized I don’t consider someone to have been successfully treated unless he or she is free of significant pain (everybody is entitled to a little bit of pain from time to time) and is able to engage in unrestricted physical activity without fear. As said before, the fear of physical activity may be more disabling than the pain for someone with a chronic pain problem. Virtually everyone I have seen has been a prisoner of fear (of hurting himself, of bringing on an attack) and that works even better than the pain to keep the attention focused on the body instead of the emotions. Certain phrases may reach some people but not others—so I use them all: “We’re going to try to stop the body from reacting physically to your emotions. Norma Puziss, who presented me with the following verse at the completion of her treatment program. No one would have guessed Emotions deeply repressed Could produce such tension Not even to mention TMS. You concentrate on pain, A back sufferer’s bane, To divert one’s attention From underlying tension. I am sure that this wonderful bit of verse has been helpful to many of my patients, since it captures one of the basic ideas so beautifully. Since it is characteristic of people with TMS to feel victimized and not in control, the treatment program must help them regain The Treatment of TMS 91 their sense of power by pointing out that the source of the pain is a harmless process. I encourage patients to develop an attitude of disdain toward the pain to replace their strong feelings of intimidation. This sends a message to the subconscious that the strategy of keeping attention focused on the body is about to fail— which means the cessation of pain. QUESTIONS PEOPLE ASK One of the more difficult concepts to grasp is the fact that one does not have to eliminate tension from one’s life. People ask, “How do I change my personality and how do I stop generating anxiety and anger? It is not changing one’s emotions; it is recognizing that they exist and that the brain is trying to keep one from being aware of their existence through the mechanism of the pain syndrome. A placebo cure is almost always temporary and we are looking for permanent resolution of the pain. People are administered a large variety of physical treatments, feel better for a few days, and then need another treatment. A second reason is that the placebo effect is based on blind faith; patients know little or nothing about the disorder they have and the rationale for treatment. I teach patients literally all I know about the disorder; they are encouraged to ask questions and they are warned that they must find the diagnosis logical and consistent. Perhaps the most compelling argument that what we do is not a placebo is the fact that on numerous occasions since the publication of the book Mind Over Back Pain, the predecessor of this one, people have reported complete and permanent resolution of pain simply by reading the book. There is no personality influence here, no bedside manner; just plain, solid information. As has just been said, any physical treatment can be a placebo, including physical therapy, and we strive to avoid this because the result is temporary.

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People with clinical Alzheimer’s disease patients if they think they have a hearing problem 100 mg epivir-hbv otc. We have recently single question is more sensitive than multi-item ques- shown that poor performance on a standard central tionnaires discount epivir-hbv 150 mg on line, which are more specific discount epivir-hbv 150 mg fast delivery. Please answer the following questions by circling the appropriate letter: yes buy epivir-hbv 100mg mastercard, no generic epivir-hbv 100mg without prescription, sometimes. Does a hearing problem cause you to feel frustrated when talking to members of your family? Does a hearing problem cause you difficulty when visiting friends, relatives, or neighbors? Does a hearing problem cause you to attend religious services less often than you would like? Do you feel that any difficulty with your hearing limits or hampers your personal or social life? Does a hearing problem cause you difficulty when in a restaurant with relatives and friends? Oral Changes Associated with Aging Candida Candida Candida albicans Candida Candida top 61. The complications with the TMJ decrease with increasing average age of diagnosis of oral cancer is 60 to 63 years. Oral cavity and treatment is usually not initiated unless discomfort or pharyngeal cancer are among the 10 leading sites for pain is involved. Symptoms range from vague or non- women, with the gender ratio of 6:1 (male to female) in specific, such as diffuse pain of the head and neck, 1950 changing to 2:1 (male to female) in 1980. It has been shown that persons with missing this disease and the treatment can be very disfiguring. Sunlight is a risk factor for lip Acute and life-threatening causes of temporomandibu- cancer. The combination of alcohol and tobacco use has lar pain, such as malignancies or infectious processes, been shown to have a multiplicative effect on the inci- should always be considered in the initial differential dence of oral cancer, accounting for 75% of all oral diagnosis. Infections of the TMJ are also rare and include the purpose of this discussion, oral cancer and squamous pain and swelling in the area that has been distinguished cell carcinoma are used synonymously. Due to the threat of intracranial spreading, aggres- molar teeth in the mandible). Other common sites include Both osteoarthritis and rheumatoid arthritis affect the the lateral borders of the tongue and the soft palate area. Although osteoarthritis is the most common type Oral cancer can present as a red or white lesion that noted in the TMJ, many patients do not exhibit pain or does not heal. Rheumatoid arthri- health professional should note anything that appears tis of the TMJ is seen primarily in younger women unusual. When and usually occurs in conjunction with inflammatory a patient does present with pain or paresthesia associated responses in other joints. Common complaints with with a cancerous lesion, it usually suggests invasive this type of TMD include stiffness, crepitus, tenderness, disease. If linked severe degradation of the TMJ from rheumatoid there is no obvious cause for the leukoplakia, such as fric- arthritis to upper airway obstruction in 70% of the cases tion or trauma, then the lesion should be biopsied if it has with severe rheumatoid arthritis54; this was hypothesized not resolved within 1 to 2 weeks. During acute exacerba- lesions, and ulcerations without pain should be held as tion of rheumatoid arthritis, the patient may benefit from highly suspicious. Again, if resolution of the lesion is not decreased mandibular movement and a soft diet, along noted within 1 to 2 weeks, a biopsy should be performed with pharmacologic therapy for rheumatoid arthritis. Oral cancer refers to lesions of the lips, tongue, pharynx, Currently, early detection is the most effective way to and all other hard and soft tissue within the oral cavity. Resnick Urinary incontinence poses a major problem for the Innervation of the lower urinary tract is derived from elderly. Afflicting 15% to 30% of older people living at the parasympathetic (S2–S4), sympathetic (T10–L2), and home, one-third of those in acute care settings, and at somatic (voluntary) nervous systems (S2–S4). The 1 least half of those in nursing homes, it predisposes to parasympathetic nervous system innervates the detrusor; rashes, pressure ulcers, urinary tract infections, urosepsis, increased cholinergic activity increases the force and 1–3 falls, and fractures. It is also associated with embar- frequency of detrusor contraction, while reduced activity rassment, stigmatization, isolation, depression, and risk of has the opposite effect. The sympathetic nervous system 1 institutionalization, as well as caregiver burden and innervates both the bladder and the urethra, with its 4 depression. Adrenergic recep- 5 manage in America in 1995, exceeding the amount tors are sparse in the bladder body, but those normally devoted to dialysis and coronary artery bypass surgery present are beta receptors; their stimulation relaxes the combined. Receptors in the bladder base and proximal Although both providers and older patients often urethra are alpha receptors; their stimulation contracts neglect incontinence or dismiss it as a normal part of the internal sphincter.

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In addition epivir-hbv 150 mg line, considerable differences in laminar NFT distribution exist among neocortical regions purchase epivir-hbv 100mg without a prescription. With a few exceptions generic epivir-hbv 150mg with mastercard, SP show a generally comparable distri- bution among neocortical areas cheap epivir-hbv 100mg amex. Feedfor- ward connections originate mostly from neurons located in the superficial layers of the cortex and terminate in the F 75 order epivir-hbv 100mg with visa. Regional and laminar NFT formation and neu- deep portion of layer III and in layer IV of the target ronal loss in normal aging and AD. The flameshaped structures cortical region, feedback projection neurons are located represent a semiquantitative assessment of NFT densities. An principally in layers V and VI and project to layers I and estimate of the percent of neuronal loss is shown by the gray VI, and lateral connections originate from layers V and scale (see % equivalent at ). The distri- a few NFT are consistently observed in layer II of the entorhi- bution of NFT indicates that elements of feedforward, nal cortex () and the superior frontal cortex () remains lateral, and feedback projections can all be affected by devoid of NFT. In def- lateral projections may be at higher risk in AD than feed- inite AD (CDR 2), NFT are found in very high densities in layer forward systems. The Interestingly, most of the projection neurons from the degree of neuronal loss parallels NFT densities in these regions. The regional and laminar distribution of SP suggests that they may be related to NFT forma- tion (see Figs. Lacunar Infarction Ischemic Stroke Cardioembolic Infarction Other Factors Hyperlipidemia Conditions Requiring Treatment Atrial Fibrillation left > 1148 J. Rodriguez-Oroz a postural tremor of higher frequency (7–12 Hz), with present, the diagnosis is not difficult. This sign is clinically expressed by stiffness of the the diagnosis, but it is not disabling until intermediate or muscles at palpation and on passive range of motion, and advanced stages, when the patient loses the capacity to by the spontaneous flexion of the joints in all extremities. The most typical feature of rigid- postural reflexes can be tested by standing behind the ity is an augmented resistance to passive joint displace- patient and pulling them backward on the shoulders ment on examination that can be smooth (lead pipe-like) ("pull test"). Simultaneous movements in traction of the tibialis anterior muscle that will correct the other body segments provoke an increment in rigidity backward tilt. It is more evident when the or two steps backward until catching themselves, but in passive movement is slowly executed, a feature that sep- more advanced stages they will be unable to maintain arates it from spasticity, in which the tone increases with their equilibrium, and the examiner must keep them from a higher velocity of motion. At this point shuffling is a common finding, and turning is typically made up of several small steps. Initially it occurs when starting to walk (start hesitation), Although, strictly speaking, means absence of turning (turn hesitation), or passing through narrow movements, this term includes both the slowness and spaces and in stressful situations. Eventually, this phe- clumsiness in the execution of movements and the reduc- nomenon may occur at any time, especially with envi- tion of spontaneous and induced movements. More ronmental stimuli such as sounds or visual stimuli that specifically, refers to the slowness of the attract the patient’s attention, causing them to stop. It is easily recognized in alternating sequence necessary for a plantar flexion fol- the reduction of the frequency and amplitude of auto- lowed by a dorsal flexion of the foot. The base of support matic movements such as blinking, arm swing while is narrow, and the patient does not accompany the walking, step length, reaching movements, and writing attempt to move the feet with truncal or swing move- (micrographia). Freezing can be overcome using sensory tricks, The three cardinal features of Parkinson’s disease mainly visual, for instance, by stepping on a piece of usually appear asymmetrically, affecting first one half of paper on the floor, or with a different motor strategy such the body and spreading to the contraleral limbs and to as a military march. Some- nostic importance, because other parkinsonian syn- times the patient may raise her feet a few millimeters, but dromes tend to cause rigidity and akinesia of both sides instead of taking a normal step, she drags her foot of the body from the inception of the disease. Once gait has been initiated, it is not infrequent that the forward flexor posture, shifting the center of gravity forward, and the failure of postural reflexes make the These abnormalities begin at a later stage of the disease, patient walk faster in a shuffling way trying to restore her usually after other signs have already appeared, and they center of gravity (festinating gait) and finally falling are responsible to a great extent for the deterioration in forward. Forward falls are more frequent than backward the motor condition and quality of life of parkinsonian falls in Parkinson’s disease, whereas in parkinsonian dis- patients. Multiple System Atrophy Other Focal Dystonias Cranial Dystonia Craniocervical Dystonia or Meige’s Syndrome 1164 H. Blazer, II of major depression in later life, then, may simply reflect 18–21 ranges from 30% to 35%. The prevalence of bipolar the fact that this cohort never experienced much depres- disorder,while only about 0.

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Older persons are more likely to have subsequent amputations on the contralateral side effective 100 mg epivir-hbv. The elbow is flexed 20° to 30° crucial role in managing these problems and in helping when holding the cane at the side cheap epivir-hbv 100 mg on-line. In frail older persons discount epivir-hbv 150mg, the decision as to level of ampu- tation is often difficult cheap 150mg epivir-hbv overnight delivery. Stair training begins during the second week 90% success rate for healing a transtibial amputation purchase epivir-hbv 100mg fast delivery. Patients need to practice advancing the walker attempts should be made to avoid serial amputations about 20 to 30 cm, then advancing the weak leg, and then (e. Some older persons may find it easier to transfemoral) because prolonged bed rest and its atten- advance the good leg first, but this practice increases dant complications are more likely. Crutches are very difficult for most There are three major types of lower extremity older persons to use. It must be remembered that special amputations: partial foot, transtibial (also called a below- walkers are needed for going up stairs and that it is very the-knee or BK amputation), and transfemoral [above- difficult to carry objects while using a walker. Partial foot amputations generally do walkers with three or four wheels are available that are not require postoperative rehabilitation. Patient acceptance of these walkers is better than of achieving independent ambulation. Indeed, the energy cost of walking with bilateral BK eral neuropathy), and significant comorbid disease 92 amputations is lower than that of walking with a single (congestive heart failure, angina, chronic lung disease). In a younger person such Those patients with cognitive deficits that interfere with energy costs may be insignificant, but in the older patient learning may have difficulties learning to use a BK pros- 93 they may precipitate angina when there is underlying thesis. However, this is a Barriers to successful use of a prosthesis include hip very individual decision, and the motivated patient still or knee contractures, preexisting joint disease of the may benefit from a prosthesis trial. Percent using prosthesis Percent additional energy Percent of total Percent recommended after intensive physical required for normal bipedal Type of LEA number of LEA for prosthetic gait training therapy program ambulation Transtibial 25 60–80 60–90 Unilateral TTA: 40–60 Bilateral TTA: 60–100 Transfemoral or higher 25 20–30 0–40 90–120 TTA, transtibial amputation. Note: 50% of all LEA are partial foot amputations that generally do not require rehabilitation. Rehabilitation 273 stump skin may be valuable in predicting success at pros- 99 thesis. In one study, 79% reported successful fitting, while below 15 mmHg there are often phantom limb sensations, 72% reported phantom limb complications. However, Even if a prothesis is not going to be used, patients can most described their phantom limb and residual limb benefit from rehabilitation. Massage and physical therapy, along with small doses Bed, chair, and toilet transfers also must be learned. The older person also may experience a change in costs of using a wheelchair are higher than those of the socket size with large weight changes (weight loss walking, patients with chronic obstructive pulmonary affects size more than weight gain), and neuroma forma- disease and cardiovascular insufficiency must be tion and local skin problems can occur. Age should not be a determinative Parkinson’s Disease factor in this consideration. The decision should be based on the patient’s medical state, motivation, and mobility The peak incidence of Parkinson’s disease is between the needs. As in the case of hip fractures, rehabilitation ages of 60 and 69 years, with as many as 40,000 to 50,000 should begin before the surgical procedure. Drug treatment has led to significant training, including strengthening of the upper body, improvements in the care of patients with Parkinson’s quadriceps, and hip extensors and practice lying prone, disease (see Chapter 78). There have been no randomized, controlled trials elastic bandage or stump shrinker, inspection for skin showing long-term, sustained effects on function from integrity, and hygiene should receive attention. Hence, the physical treatment of dressings may also be used and appear to accelerate the Parkinson’s disease can be considered an example of time to prosthesis fitting. Strengthening and chair for longer distances, so they also must receive train- endurance training and proper use of assistive equipment ing in its use. Involvement A permanent prosthesis is usually fitted 6 to 8 weeks in a support group may help to maintain newly learned postoperatively to allow for stump shrinkage and wound skills. A temporary pylon prosthesis is often employed Gait and balance training emphasizes a safe gait and in the meantime. The patient should be taught to keep at the time of the operation to promote early ambula- the head up, to counter the flexed posture consciously, tion. A physiatrist or orthotist usually It also may help to take longer steps and widen the base.

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