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Tolerability failure is defined as a permanent discontinuation of Danggui Study Centre: Multi-centre Buxue Tang as the result of an adverse event cheap proscar 5mg without a prescription prostate 68. Objective: • The primary efficacy endpoint is change in frequency and severity of menstrual Primary bleeding proscar 5 mg low cost prostate cancer quilt patterns. Title of Study: A Randomised, Double- Design: A multi-centre, randomised, dou- Blind, Placebo-Controlled Parallel Study of ble-blind, placebo-controlled study. Sub- the Effect of Relieve Wheezing Tablet in jects will be randomised to one of the two the Treatment of Childhood Asthma. Study Centre: Single-centre Study Population: A minimum of 80 Objective: diabetic foot ulcer patients will be enrolled, 40 subjects per treatment group. Primary • To evaluate the medication score, includ- Definition of Endpoints: ing daily use of inhaled steroids. Tolerability failure is defined as a wheeze/chest tightness on daytime and permanent discontinuation of formula A nighttime, degree of shortness of breath and Formula B as the result of an adverse on exertion. Duration of Treatment: 6 months Design: A single-centre, randomised, dou- Statistical Methods: ble-blind, placebo-controlled, parallel study. Subjects will be randomised to one of the two treatment groups and treated for a • Results will be presented as the mean ± duration of 6 months. COMPLEMENTARY MEDICINE 79 Definition of Endpoints: Secondary • To evaluate the lipid and homocysteine- • The primary safety endpoint is tolera- lowering effect of Danshen and Radix bility. Design: A single-centre, prospective ran- • The primary efficacy endpoint is a domised, double-blind, placebo-controlled, change in improving the symptoms of parallel study. Patients will be randomised asthmatic children and use of inhaled to one of the two treatment groups and steroids. Study Regimen: Subjects will be ran- Study Population: A total of 100 patients domly and alternatively assigned to receive with Coronary Artery Disease (CAD) will Relieve Wheezing Tablet or placebo for be enrolled, 50 subjects treated with Dan- 6 months. Definition of Endpoints: Synopsis VI • The primary safety endpoint is tolerabil- ity. Name of Study Medication: Danshen and • Tolerability failure is defined as a per- Radix Puerariae Compound manent discontinuation of Danshen and Radix Puerariae Compound as the result Title of Study: A Prospective Randomised, of an adverse event. Double-Blind, Placebo-Controlled, Parallel • The primary endpoint is improving car- Study to Evaluate the Effect of a Herbal diovascular function (endothelial func- Preparation with Compound Formula of tion and carotid intima-medial thickness) Danshen and Radix Puerariae as Cardio- from the baseline. Objective: Study Regimen: Subjects will be randomly Primary assigned to receive Danshen and Radix • To evaluate the safety of Danshen and Puerariae Compound (TCM) or placebo Radix Puerariae Compound as adjunc- for 24 weeks in a prospective parallel tive therapy in patients with coronary study. Statistical Analyses While the needles stay inside the soft tissue, the puncturist may give regular or occasional • The statistical significance of changes rotary movements on the nail. In recent years, between TCM and placebo groups will acupuncturists have applied direct electrical cur- be assessed by one-way analysis of rent stimulation, so as to unify the stimulations, variance. Acupunc- • Group differences with an error proba- ture is an invasive process directly aiming at the bility of less than 5% (p < 0. Likewise, if there were other placebo punctures which fulfil the requirement ACUPUNCTURE of randomisation and placebo control, very few patents would be willing to participate. Placebo points–entry points are sites outside Chinese medicine, it aims at symptom control, the acupuncture meridians. Sham puncture–puncture lightly then with- The most popular use must be in the field of draw. Hiding entry points–while entry points are In 1998, the National Institutes of Health in the hidden, it might be possible to achieve real USA held a consensus conference on the use of placebo effect. The conclusion was achieved by puncturing through plastic tubes that acupuncture should be accepted as an effec- or soft plastic blocks. Camouflage puncture by which a needle is just problems and under other specific situations. Since then, interest in the use of acupuncture in the United States grew and many clinical studies None of these methods could be endorsed were started. Examples include ents could differentiate right away whether it is nerve damages, allergic conditions like rhinitis, true or false puncture. Or would it be even more difficult of electrical stimulation is a means to enhance compared with herbal medicine? We have first the effects in modern situations where there is of all, to look at the procedures involved and the insufficient experience on acupoint identification explanations given to the effects produced. It is also con- Acupuncture involves the insertion of thin nee- sidered as a method of modernising acupunc- dles, through specific acupoints on the body ture. When electrical stimulation is used, placebo COMPLEMENTARY MEDICINE 81 becomes absolutely impossible because the elec- the spinal cord, loss of neurological and sec- trical stimulation is always felt. The considerations are further complicated by Acupuncture is widely used under such difficult the theories of acupuncture. Although many reports of impressive able theories–the neurological and the humoral. Scientific data coming from well- of the meridians and most of the acupunc- planned cohort studies for the observation of ture points are related to the peripheral nerves, functional restoration is still difficult to inter- stimulation of these points leading to physio- pret, since the damage could not be uniform and logical effects could be working via neurolog- the factors affecting the different aspects of reha- ical pathways, possibly through proprioceptive bilitation and functional return are multiple and receptors.

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In case surgery is indicated should be planned before irradiation in Orthopedic Surgery generic proscar 5 mg mastercard man healthcom, – neural compression generic 5 mg proscar mastercard prostate cancer hormone shot, pathological since surgery after irradiation has a University of Berne, fracture, instability, and progressive significant higher complication rate. Box 8354, deformity, nursing reasons – the most 3001 Berne, Switzerland straightforward procedures should be Keywords Spinal metastases · Tel. In the thora- Spinal tumor · Vertebral tumor 121 Introduction prevalent in the elderly such as prostate cancer and multi- ple myeloma (Table 1). Prostate cancer, for example, is at Bony metastases are a frequent event in breast, prostate, least six times more frequent in men aged 60 – 79 years lung, kidney urinary bladder, and thyroid cancer as well as than in those 40 – 59 years old. Breast cancer is almost in multiple myeloma and other hematological malignan- double and lung cancer five times higher in the elderly (60 – cies which may, however, be considered as primary tu- 79 years) than in the middle-aged (40 – 59 years). About 10% of the cancer patients are attained by though cancer is one of the major causes of morbidity and metastases located in the spine [23, 36] (incidence 1999, mortality, elderly persons are often excluded not only SEER and NPCR Registries, United States Cancer Statis- from clinical cancer studies but also from standard treat- tics; SEER Cancer Statistics Review 1975–2000, National ment, and generally also from cancer screening because Cancer Institute). Among adults 60% of spinal metastases comorbidity and frailty alter the risk benefit of screening are either from breast, lung, or prostate cancer. Renal and (World Health Organization report: Pain in the elderly gastrointestinal malignancies each account for about 5% with cancer, www. There is of spinal metastases, and thyroid carcinomas and melanomas clearly an underrepresentation of older persons in drug occurring with a lesser frequency [2, 24] (incidence 1999, studies, as documented by the United States Food and SEER and NPCR Registries, United States Cancer Statis- Drug Administration (http://cbsnewyork. Since these tumors are increasingly ac- derly because it usually affects the quality of life by re- cessible to treatment by surgery, radiation therapy, and ducing the endurance, the capacity to ambulate, and the chemotherapy, thus prolonging the survival of the affected ability for physical activity. Due to their age these patients patients, there is also an increased probability of them be- often have other diseases which already limit their quality ing affected by metastases, i. Metastatic disease involving the spine most often af- fects the vertebral bodies of the thoracic, lumbar, cervical, and sacral spine. Pathological anatomy and classification 5% of patients with cancer metastases develop cord com- pression. It is postulated that incidence 1999, SEER and NPCR Registries, United the venous blood return is shifted into the paravertebral States Cancer Statistics; SEER Cancer Statistics Review plexus via the intervertebral and basivertebral veins due to 1975–2000, National Cancer Institute; World Health Or- increased intra-abdominal and intrathoracic pressure. The average age of are seeded by this mechanism into the capillary network patients affected by secondary spinal tumors is 55 – 60 years of the vertebral bodies. Due to its avascular nature the when considering all metastases; however, it is sig- disc is usually spared from tumor involvement: however, nificantly higher when considering tumors that are more the most frequently and severely affected part of the ver- tebra is the vertebral body (in about 80%) followed by the pedicles and the posterior elements. This constellation ex- plains why most of the spinal metastasis are located in Table1 Probability of developing invasive cancer (percentages) front of the spinal cord or dural sac ending up with an an- at selected ages with spinal metastasis (from) terior epidural compression. More than 90% of spinal 40–59 years old 60–79 years old metastases are extradural and only 5% intradural and less than 1% intramedullar. Finally there is also the Lung cancer option of direct spread through direct tumor infiltration Male 1. The system differentiates between intra- groups covering most of the possibilities of spinal metas- compartmental, extracompartmental, and multiple tumor tases appearance: involvement. The first two categories include types 1 – 3 and types 4 – 6, respectively, whereas multiple tumor in- – Class I: destruction without collapse but with pain. This scoring – Class II: the addition of moderate deformity and col- system found increasing application in recent years as a lapse with immune competence. This class is consid- baseline in publications to make the results comparable ered a good risk for surgery. This class is con- Clinical presentation and Imaging sidered a relative surgical emergency. This class is not considered a good dominantly pain, neurological deficit, progressive defor- operative risk. Pain may be localized to a This classification allows consideration of the tumor, po- certain structure and region of the spine and may be of tential instability, and patient physiology, which is a sen- radicular or medullary origin. The WBB Surgical Staging fibers, by a secondary instability due to the osteoligamen- System was been introduced in 1997 primarily for pri- tous destruction of parts of the axial skeleton, or by the in- mary bone tumors of the spine. This can be applied for filtration of the dura or other neuroanatomical structures. Tokuhashi et to be influenced by the regulation of the physical activi- al. Generally speaking, slowly progressive, dull neck or evaluation of metastatic spine tumor prognosis that, in- back pain which occurs in a patient with a known cancer stead, allows a correlation of the tumor extent with the disease or which may become apparent in an elderly pa- 123 tient without a history of a tumor, should be considered as tebral body is weakened by the replacement of bone by tu- caused by a spinal metastases until proven otherwise. Usually the posterior period between initial pain and neurological deficit is for elements are also involved to some extent at this point and the cervical and thoracic spine weeks to months but in the render the segment definitely unstable. The patients may metastases are prone to pathological fractures with frag- have motor or sensory deficit or both, whereas there is the ment displacements only if there is a certain mix with os- option of pure radicular and/or a medullary compression. Osteoblastic metastases can reach a Since most tumors start in the vertebral body, an anterior considerable hardness which makes a fracture rather im- cord compression can be expected which is represented probable; however, they can initiate radicular or medullar by a deficit of the corticospinal pathways with the clinical compression due to the solidity of the tumor tissue. Spastic parapare- pain which occurs also during sleeping in the low back re- sis appears usually before sensory disturbances. It can gion, gluteal region, groin, knee, or generally in the lower progress slowly but always have the potential to deterio- extremity, may have a hip or knee problem, however, re- rate within days.

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Newly shared knowledge gives the team a prove the functional use of an affected upper greater sense of competence and gets all re- extremity generic 5mg proscar with amex prostate cancer 911 commission report, language and memory skills generic proscar 5mg mastercard prostate oncology unit, and so- thinking what they do. For pa- Responsibilities tients with chronic diseases that progress, prac- tice is perhaps even more important, since it Inpatient rehabilitation nurses monitor the may spur gradual neural reorganization to vexing medical complications that accompany maintain function (see Chapter 3). A follow-up by 1 month after inpatient patient every 2 hours, along with other meas- discharge and at 3 and 6 months for disabled ures to prevent pressure ulcers over bony patients will allow adjustments in the formal prominences. They protect patients from be- and informal rehabilitation program, changes in ing pulled across the bed, which can shear the assistive devices and braces, and ascertainment skin, and work out ways to prevent inconti- of community resources over the time that most nence so that moisture does not macerate the patients make their fastest improvements. Nurses also educate ancillary hospital per- With a background in general medicine, sonnel who might tug and sublux a paretic neuromedicine, neuroscience, mechanisms of shoulder. Other responsibilities include assess- plasticity, and scientific experimentation, reha- ments for sleep disorders such as apneic spells, bilitation physicians should serve as clinician- respiratory function, swallowing, nutrition, and scientists. The physician can encourage thera- bowel and bladder function; training in self- pists to weigh, formulate, and test strategies. During ward rounds Nurses check supine and sitting or standing and team meetings, a good leader amiably ques- blood pressure and pulse rate when indicated tions whether particular practices of the team and can teach hypertensive patients and their reflect the best means of restoration for a families how do use a digital blood pressure patient. Diabetics are taught The Rehabilitation Team 219 about diet, exercise, medications, and glucose PHYSICAL THERAPISTS self-monitoring techniques. A nurse practi- tioner can be a great asset to the physician and Responsibilities team on a busy inpatient service, especially in a university hospital, where patients tend to Physical therapists or physiotherapists (PTs) have complex medical illnesses and needs. Interventions Their assessments emphasize measures of vol- untary movement, sensory appreciation, range Nurses are on the front line, where they must of motion, strength, balance, fatigability, mo- help balance between what a patient can rea- bility and gait, and functional status. They have to be attuned to fluctua- toward compensatory strategies for carrying tions in the stamina and alertness of their pa- out ADLs, such as the use of a wheelchair, as tients that may affect taking fluids and per- well as interventions to lessen specific impair- forming ADLs. Therapists play a pri- family in less structured activities, away from mary role in managing musculoskeletal and the formal therapy provided by other team radicular pain, contractures, spasticity, and members, nurses provide unique insight into deconditioning. Nurses are Like other rehabilitationists, PTs have in- also in an ideal position to get patients to com- creasingly sought strategies to improve the ac- ply with lifestyle changes for disease preven- curacy and reproducibility of clinical evalua- tion. Two broad physician, psychologist, and social worker, they categories of exercise programs, therapeutic can initiate discussions about drug abuse with exercise and the so-called neurophysiologic young patients on a TBI or SCI unit. For new and neurodevelopmental approaches, have re- medication that will be used after hospital dis- ceived the most attention in the past. Newer charge, nurses can develop cues and rituals concepts related to neuroplasticity, motor con- with the patient and caregiver that reinforce trol, and how motor skills are learned are merg- compliance. The Association of Rehabilitation from the dynamic interplay between multiple Nurses has excellent resources for continuing CNS, peripheral, and biomechanical systems education (www. Practices in Physical and Occupational Therapy Therapeutic exercise and reeducation Massed practice Neurofacilitation techniques Biofeedback Proprioceptive neuromuscular facilitation Virtual environment training Bobath Musculoskeletal techniques Brunnstrom Rood Electromyogram-triggered neuromuscular stimulation Motor skills learning Orthotics and assistive devices Task-oriented practice Forced use 220 Common Practices Across Disorders constrained by the environment. The schools of neurofacilitation generally Success in retraining during rehabilitation frown upon attempts to strengthen muscles depends on diverse variables that include the that are hypertonic (see next section). The con- characteristics of a task, changing contexts and cern is that this leads to heightened spasticity environments when performing a task, psy- and diminished motor control. Strengthening chological reinforcements, motivation, atten- exercises, however, may be underutilized by tion, memory for carry-over of what is taught, therapists who are aiming only for compensa- environmental distractions, anxiety, sleep dep- tory gains in function or for more precise mo- rivation, and family support. A variety of experimental stud- for rehabilitating patients with upper motor ies, however, suggest that hemiparetic subjects neuron syndromes. Traditional exercise pro- can increase force output when pushing against grams emphasize repetitive passive and active higher loads, such as when pedaling to gain joint-by-joint exercises and resistance exercises muscular force output, without any worsening in anatomical planes to optimize strength and of motor control. The acquisition of self-care and mo- muscles by pedaling against resistance even at bility skills often takes precedence over the only 20 cycles per minute or by walking on quality of movement, so long as patients are a treadmill also improves cardiovascular fit- safe. Upper and lower extremity orthotics and ness in patients who have at least fair motor assistive devices tend to be used early in ther- control. When needed, therapists also employ NEUROFACILITATION APPROACHES breathing and general conditioning exercises and energy conservation techniques, particu- Many schools have developed what their pro- larly to reduce the energy cost of a pathologi- ponents call neurophysiologic approaches. The approaches involve hands-on in- believes that a task-oriented therapy for am- teraction between the therapist and the pa- bulation is most likely to provide the sensory tient. The interventions utilize sensory stimuli feedback and learning stimuli that can modu- and reflexes to facilitate or inhibit muscle tone late neural assemblies and step generators at and patterns of movement. Therapists may try to activate or suppress a stretch reflex, the This empiric technique, initiated by Kabat and asymmmetric and symmetric tonic neck re- Knott, arose in part from observing smooth, co- flexes, the tonic labyrinthine reflex, and with- ordinated, diagonal and spiral movements in drawal and extensor reflexes. It is based on the belief that since anterior horn cells for synergistic muscles are near each other, an appropriate Neurodevelopmental Techniques level of resistance will bring about changes in Most schools have emphasized a progression in muscle tone by overflow to these motoneurons. Neurodevelop- desired movement and inhibit unwanted mental techniques (NDT) call for reproducing movements. For example, the therapist places the developmental sequence shown by infants the upper extremity in extension, abduction, as they evolve motor control. Specific techniques include repeated abnormal motor behaviors are compensatory, quick stretch, contraction, contraction-relax- and that the quality of motor experiences helps ation, and rhythmic stabilization in which the train subjects for normal movement. Practi- patient tries to hold the arm still as resistance tioners emphasize normal postural alignment is applied by the therapist in an opposite di- prior to any movement. Proprioceptive neuromuscular facilita- ceed in a developmental pattern from rolling tion stretching techniques call for an isometric onto the side with arm and leg flexion on the contraction of the muscle under stretch, such same side, to extension of the neck and legs as the hamstrings, followed by a concentric while prone, to lying prone while supported by contraction of the opposing quadriceps muscle the elbows, and then to static and weight-shift- during stretch of the hamstrings, designated as ing movements while crawling on all four ex- contract-relax agonist-contract (CRAC).

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