As the person with Parkinson’s feels her spouse growing further away order 50 mg nizagara amex erectile dysfunction pills that work, her deepening depression intensifies her symptoms buy discount nizagara 25mg on-line impotence meds, which causes her spouse to withdraw even further. Psychological counseling is beneficial for both the person with Parkinson’s and the spouse—at the outset and from time to time over the years. But with or with- out counseling, the partners must communicate with each other at home: they must confront problems, discuss feelings, and look for answers. Both partners need to communicate; it is important that neither one gives up in the effort. One couple we know was able to solve a lingering prob- lem by communicating openly. Both partners were retired and generally enjoyed their time together; however, the husband with Parkinson’s felt that his wife involved him in more social activities than he could cope with. Through discussion he learned that most of the time, to her he appears to be able even when he feels very limited. She learned that even if he seems able, he may not actually be able to undertake as many activities as she plans. Together they realized that they could do with fewer planned activities; they could undertake activities when the husband felt up to them. We have heard of caregivers who berate people with Parkinson’s for not being able to do for themselves on a given day what they were able to do perfectly well, unassisted, the day before. It is vital for people with Parkinson’s to have con- fidence that their caregivers will listen and understand when they explain that "on-off " periods are characteristic, that there are bet- ter and worse days, and that there are even times of the day when the medication works more effectively than at others. It is also vital for the person who has Parkinson’s to be able to communi- cate his or her feelings: "I feel demoralized when you berate me for something I can’t control or change. The people with Parkinson’s all agreed that we worried more as the disease progressed, and the primary worry was centered on the dependency we felt on our spouses or 106 living well with parkinson’s principal caregivers. In this group, where spouses and caregivers are very devoted, one of the main questions was, "What would happen if my spouse/caregiver died first? Although we should not make generalizations (because we are all different), I expect that one of the concerns common to most patients and their spouses is the effect that Parkinson’s may have on the marriage. Of course, any change in circumstance will probably have some effect on one’s marriage, whether that change is due to a move to a new location, a new member of the family, a new job, a financial windfall or setback, or a chronic illness. But if the relationship was strong before the illness, it will withstand the additional stress. For example, the prospect of early retirement may be extremely difficult for men who feel responsible for earning the family’s liv- ing. Many men, especially older men, have been conditioned to feel that they must be strong. The arrival of Parkinson’s into their lives may result in feelings of weakness and loss of control. Such feelings can impact on a marriage if they are not confronted, dis- cussed openly, and resolved in some mutually acceptable way. I believe that in general, one’s marriage will be as good or as poor as it was before Parkinson’s. Nevertheless, in any marriage there are opportunities for growth and insight; often a major change in circumstance is just what creates these opportunities. The partners are shaken out of their routine existence and prompted to take a fresh view of their goals, activities, and lives. They reevaluate what is really impor- spouses—special and otherwise 107 tant to them. They dig a little more deeply within to see what they can contribute and how creative and innovative they can be. But couples embarking on this effort themselves, especially with the help of support groups, can accomplish much. In the process, both partners grow, discovering new potential within themselves and new resources that they never recognized before.

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Previous studies suggested that the isometric component caused reduced ejection fraction cheap 100 mg nizagara with mastercard erectile dysfunction treatment new drugs, left ventricle wall motion abnormalities and increased incidence of arrhythmias (BACR discount nizagara 25 mg visa injections for erectile dysfunction after prostate surgery, 2000). However, due to the lack of evidence, there is reluctance to include RE in the cardiac rehabilitation setting for high-risk patient groups (Pollock, et al. Contraindications to resistance Contraindications to resistance exercise are similar to those for the aerobic component. For RE these include: • abnormal haemodynamic responses with exercise; • significant ischaemic changes during graded exercise testing; Exercise Prescription 111 • poor left ventricular function; • uncontrolled hypertension or arrhythmias; • exercise capacity <6 METs. When to start resistance exercise There is some dispute as to when coronary heart disease patients should com- mence an RE programme. There is general consensus that patients should complete a period of aerobic exercise prior to initiating resistance training. The ACSM (2001) and SIGN (2002) recommend a period of four to six weeks’ aerobic acclimatisation. This period allows for patients’ haemodynamic responses to exercise to be assessed and for any complications to be ruled out before progression to RE. Additionally, the patient can use this time to become familiar with self-monitoring and to establish the correct training intensity. The ACSM (2001) suggest that patients post-MI and CABG should wait for four to six weeks post-event before commencing RE. For patients following percutaneus transluminal coronary angioplasty (PTCA) a shorter period of one to two weeks may be adequate (ACSM, 2001). Prior to commencing upper limb resistance training CABG patients should have their wound and sternal area assessed, to ensure adequate healing and stability (Pollock, et al. Caution is advised for patients who demonstrate symptoms of chest clicking or discomfort, as this can signify problems with healing. There is some evidence that an exercise programme should avoid any exercises that place strain on the sternal area for three months post-operation (Pollock, et al. This will vary considerably between individuals, due to differences in pain tolerance and wound healing. Exercise prescription for resistance training Recommendations on the prescription of resistance training will be consid- ered under the FITT principle. Frequency To achieve the benefits of resistance training, a frequency of two to three days a week is recommended (AHA, 1995; AACVPR, 1999; SIGN, 2002). Intensity Cardiac patients should start resistance training at a low intensity and slowly progress. Initially, the exercises may be taught with little or no resistance, 112 Exercise Leadership in Cardiac Rehabilitation in order to familiarise patients with safe technique. During RE the correct breathing pattern should be taught, in order to avoid the valsalva manoeuvre, when an individual forces exhalation against a closed glottis. During this manoeuvre there is an alteration in BP response, due to increased total periph- eral resistance and reduced blood flow to muscles. The intrathoracic pressure increases, and this can reduce venous return and stroke volume. The result of these changes is increased myocardial oxygen demand when cardiac output is reduced (ACSM, 2001). To avoid valsalva, participants should be taught to breathe out during the contraction phase of the exercise and to breathe in during the relaxation phase (Fardy, et al. They should also be taught why correct breathing is important and to breathe properly when carrying out daily activities that require moving or lifting loads. In order to determine the correct workload, much of the literature refers to the one repetition maximum method (1RM), or maximum voluntary contrac- tion. One RM is defined as the maximum weight that can be lifted in a smooth continuous movement, using proper technique without strain or breath- holding (Daub, et al. An initial intensity that corresponds to 30–50% repetition maximum (RM) is recommended (AACVPR, 1999). However, most studies are based on low- risk cardiac patients using maximal workloads of 60–70% RPM (SIGN, 2002). This maximal testing method for cardiac patients is controversial, due to the increased risk of valsalva and other cardiovascular complications (Bjarnason-Wehrens, et al.

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The greatest variation is in the use of Flexeril order nizagara 50 mg visa erectile dysfunction drugs buy, with some providers preferring using other drugs (e buy generic nizagara 100 mg online doctor yourself erectile dysfunction. During the calendar year 1999, there was a shift in the distribution of dispositions for active duty personnel with low back pain. The pa- tients with profiles declined from nearly one-half of the dispositions to less than 25 percent, while returns without leave increased. Other dispositions remained relatively constant, ranging between 5 and 13 percent for immediate referrals and between 6 and 10 percent for assignment to quarters. On average, there was one inpatient admis- sion due to low back pain per month for active duty personnel. The chart review performed at the CTMC in March 1999 showed that form 695-R was present in a relatively high portion of the medical charts, but there was a low rate of documentation that the provider had checked the patient for red-flag conditions. For these 27 patients with a 695-R form, 67 percent were appropriately coded as having low back pain, 19 percent had documentation that the red flags had been checked, and 56 percent had a profile in the chart. Appropriateness of referrals was not being monitored as of the time of our final site visit. PT staff estimated that 5 percent of the referrals they received were inappropriate, while neurosurgery staff estimated that 10 percent of the referrals they received were inappropriate. Reported Effects on Clinical Practices In general, the Site D staff perceived that the low back pain guideline had little, if any, effect on clinical practices for care of acute low back pain. Staff believed conservative care was already being provided to acute low back pain patients, and the emphasis continued to be placed on getting soldiers back to training. Some staff indicated, Reports from the Final Round of Site Visits 151 however, that the low back pain guideline contributed to the decline in the relative number of profiles written and to the increase in the number of referrals to MEB. Some staff in the family practice clinic indicated that staff at that clinic had not been familiar with low back pain treatment, and the guideline education and the key element cards they received had been helpful. Clinical practice for chronic cases has changed with the designation of a gatekeeper for referrals and coordinator for complicated cases. According to the team members, "This has helped standardize the treatment of chronic care cases. Es- tablishment of the gatekeeper function is also credited with reducing the backlog in neurosurgery from three months to two weeks. Conclusions Site D is seeking to integrate the implementation of the low back pain guideline into the hospital’s new paradigm of care that places more emphasis on primary care and prevention. Having the percep- tion that conservative treatment was already being provided for acute low back pain cases, the MTF focused initially on the portion of the guideline addressing management of chronic cases. An emphasis was placed on designating one clinic as the gatekeeper to resolve ex- isting difficulties with inappropriate referrals of low back pain pa- tients to neurosurgery and inadequate coordination with the numer- ous relevant specialties available at the medical center. At the same time, the MTF sought to formally implement use of the guideline in its CTMC and other primary care clinics. There was substantial initial buy-in for the guideline recommendations, but turnover and other pressures reportedly led to a decline in compliance over time. MTF leadership at Site D believes that full compliance with the low back pain guideline, and eventually any guideline for primary care, cannot occur without increasing electronic applications related to the guideline, especially online documentation of care. To this end, the MTF developed its own computerized algorithm for management of low back pain that follows the guideline in steps and allows online checks of the examinations performed and treatment provided. This 152 Evaluation of the Low Back Pain Practice Guideline Implementation approach was being tested at the CTMC at the time of our final visit. An important issue, which is a chronic problem in MTFs, is that this automated system was created by one entrepreneurial, computer savvy military person, who left in the summer rotations, and his computer skills will be difficult to replicate. This issue speaks to the need for systemwide applications to institutionalize such systems. Appendix C MULTIVARIATE ANALYSES OF LOW BACK PAIN METRICS To test for effects of the introduction of the DoD/VA low back pain guideline on service utilization and prescription patterns, we fit a se- ries of regression models to predict each of the six measures of guideline effects during the treatment of acute low back pain. We calculated the following measures for activity within six weeks of the initial low back pain encounter: • whether a patient was referred to PT • the number of follow-up primary care visits • whether a patient was referred to specialty care • whether a patient was prescribed muscle relaxants • whether a patient was prescribed narcotics • whether an NSAID prescription was for a high-cost NSAID. The unit of analysis for the first five measures was the episode of care, so there was one record in the data file used for each episode of care with variables for the five measures. As described in Chapter Two, this study was limited to episodes of low back pain care for ac- tive duty Army personnel. The variables for PT referrals, specialty referrals, muscle relaxant prescriptions, and narcotic prescriptions were dichotomous variables (equal to one if one of these events had occurred). For these measures, we used logistic regression models to test the size and statistical significance of effects.

It may result either from not being able to reach the toilet in time or from being unaware of the need to empty the bladder because of block- age of the pathways between the voiding reflex center and the brain order 25mg nizagara overnight delivery buy erectile dysfunction pills online uk. Despite the ability of the bladder to stretch as it fills nizagara 25mg without prescription erectile dysfunction low blood pressure, it can hold only a certain amount of urine and empties spontaneously after this limit is reached. Because the pathways to the brain are blocked, bladder emptying no longer is under voluntary control. Voiding then becomes a reflex activity, with messages to "empty" coming only from the spinal center. A small spastic bladder may produce symp- toms of increased frequency, urgency, dribbling, and/or incontinence. Types of Bladder Dysfunction Problem Symptoms Treatment Small, spastic Increased Oxybutynin (Ditropan®, bladder frequency, urgency, Ditropan XL®) (failure to dribbling, and/or Hyoscyamine store) incontinence (Levsinex®, Levbid®) Tolterodine tartrate (Detrol®) Flavoxate HCl (Urispas®) Imipramine (Tofranil®) Antihistamines Flaccid (big) Frequency, urgency, Credé technique bladder dribbling, hesitancy, Intermittent (failure to incontinence self-catheterization empty) Dyssynergic EITHER Alpha blockers bladder (a) urgency followed (conflicting) by hesitation in beginning to void; OR (b) dribbling or incontinence 67 PART II • Managing MS Symptoms Brain At the appropriate And on time, the brain to the 3 4 sends release brain. Spinal Cord Message is sent From here, the bladder muscles are to the VRC in 2 5 instructed to A, contract the bladder the spinal cord. Voiding Reflex Center (VRC) A Urine Bladder Muscle B The bladder The relaxed Urethral is stimulated sphincter muscles Sphincter 1 as it expands keep the urethra 6 Muscle by filling. Message is sent Bladder contractions exist (A), to the VRC in 2 5 along with relaxed (B) sphincter. A B This produces automatic emptying Voiding Reflex Center (VRC) A Urine The bladder is stimulated as it 1 expands by filling. B Bladder responds in an exaggerated way—receiving 6 Bladder muscle becomes frequent calls thickened and spastic. Uninhibited bladder SYMPTOMS TREATMENT •Urgency •Probanthine •Ornade •Frequency •Cystospaz •Ditropan •Incontinence •Urispas •Detrol B. Spinal Cord Message is sent Impulses are prevented from going to the VRC in 2 5 to bladder—it is not under the spinal cord. Sphincter Muscle SYMPTOMS TREATMENT •Urgency/hesitancy •Urecholine (duvoid) •Intermittent self- •Frequency •Valsalva catheterization •Occasional incontinence •Credé C. Bladder muscle and sphincter do not work together normally— resulting in a combination of symptoms. The prescribed medication helps the bladder and sphincter muscles to work together properly. SYMPTOMS: either TREATMENT •Difficulty in urinating •Dibenzyline, Hytrin or •Blocking agents •Incontinence D. The bladder fills with large amounts of urine, but because the spinal center cannot transmit messages on to the brain, the person is unaware of this fullness. Because the spinal center also cannot transmit messages to the bladder and sphincter, there is very little voluntary or reflex control over urination. The bladder fills and then overfills, producing symptoms of frequency, urgency, drib- bling, hesitancy, and incontinence. The third type of bladder dysfunction is the dyssynergic or "con- flicting" bladder, in which the problem is related to coordination between bladder wall contraction and sphincter relaxation (Figure D) rather than to the size of the bladder. In the dyssynergic bladder, either (1) the bladder wall contracts while the sphincter remains closed, resulting in a sense of urgency followed by hesitancy in beginning to void; or (2) the bladder wall relaxes while the sphincter remains open, resulting in dribbling of urine or incontinence. This lack of coordina- tion between the bladder wall and the sphincter frequently is seen in combination with either the spastic or the flaccid bladder. It is important to remember that the bladder does not make urine—urine is made by the kidneys. It only occurs if infection of the blad- der is uncontrolled, and is surprisingly uncommon in MS, which makes the routine kidney X-ray (intravenous pyelogram, or IVP) for the most part unnecessary. However, the risk of urine backing up from the bladder toward the kidney is increased in a man with a dyssynergic bladder (women usually do not experience this prob- lem because the pressures within the female bladder are lower). Management of Bladder Problems Bladder problems often may be managed with medications and/or other approaches. To determine the most appropriate mode of treat- 72 CHAPTER 10 • Bladder Symptoms ment, it first is necessary to distinguish between the spastic (failure to store), flaccid (failure to empty), and dyssynergic bladder. This is easily done by carefully recording the frequency of urination and the amounts of fluid urinated over a 48-hour period, followed by deter- mining how much urine remains in the bladder after voiding. The amount of this "residual" urine is measured by inserting a catheter into the bladder or by ultrasound technology after urination; a residual of less than 5 ounces (150 cc) indicates either a normal bladder or a small spastic bladder, whereas a larger amount indicates a flaccid bladder. The small spastic bladder is best treated with medications that "slow" the bladder by decreasing transmission in the nerves to the bladder that cause it to empty.

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