By E. Derek. University of Osteopathic Medicine and Health Science. 2018.

However 200mg doxycycline for sale bacterial nucleus, when weakness is the result of poor transmission of electrical impulses order doxycycline 100 mg visa virus neutralization assay, lifting weights may only fatigue the nerve and further increase muscle weakness. For people with MS, it is important to realize that exercises that involve lifting weights or repetitive movements of muscles to the point of fatigue do not increase strength, they increase weakness. It is somewhat akin to a light fixture that does not work because there is a problem with the fuse. Changing the bulb or flicking the switch 43 PART II • Managing MS Symptoms will not fix the problem. In MS the problem is with the fuse, and attempting to correct the problem at the muscle or nerve level will only result in frustration. Exercises that involve lifting weights or repetitive movements of muscles to the point of fatigue do not increase strength, they increase weakness. Such disuse weakness or atrophy may have happened to any- one who has had an arm or leg placed in a cast for any length of time; when the cast is removed, your muscles have shrunk. This likely will require the assistance of a trained physical therapist who has knowledge of both the neuromuscular system and the specific problems involved in MS. The problems experienced by the person with MS must not be treated as they would be if they were the result of a broken bone rather than a misfiring central nervous system. It is impossible to separate the management of weakness from that of spasticity and fatigue. Frequently, therefore, drugs or other treatments that lessen spasticity also increase strength. This means using your muscles for practical, enjoyable activities and planning the use of time accordingly. For example, difficult activities should be done before those that are easier to perform. The appropriate use 44 CHAPTER 5 • Weakness of assistive devices also may be extremely helpful in increasing overall efficiency. Strength also may be increased with the use of an aero- bic exercise machine such as an exercycle or a rowing machine. However, the principle of not becoming fatigued and exercising those muscles that can be strengthened to compensate for the weaker muscles must be applied. This symptom of MS often is associated with difficulty in bal- ance and coordination. There are many different kinds of tremors; some have wide oscillations (a gross tremor), while others are barely perceptible (a fine tremor); some occur at rest, others occur only with purposeful movement; some are fast, others are slow; some involve the limbs, while others affect the head, trunk, or speech; some are disabling, but others are merely a nuisance; and some are treatable, while some are not. As with all symptoms, proper diagnosis is essential before correct management decisions can be made. BALANCE Balance is necessary to perform coordinated movements, whether one is standing, sitting, or lying down. The cerebellum is the main center for bal- ance, but the eyes, ears, and nerves to the arms and legs also con- tribute to balance. An impairment in any of these areas may cause balance to worsen, and it may help to compensate for others that are 46 CHAPTER 6 • Tremor and Balance The Management of Tremor •Exercises for balance and coordination – patterning –vestibular stimulation – Swiss ball – computerized balance stimulation •Medications • Mechanical approaches –immobilization –weighting –stabilization with braces not working properly. For example, a person with a balance problem caused by poor sensation in the feet may use her eyes to see the ground and avoid falling; obviously, this is a problem in the dark. No medication is available to improve balance, so it is neces- sary to rely on exercises. Although there are no specific exercises for tremor, there are exercises for balance and coordination. Patterning refers to a technique that is used by physical and occu- pational therapists to trace and repeat basic movement patterns. It is based on the theory that certain muscles may be trained to move in a coordinated fashion by repeatedly using the nervous circuit that is involved in a movement. These normal movements are guided and assisted by the therapist until they become automatic. Minor resistance is then added and removed while the patient repeats the pattern independently.

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The position vec- f tors ri/o doxycycline 100 mg for sale antibiotics for sinus ear infection, ri/c generic doxycycline 100mg on line antibiotics for uti to buy, and rc/o connect, ji c/o respectively, the point O to par- r i/c r ticle i, the center of mass C to fij point i, and point O to the cen- i/o ter of mass C. Also shown in the r figure are internal forces fij and E e1 j O fji and external forces F and mk g. Thus, internal forces do not contribute to the acceleration of the system at all and hence Eqn. According to this equation, the time rate of change of linear momentum of a system of particles is equal to the resultant external force acting on the system. When a body is at rest or moving with constant speed, its linear mo- mentum remains constant and hence the sum of all forces acting on the body must vanish. Later in the text, in Chapters 5 and 6, we discuss statics as it relates to human movement. The position of center of mass may be occupied by different particles of B at different times during motion. The time rate of change of position vector rc (derivative of rc with respect to time t) is equal to the velocity of the center of mass, which we denote by vc. The acceleration of the cen- ter of mass ac is the time derivative of vc: rc 5 [S(mi ri)]/(Smi) (3. For a sphere of uniform mass density, the center of mass is posi- tioned at the center of the sphere. The tables at the end of the text provide information about the position of the center of mass for solid bod- ies of a variety of geometric shapes as well as human body configurations (see Appendix 2). Consider a body consisting of two slender rods ab and bc of length L and mass m that are connected with a pin at b. Solution: We draw a reference frame whose origin O is at the pin b connecting the two rods (Fig. In a uniform slender rod, the center of mass occupies the midpoint along the axis of the rod. Thus, the cen- ters of mass of the two rods ab and bc are located at the following posi- tions: x1 52(L/2) cos 45°; x2 5 (L/2) sin 45°; x3 5 0 for the rod ab x1 5 (L/2), x2 5 0, x3 5 0 for the rod bc 60 3. The location of the center of mass of a system composed of two slen- der rods that are linked together at point b. Determine the change in the elevation of his center of mass when he raises his arms from the sides of his body 180° over his head. Solution: We will consider the athlete to be composed of three parts: two arms each having a mass m and the rest of his body (M). The loca- tion of the center of mass in the vertical x2 direction before and after rais- ing the arms is given by the following equations: (M 1 2m) (38) 5 Md 1 2m h (3. The mass of the body part, say a foot or an arm, is equal to the volume of water displaced times the average specific density of human body, which is about 0. If during the rising phase his acceleration reaches a peak of 4 m/s2, determine the contact force exerted by the hor- izontal bar on the athlete at that instant. Solution: The forces acting on the athlete are the gravitational force (2mge2) pointing downward and the contact forces F exerted by the bar on the athlete, pointing upward. The resultant of these forces must be equal to the mass times the acceleration of center of mass. This example shows that when the man ac- celerates upward, the force the bar exerts on the man is an upward force that is greater than the man’s body weight. Because action equals to re- action, this is also the force the athlete exerts on the bar as he pulls on the bar. Animals and humans jump to reach higher places, to leap over obstacles, or for competition. Volleyball and basketball players must react instantaneously to the ball and jump within C 69" 38" FIGURE 3. Videotapes of jumping events show that the entire duration of the propulsive stage of the human vertical jump, from back- ward rotation of the trunk to toe-off, lasts about 0. In this brief period of time, the angles between various segments of the lower body (feet, shank, thigh, and hips) change to lift the upper body (70% of the body weight) vertically.

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If the organization is primarily involved in provid- ing inpatient services discount 100 mg doxycycline free shipping homeopathic antibiotics for dogs, an appreciation of the point in the product life cycle where inpatient services can be placed is required buy doxycycline 200mg online virus ebola espanol. If a marketing plan is being devel- oped for a specific procedure, the point in the life cycle where this product resides must be determined. The first stage in the life cycle of a product is the introduction or market development stage. Because the product is likely to be inno- vative, most of the marketing effort is directed toward creating awareness and cultivat- ing early adopters in the market. At this stage there are relatively few competitors, and goods and services are not standardized. Entry into the market is relatively easy because there are few established players; the introduction of desktop computers in the 1980s is an example of this stage. At this point the industry has become established, and the good or service has been accepted by the market. Expansion is rapid as new cus- tomers are attracted and additional competitors enter the arena. Products or services become increasingly standardized, although enhancements may continue to contribute to product evolution. Marketing planning at this stage emphasizes differentiation of the organization, product, or service. The rapid growth of home health care during the 1980s provides an example of this type of expansion. At this point most of the potential customers have been captured and growth begins to trail off. Because few new customers are available, competition for existing customers increases. Product features and pricing are highly standardized, and little differentiation remains between competitors. The num- ber of competitors decreases as consolidation occurs among the various players in the market, and it becomes increasingly difficult for new players to enter the market. Marketing activities emphasize retaining existing customers or capturing competitors’ customers. Traditional hospital inpatient services are an example of a product that has reached the maturity stage. At this point there are three strategies for stretching the life of the product: (1) product modification, (2) market modification, and (3) product repositioning. Hospitals have attempted to employ all of these strategies in the face of product maturity. Hospitals have attempted to add goods or services to ensure that utilization does not continue to decline. Categories of Services Aging baby boomers—the majority of the individuals who consume retail medi- cine—are more concerned about their health than any previous generation, and they drive much of the interest in retail marketing. One of the most sought-after components of the retail medicine trend is the full-body scan, which medical entrepreneurs say will reveal abnormalities in the body that can be addressed before they have a chance to become life threatening. CT scans promise to detect latent signs of conditions ranging from tumors to gallstones, clogged arteries to cancer. Retail medicine often emphasizes prevention, an aspect of care largely ignored by hospitals and physician practices. Proactive citizens frequently will pay out of pocket for more sophisticated or attentive medical services. The owners of screening centers are giv- ing the public what they inherently understand—prevention is better than a cure, and early detection is the key to successful preventive strategies. Also included as examples of retail medicine are the variety of fitness and wellness programs that healthcare organiza- tions offer to the general public. There has also been a trend toward the retailing of various goods through physi- cians’ offices.

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The number of encounters remained relatively stable over time cheap doxycycline 200mg with amex virus 3 weeks, as shown in Table 6 purchase doxycycline 100 mg with visa how much antibiotics for dogs. Of the initial low back pain encoun- ters, 83 percent occurred in primary care–type clinics, including pri- mary care (41 percent), family practice (37 percent), internal medicine (one percent), and flight medicine (three percent). Measures and Methods As described in Chapter Two, six indicators were selected for analysis in the evaluation. In Chapter Three, we presented the baseline performance of all the demonstration and control MTFs on these indicators. In this chapter, we examine the extent to which the indicators changed for the demonstration sites during the period they implemented new practices for the low back pain guideline. These indicators address the following aspects of care in the first six weeks after an initial low back pain visit: 1. Expected reductions in these indicators are based on the assumption that an MTF effectively introduces and maintains the new approach Effects of Guideline Implementation 79 of conservative treatment. Therefore, we would expect to observe hypothesized changes in clinical practices only in those MTFs that proactively worked to implement the new practices. In addition, we also expect that the particular intervention strategy of each MTF will determine which effects will be observed in the analysis. For exam- ple, there should be a reduction in referrals to specialty care only for those MTFs that defined specialty referrals as a priority and actually undertook actions to reduce inappropriate referrals. For each of the six indicators, we present the average values by quarter for the demonstration sites and for each of the two groups of control sites, and we provide graphs showing trends visually. We collapsed the two control groups for all the trend analyses and tests of significance because there the trends for the two groups did not differ for any of the measures. To test the significance of observed trends for each metric, we fit a multivariate regression model with predictor variables for demonstration versus control, individual facil- ity, and quarter. Interaction terms were used to test differences in rates during the demonstration period relative to the two baseline quarters. Referrals to Physical Therapy or Manipulation We hypothesized that use of the guideline would lead to reductions in physical therapy and manipulation services as MTFs increasingly used the conservative treatment approach. To test this hypothesis, we examined trends in the percentage of acute low back pain pa- tients referred to these services within six weeks of the initial low back pain encounter. A total of 3,181 patients were referred for physical therapy or manipulation services across the five quarters, about one-half of them in the demonstration MTFs and one-half in the control MTFs (Table 6. After introducing the guideline, physi- cal therapy referral rates declined at the demonstration sites but did not decline at the control sites. In the second quarter of 1999, 11 per- cent of low back pain patients at the demonstration sites were re- ferred to physical therapy or manipulation services (Table 6. Site B was the only one showing no decline in physical therapy or manipulation referral rates, and this site had taken very little action in implementing the guideline. We did a separate graph of the trend in rates for the other three demonstration sites, excluding Site B, to assess the strength of effect for the MTFs that did take actions in this area. The downward trend in referral rates for the remaining three demonstration sites became more pronounced, as shown in the third trend line in Figure 6. There was substantial variation across the demonstration sites in physical therapy referral trends (see Figure 6. This variation is consistent with observations of the implementation process at the demonstration sites. Site A had made the strongest reduction in physical therapy referrals, and Site C made a moderate early reduc- tion in referrals that remained stable in subsequent quarters. Site D had a reduction in the last quarter, and Site B had no effect at all on physical therapy or manipulation referrals. The 31,273 new low back pain pa- tients had a total of 27,187 follow-up primary care visits within six weeks of the initial low back pain encounters. There was no dis- cernible trend in the average number of follow-up visits for the demonstration sites, while the average number of visits per patient gradually increased at the control sites (Table 6. The decline in follow-up visits per patient for the last quarter in the demonstration sites, compared with the control sites, was found to be statistically significant (see Appendix C). Looking at the individual demonstration sites, there was little variation across the sites in trends for average number of follow-up primary care visits (Figure 6. The specialties included in these analyses were orthopedics, neurology, neuro- surgery, and physical medicine and rehabilitation. A total of 3,750 acute low back pain patients had a specialty care visit within six weeks of the initial low back pain visit (Table 6.

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Hospitals depend on admissions from their medical staffs buy generic doxycycline 200 mg line antimicrobial phone case, and their staff members in turn depend on referrals from other physicians generic doxycycline 100 mg with visa homeopathic antibiotics for acne. Indeed, except in emergency situations, patients can only gain hospital admission through a referral. Many specialists will not accept self-referred patients but rely on other physicians to send them patients. The same types 28 arketing Health Services of referral relationships exist with regard to other services (e. This situation has become more complicated in that health plans may exert some level of influence over the referral process. Not only do health plans determine which providers can be seen under a particular coverage plan, they may require patients to be referred to specialists and may even seek to authorize any such referrals. In no other industry do parties who are not the end user exert such an influence on the process (see Box 2. Referral relationships as used here include any Importance of mechanism for the steering of consumers by a third party into the dis- Referral tribution channels of a healthcare organization or any use of an inter- Relationships mediary to promote goods and services to healthcare consumers. The importance of such relationships in healthcare is reflected by the fact that the end users of health services frequently do not make the consumption decision themselves. The purchase decision may be made by a physician, health plan, or some other party. This means that the marketer is more likely to target physicians, provider networks, health plans, and other gatekeepers that may influence the referral process rather than the end user. A wide range of consumer health products are marketed like any other retail product, and over-the- counter pharmaceuticals are marketed in the same manner as other goods. With the advent of Internet-purchase options, an increasing range of health-related products are offered directly to consumers. Elective procedures are often promoted directly to prospective patients, with the organizations offering them using standard promotional techniques to attract customers. Nevertheless, the bulk of health services utilization is a function of referral rela- tionships and intermediaries. The most entrenched example of this is the requirement of a physician referral for hospital admission. Patients cannot present themselves directly to a hospital for purposes of admission; they must have an admitting physician. Even emer- gency cases require that a physician take responsibility for admitting the patient before he or she will be accepted into the hospital. If a physician does not have admitting priv- ileges at a particular hospital, he or she cannot admit a patient there or treat patients hos- pitalized by other physicians. Other institutions, such as nursing homes and hospices, may depend on referrals from physicians as well. Physicians themselves often depend on referrals from other physicians and, in some cases, health or social service agencies for customers. Medical and surgical spe- The Challenge of Healthcare M arketing 29 Healthcare Products The goods and services that constitute healthcare products are also some- what unique to healthcare. Indeed, even the most common of consumer-oriented healthcare products—pharmaceuticals—must be prescribed by a middleman before they can be acquired and consumed. Instead, they rely on referrals from other physicians who are usually generalists. With most contemporary health insurance arrangements, a referral from a primary care physician to a specialist may be required before the insurer will cover the treatment episode. Depending on their specialty, physi- cians may also depend on referrals from nonphysician providers. Providers such as psy- chologists, optometrists, and chiropractors may make referrals to psychiatrists, ophthalmologists, and neurosurgeons, respectively, if the treatment requirements exceed their capabilities. Mental health centers and social service agencies may be major sources of patients for some specialists, as these agencies represent the front line of contact with many potential patients. Prescription drugs are becoming an increasingly important aspect of patient care, and this area also involves indirect access to the end user. Except in the case of over-the-counter drugs, pharmaceutical companies cannot deal directly with patients. The patient must have a prescription written by a physician to obtain the drug from a pharmacist, and numerous safeguards prevent unauthorized access to prescription drugs. The pharmaceutical company relies on the physician to recommend its brand of drug, and, understandably, the main thrust of pharmaceutical marketing is toward physicians.

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