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Areas for ongoing education in the class can include warm-up discount avana 50mg with mastercard 2010 icd-9 code for erectile dysfunction, over- load purchase avana 200 mg on-line impotence for erectile dysfunction causes, cool-down, strengthening and self-monitoring skills covered in Chapters 3 and 5. The exercise leader and team members can reinforce and consolidate the benefits and reasons of each section of the class and the content of each. For example: • reasons for warm-up: We are warming up to bring our heart rate slowly up before our more vigor- ous circuit section. To review aspects of education during the class the exercise leader can invite the class to answer questions during the class. USE OF VOICE The voice for an exercise leader serves many purposes; it is not, as is often assumed, only for instructing the group. The voice is an instrument 190 Exercise Leadership in Cardiac Rehabilitation that can impart authority, atmosphere and interest to the class, if used well. Volume The leader must use enough volume for the group to be heard, often in large spaces with poor acoustics. This can be problematic for CR exercise leaders, who must be aware of the potential to damage their voices (Kennedy and Yoke, 2005). In addition, in a typical week CR exercise leaders can be teach- ing up to 10 hours (Thow, et al. There is an extra demand on the exer- cise leader if he/she is performing the exercise as well as teaching. There is an increased oxygen demand, which could cause the leader to develop laryngitis (Bernardi, et al. To minimise potential problems, the leader should use good lower torso diaphragmatic breathing. It is important to avoid voice strain by forcing tension on the throat and shoulder muscles. Exercise leaders should also take care not to instruct all the time but allow vocal pauses. In large spaces, where acoustics are poor, a voice microphone can be useful to reduce the need for the leader’s voice to be used above music and the noise of exer- cise. Alternatively, a whistle can be used to attract attention, or, in the case of circuits, to indicate a time change, rather than voice commands. The circuit mode of delivering the aerobic overload period uses the voice in a slightly less demanding way as the exercise leader does not need to communicate to the whole group for the entire session. Tone and pitch Tone and pitch of the voice can make it more interesting and can introduce variety and motivational emphasis to the voice. Using variety also engages the participants, and the leader can use more expression to encourage the group. Varying tone and pitch can be used with emphasis on different types of exercise and can main- tain the group’s interest and motivation. For example: For performing a calf stretch, the tone of voice goes down to emphasise pushing the heel into the floor: We push the heel down into the floor. The exercise leader should also provide the group with information on how dif- ferent exercises should feel. Variety of tones and pitch can also add to the leader’s vocal comfort, avoiding abuse of the vocal cords in sustained use. Furthermore, vocal variation enhances the leader’s facial expression, allowing for more flexible movement of the jaw, soft palate, tongue and lips. These are speech organs that shape the leader’s outgoing breath into clear, effective speech. Teaching Skills for Exercise Classes 191 Cueing and Linking Exercise In Chapter 5 the different modes of delivery were discussed, with aerobic cir- cuits and free aerobics as key methods in delivery. In free aerobics, where the leader is introducing dif- ferent combinations and moves with music, the leader is required to link and combine exercises with an element of choreography, i. This teaching skill can seem very difficult, as the leader is not only demonstrating and instructing, but also exer- cising along with the class. As exercise leadership is a motor skill combining many elements, it is advisable to practise moves and combinations of steps prior to taking the class, particularly in the early developmental period of class leadership. Cueing requires the leader to give the class verbal instruction of the exer- cise they are about to perform and to fit the exercise to the music.

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In particular avana 200 mg generic erectile dysfunction due to diabetic neuropathy, as it has been graphically put generic 100 mg avana fast delivery goal of erectile dysfunction treatment, often ‘the most important sex organ for women is between the ears, not in the genitals’. Thus it is not at all clear that many women as might be expected will be helped by the physical effects of such drugs alone, although it is important to note, for some women with MS in particular, the local genital effects of such a drug might be beneficial when there are difficulties, for example, with lubrication. Nonetheless many drug companies over the last two years or so have begun the development and testing of drugs, which potentially may have a range of effects on women’s sexual desire, in addition to similar effects to those of Viagra. Difficulties with erections First, it may be helpful just to explain a little of the ‘mechanics’ of an erection. The penis is made up of the ‘urethra’, which runs through it and carries both urine from the bladder and semen from the testes, and which is surrounded by the ‘prostate gland’. On the underside of the penis, and running along its length, is a mass of spongy tissue called the corpus spongiosum. Alongside this spongy tissue are two ‘chambers’ called the ‘corpora cavernosa’ in which millions of tiny pockets fill up with blood during an erection. Special cells in the penis limit the flow of blood into these pockets most of the time, for otherwise there would be a perpetual erection! When these special cells ‘relax’, they allow the pockets to fill with blood, and thus the penis becomes erect, and when they ‘contract’ the blood is expelled and the erection subsides. A range of enzymes and other chemical substances work together to facilitate blood flow into and out of the penis. Managing erectile problems in principle involves attempting to deal with the problems in the nervous system; dealing with problems in the vascular system, and in addition dealing with psychological and related issues. For many men with MS with erectile problems, drugs like Viagra have appeared to provide an immediate and helpful way forward. Essentially they act on the vascular problems in MS, by assisting the penis to fill with blood. They do this by breaking down an enzyme (a chemical messenger in the blood) that is preventing or seriously slowing down the process of engorgement of the penis. By magnifying the effectiveness of the erectile process, even where this was previously weak or virtually non-existent, erections can be maintained as long as the drug effect lasts. These drugs may be able to help such problems in many men with MS; indeed, there is very strong evidence that men with erection difficulties caused by MS are likely to benefit from them. At present they are taken orally (by mouth) and, because of the relatively slow digestive process, it may be an hour or two before the drugs produce their effects – certainly an issue in planning sexual activity. Viagra, Cialis and Levitra affect not just the penile area, but have potential effects all over the body, so there may be some side effects elsewhere. Not everyone will benefit, although firmer, more frequent and longer lasting erections have been found in two-thirds to four-fifths of men who used Viagra. Because the drugs are costly, and the demand is assumed to be large, the Department of Health has been extremely circumspect about those who can be prescribed them. However, MS is now one of the designated medical conditions by the Department of Health for which these drugs can be prescribed, and so there should be fewer difficulties in obtaining them on these grounds, although there may still be local variations in supply plus, of course, any clinical reasons for their non-prescription. Currently there are a number of other drugs under development, which promise similar overall effectiveness to that of Viagra, but with a greater immediacy and convenience of use. In particular the aim has been to ensure as far as possible that spontaneity can be preserved in relation to sexual activities. The forms in which Viagra can be used are also being developed and before long there will be several different ways in which it can be administered. Side effects With the publicity for these drugs have come reports of some potentially dangerous and unpredictable effects. SEXUAL RELATIONSHIPS 63 We have already noted that they work on the vascular system. Most reports have centred on vascular incidents, such as deaths from heart attacks. In the population at large, impotence and erection problems increase with age, and so statistically much of the demand has come from older men. However, cardiovascular problems – heart disease and high blood pressure – also increase with age.

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Although mic differences (see following) or idiosyncratic aspects of many studies have reported reduced metabolic clearance specific patients 200 mg avana with visa impotence effect on relationship. The volume of distribution is heavily influenced hepatic drug metabolism than the aging process itself buy discount avana 100mg erectile dysfunction ear. Therapeutic considerations therefore should be based Because the latter increases in the elderly at the expense on individual patient characteristics as well as expected of the former, lipid-soluble drugs (such as some benzo- physiologic changes due to aging. Women have a lower lean old age, amounting on average to a reduction in glomeru- body mass compared with men at all ages, and there lar filtration rate by nearly a third. Hepatic biotransformations of drugs wisdom and in nomograms used to calculate drug dosing are categorized into phase I (preparative) and phase II with age, these longitudinal studies make it clear that (synthetic) reactions. Phase I reactions include oxidations the effect of age on renal function (and therefore on the (hydroxylation, N-dealkylation, and sulfoxidation), re- excretion of many drugs) can be quite variable. Phase II reactions involve differences among patients often will be as important as conjugation of the drug molecule to glucuronides, sul- the changes attributed to the aging process itself. Although blood urea nitrogen (BUN) and serum cre- Earlier studies in animals had suggested that normal atinine levels may be useful (albeit crude) markers of aging is accompanied by reduced activity of liver micro- renal function, it must be remembered that each is sus- somal drug-metabolizing enzymes as well as diminished ceptible in its own way to perturbations that can occur microsomal enzyme induction, but data on hepatic drug with aging but have nothing to do with renal function metabolism in aging human subjects are much more itself. However, the origin of much of this ated with a reduction in the liver mass, as well as in urea is ingested protein, so that a malnourished older hepatic blood flow. These changes are likely responsible patient may not consume enough nitrogen to produce an for the reduction in hepatic metabolism of drugs, which appropriate rise in BUN, even in the face of renal impair- can be as great as 25% over the life span. Principles of Pharmacology 67 and if a patient has a markedly diminished muscle mass, ther magnified by its biotransformation into the active whether because of chronic illness or any other cause, he metabolite desalkylflurazepam, which also has benzo- or she may not produce enough creatinine to reflect a diazepine effects on the central nervous system. Thus, overreliance on "normal-appearing" BUN action of a drug is related to its half-life. Under this and creatinine in older patients can severely under- assumption, long elimination half-life implies a long dura- estimate the degree of renal impairment. Although this presumption is estimate renal function in older patients who are to sometimes incorrect,22 some epidemiologic data support receive potentially nephrotoxic drugs (e. It should be emphasized that these estimates are valid A common goal of long-term pharmacotherapy is to only in patients whose renal function is in steady state achieve and maintain a therapeutic steady-state serum and who are not taking medications that directly alter concentration. The steady-state drug concentration is renal function or affect creatinine excretion. This formula proportional to the medication dosing rate (dose/dosing has some utility in assessing renal function in healthy interval) and is inversely proportional to drug clearance. Although drug clearance is a biologi- cally determined characteristic of each patient over The elimination half-life of a medication (t1/2) is deter- which the prescriber has no control, dose and dosing mined by the volume of distribution (Vd) for that med- interval are variables that can be modified. To prevent the ication in a given individual, divided by its clearance (Cl) excessive accumulation of a drug when its clearance is in that subject (generally through metabolism in the liver reduced (as is often the case in an elderly patient), one and/or renal excretion); this can be expressed as follows: can reduce the dose, increase the interval between doses, or both, depending on the situation. If the volume of distribution is also increased (as with a lipophilic drug in an older Pharmacodynamic changes with aging (i. The study of this phenomenon is relationships are illustrated by the benzodiazepine hyp- complicated by the fact that the effect of many drugs is notic flurazepam. In a study comparing the kinetics of magnified in the elderly because of reduced drug clear- flurazepam in young and elderly subjects, the drug was ance, resulting in higher serum levels. A small but growing the clearance of flurazepam by the oxidative pathways number of ingeniously conducted studies are helping to in the liver and an increase in the volume of distribution clarify the unique contribution of age-related pharmaco- for this highly lipid-soluble drug. The clinical impact of dynamic changes to the overall picture of drug response such massive prolongation of flurazepam half-life is fur- in aging. Rochon One of the first studies describing changes in drug sen- Recognizing and Preventing Adverse sitivity with aging involved patients between the ages of 28 Drug Events in Older Adults 30 and 90 years who underwent elective cardioversion. The clinical endpoint used was the patient’s inability to respond to voice, with preservation of response to a Many hospital-based studies have suggested that risk for painful stimulus. The serum level of diazepam at which the occurrence of adverse drug reactions increases with this effect occurred was significantly lower in elderly 38 advancing age. Unfortunately, this finding is of limited patients than in younger ones, suggesting that the older usefulness in guiding medical practice because most brain was sensitive to smaller concentrations of circulat- investigations have assessed all adverse drug reactions ing drug. Analogous findings emerged from a study of the from all medication exposures as a single outcome cate- performance of patients given a single dose of another gory. Patient-specific physiologic and functional a lower dose was administered to older patients com- characteristics are probably far more important than pared with younger ones, overcoming the expected phar- chronologic age in predicting either the adverse or ben- macokinetic differences between the two age groups. In vitro assess- increasing burden of chronic illness in the older popula- ment of benzodiazepine receptor binding and function tion, assessing and reducing the risks for adverse drug in brain tissue from young and aged rodents has effects becomes critically important in the practice of not revealed clear age-related differences in benzodiaze- geriatric medicine. Clinicians are most familiar with effect as well as an increased potential for toxicity.

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Viktor Lowenfeld revisited: A review of Lowenfeld’s preschematic purchase avana 50mg line erectile dysfunction underlying causes, schematic best 50mg avana erectile dysfunction treatment gurgaon, and gang age stages. Actions, styles, and symbols in Kinetic Fam- ily Drawings (K-F-D): An interpretative manual. Kinetic Family Drawings (K-F-D): An in- troduction to understanding children through kinetic drawings. Myth and mythmakers: Old tales and superstitions interpreted by com- parative mythology. Interpreting psychological test data: Associating personality and behavior with responses to the Bender-Gestalt, Human Figure Drawing, Wechsler Adult Intelligence Scale, and the Rorschach ink blot tests (Vol. The validity of interpretive signs of ag- gression in the drawing of the human figure. Intelligence and Adaptation: An Integration of Psycho- analytic and Piagetian Developmental Psychology. Essays on a science of mythology: The myths of the divine child and the divine maiden. The book about Daddy dying: A preventative art therapy tech- nique to help families deal with the death of a family member. The theory, structure, and techniques for the inclusion of children in family therapy: A literature re- view. Children in cus- tody: Census of public and private juvenile detention, correctional, and shelter facil- ities 1994/5. Using drawings in assessment and therapy: A guide for mental health professionals. A quick scoring guide to the interpretation of children’s Kinetic Family Drawings (KFD). The artistic tower of Babel: Sex traceable links between cul- ture and graphic development. See also Formal analysis 36 Bipolar disorder: Accommodation, 54 8CRT and, 167 Adaptation, 45–53 DAP and, 119–125 "The Adventures of Pinocchio," self-disclosure, 270 89 Blackening body parts, 308. See Aggression: also Formal analysis DAP to assess, using the, 112– "The Book About Daddy Dying," 113 176 developmental stages and, 52 Borderline Intellectual Function- intellectualization and, 21 ing, 133, 136 Animism, 65 Boxes, 9–10 Antisocial behavior, conversion here-and-now interaction and, and, 25 252–253 Anxiety, regression and, 36–37 Branches, 313–314. See also Formal analysis analysis Brothers Grimm, 87–88, 89, 90 Assimilation, 54 Buck, John, 104, 125, 131, 208 Attar, Farid-Uddin, 5 Buttons, 307. See also Formal analysis Carpenter, Edward, 5 335 Index Caste system, 139 Collodi, Carlo, 89 Castration complex, 74 Color usage, 117, 298–299. See also Chaotic discharge, 252–253 Structural analysis Child Protective Services, 229 Comic strip figures, 8CRT and, Chimney, 311. See also Computer-assisted screening pro- Developmental age cedures, 106 Cigarette, 308. See also Formal Condensation, 30–36 analysis Conduct Disorder, 229 "Cinderella," 91 Conversion, 25–30, 75 Circular reactions, 54–55 Coping strategies, 9 Classification, 63–64 vs. See also Formal 248–249 analysis individual therapy, 207–209, 211 Creative and Mental Growth, 126 case study, 231–241 Criminal behavior, conversion problem-solving directive and, and, 25. See also Physical 188–189 abuse; Sexual abuse; Sub- The Clinical Application of Projective stance abuse Drawings, 105 Crown, 313. See also Formal analysis analysis Cultural issues: Cognitive development, 46, 49, family therapy and, 278–283 53–54, 71, 85–86 HTP and, 136–142 concrete operations, 62–69, 80, interpreting art and, 47 88, 98 Culture Fair Intelligence Test, 130, formal operations, 69–71, 136 136 preoperational, 56–62, 88 sensorimotor, 54–56, 88 Defense mechanisms, 19–21, Collaborative drawing technique, 43–44 283–285 directives and, 181–182 Collage, 180–181 psychosexual development empathy and, 258–260 and, 72 individual therapy, 206–207, 215 See also specific type Collecting, 94–97 Delinquency, conversion and, 25 336 Index Delusions: insight and self-disclosure, 189– 8CRT and, 158 193 individual therapy case study, 203 sample, 320–321 Dementia, 148 as interventions, 177–178 Dependency: institutionalized, 52 introductory, 178–183 Deprivation, 71, 84 sample, 317 Detailing, excessive, 299. See also paired communication drawing, Structural analysis 278–283 Developmental age, 87 problem solving, 186–189 directives and, 171–177 sample, 318–320 See also Chronological age Distortion of body parts, 308. See Developmental delays, 84 also Formal analysis Developmental history, interpret- Doors, 310. See also Formal anal- ing art and, 47 ysis Diagnostic and Statistical Manual of Dr. Seuss, 87, 89 Mental Disorders—Fourth Edi- Draw-a-Man assessment, 14 tion (DSM-IV), 20 Draw-A-Person (DAP), 103, 107– Differentiation, 52 108 Directives, 171–177, 197 8CRT and, 157 closure, 193–197 art assessments, 116–118 sample, 321–322 case illustrations, 119–128 ego-modifying, 212–213 development of, 104 family mural drawing, 283–285, examples, 111–116 289–295 HTP and, 143 family therapy, 274–285 validity and, 105 case studies, 285–295 Drawing, 12–14 feelings expression, 183–186 norms of, 46 sample, 318 children’s stages, 126–127 group therapy See also specific type empathy, 257–265 Dual scribble drawing, 181–182 sample, 324–325 here-and-now interaction, 245– Ears, 303. See also Formal analysis 257 Eight-Card Redrawing Test family therapy and, 274, 283, (8CRT), 14, 103–104, 151, 287–288 166 individual therapy case study, adapted scoring sheet, 315–316 222–223 art assessments, 152 sample, 323–324 case illustrations, 152–165 personal change, 325 collecting and, 95–96 self-disclosure, 265–273, 325– development of, 104 326 family therapy and, 285–286 337 Index Eight-Card Redrawing Test (cont. See Family genogram individual therapy case study, directive 230–241 Goethe, Johann Wolfgang von, Fairy tales, 87–93 168 individual therapy case study, Goodenough, Florence, 14, 104 230–241 "Grandmother Marta," 90 Falling figures, 308.

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