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    If such sessions are not available 400mg quibron-t with amex, try lobbying your local leisure centre/swimming pool for one buy quibron-t 400 mg. It may be worth asking whether there are quiet times of the day when the pool will be freer order quibron-t 400 mg free shipping, and assistance is more likely to be available. A small box sends electrical stimulation to muscles in the lower leg, so that you can regain useful movement. This is connected to a pressure pad in a shoe that enables the impulse to be triggered when you are walking, improving mobility. Much lower temperatures appear to be too cold, although still tolerable, whereas much higher temperatures, often found in jacuzzis or spa baths, are sometimes associated with the onset of (temporary) MS symptoms. Also, in relation to your swimming activities, if you have troublesome bladder control, it may be worth discussing this with your neurologist or GP beforehand to try and ease your concerns. Foot drop and exercise ‘Foot drop’ occurs when the muscles of the foot and ankle become weak, caused by poor nerve conduction, and either your ankle may just ‘turn over’ or, more commonly, your toes touch the ground before your heel – in contrast to the normal heel–toe action – and this might lead you to fall. One way is by exercising the relevant muscles as much as possible, through passive exercises if necessary. A special brace may be helpful, which supports the weakened ankle and allows you to walk again with the normal heel and toe action, if your leg muscles are strong enough to allow this (Figure 8. In this situation the muscles turning the foot out have weakened, and the muscles and tendons on the inside of the foot have become shortened – largely due to disuse. Thus it is vital for people with MS to try and prevent such a situation occurring by exercising the muscles controlling the ankle as much as possible. It will be important to seek some help from a 102 MANAGING YOUR MULTIPLE SCLEROSIS Figure 8. Wheelchairs and exercise Although it may sound paradoxical, it is almost more important for someone confined to a wheelchair to undertake regular exercise than someone who can walk. You should try and undertake exercises that maintain the movement and flexibility in your joints as much as possible – through the ‘range of motion’ and stretching exercises described earlier. As far as possible, try and maintain also your upper body strength – this is particularly important for good posture, which itself will help prevent some of the more problematic aspects of being in a wheelchair for a long time. If possible, it is very helpful just to stand for a few minutes each day, with the help of someone else or with an increasing range of equipment now available for this purpose. It is known that bone density tends to decrease (causing ‘osteoporosis’) more quickly if weight is not borne by the legs and feet on a regular basis and low bone density is also one of the contributory factors of fractures. This is another reason why standing should, if possible, be undertaken – even if only for a very short period. As with sitting in a chair, you ought to learn specific exercises to be able to shift your weight on a regular basis, to prevent skin breakdown at the points where your body is in contact with the wheelchair, and ultimately to prevent pressure sores. Basically, as the name suggests, they arise when the skin begins to break down from too much continuous pressure, from a chair or bed, for example, on key points of your body. Once this pressure has been applied for a long time, blood circulation to the area lessens or ceases, the tissues get starved of oxygen, and the skin and related tissues break down. Such pressure sores are particularly dangerous because, left untreated, they can lead to infection of the underlying bare tissue or to blood infection (‘septicaemia’), which can threaten your life. Most people do not get pressure sores because they move very frequently and thus pressure is never exerted on one point of their body for long enough for a pressure Figure 8. Danger areas are the lower back, the shoulder blades, the insides of knees, hips, elbows, ankles, heels, toes, wrists, and even sometimes ears (Figure 8. Pressure sores are more likely if you are in a wheelchair, or are sitting or in bed for long periods of time.

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    In a time when books on pseudo-Egyptology have started to flour- ish again buy discount quibron-t 400 mg, it is no surprise that lithotherapy feeds on themes that resem- ble the curse of Tutankhamen and the adventures of Indiana Jones order quibron-t 400 mg free shipping. At any event purchase quibron-t 400mg mastercard, lithotherapists say that the stones are equipped with magical and dynamic powers that are supposed to induce in the patient an energy-boosting or a relaxing effect that is psychological as physical. For anyone who might be tempted by this language to give 108 Tastes and Colors the stones a try, we report below some passages selected from a talk given by a lithotherapist, spelling out which stones have which effects. It relaxes, helps us learn about the inner self and universal truths, aids communica- tion, and was used by sailors for protection. Do not meditate with obsidian, for it gives us too much of the truth about ourselves. Suitable for Sagittarius, Capricorn, Aquarius, Cancer, Aries, Scorpio; it interacts with Pluto. A marvelous gift for the person whom you love; brings as much to the giver as to the receiver. Effective against intoxications, beneficial for all the fluids of the body; protects against poisoning, cholesterol and the effects of sugar. Crystal therapy and gemstone-therapy borrow their theories from a melting pot of ideas in which chromotherapy, astrology, and modern medicine are all stirred together, the whole doused with a New Age 109 Healing or Stealing? Tele-Therapy Chromatic tele-therapy is a way of providing long-distance care based on the vibrations of quartz and the iridescent spectrum of cosmic rays. This Oriental therapy, which is little by little taking hold in Europe, does not require the patient to be in the therapist’s physical presence. Batthacharaya (1897 — 1964), tele-therapy works because everything that exists in the universe is composed of the seven colors of the rainbow. The doctor had the "brilliant in- tuition" of dangling a crystal pendulum over the animal. After 1,200 rotations, the cat’s head and neck lost some of their rigidity; after 3,000 turns, the tail became flexible. After being treated for 15 days with the pendulum, the cat regained its desire to live, and Batthacharaya had the foundations of tele-therapy. Since swinging a pendulum over a sick organism for several days is no easy job, the new master in tele-therapy built a cardboard booth, with a cardboard disk on top to hold four crystal balls to be moved by the motor from an electric. He repeated his experiment on the next sick cat to come along, and Batthacharaya noted that the cat recovered all its functions after three days of continuous treatment, in spite of having been in a coma for 24 hours. Our inventor then tried one appa- ratus after another, refining his technique; he replaced the rotating crystal balls with electronic vibrators that would emit rapid flashes of light — colored light coming through prisms. The ultimate stage in the development of tele-therapy came when Batthacharaya replaced the sick organism (whether cat or human) with 110 Tastes and Colors a photograph, and subjected the photograph to color vibrations se- lected according to whatever diagnosis had been made. The diagnosis was reached — needless to say — based on a reading of the colors of the patient’s photograph through the prism; any modification of the basic color was the reflection (in both senses of the term) of the dis- ease, and the therapy would aim to restore the chromatic balance of the organism by stimulating the photograph. The history of tele-therapy does not say whether the technique is effective with instant photographs like Polaroids. In any case, although the founder of tele-therapy has passed away, it is slowly but surely making its way across Europe, seducing fans of chromotherapy and crystal therapy as well as advocates of the Kirlian effect. W AVES AND MAGNETS Do not imagine that I am an ordinary doctor, just the common run. The need to explain the inexplicable — the non-reproducible, the unverifiable and the unreal — forces "different" doctors to torn to inter- pretations based on pataphysics. All the talk about various forms of "energy" becomes a bottomless well into which one can dip at any time, looking for more and more explanations to try to rationalize such and such phenomenon that is presumed to have been observed, or not even observed — only described ad infinitum.

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    During the latter phase (termed propulsion) discount 400 mg quibron-t with visa, its direction leads to forward ac- celeration generic 400 mg quibron-t mastercard. The relative magnitudes of the braking and propulsive im- pulses for a given trial can serve as an objective measure for verifying 218 7 buy discount quibron-t 400 mg online. Impulse and Momentum whether a runner satisfies the so-called constant velocity criterion. In constant velocity running, the forward and backward impulses exerted by the ground must be equal in magnitude. The risk of head injury from striking an automobile dash- board is often correlated with the maximum linear acceleration of the head during the collision. To better understand the mechanics of colli- sion, a team of researchers dropped rigid balls of different masses from a height of h onto an elastic surface with spring constant k. They found that the maximal displacement of the surface during the collision was given by the following relationship: D5(2m g h/k)0. Hint: Write down the equation of motion of the object in the vertical direction and substitute k D for the spring force. Your result should predict that the smaller the mass of the object, the greater the peak ac- celeration during impact. Based on this observation, some researchers argued that children may be at greater risks than adults when striking a padding surface. Assuming that the leg can be represented as a weightless uniform rod of length L with the lumped mass m of the body attached to it at the hip, determine the impulse exerted by the treadmill on the runner. About a quar- ter of the chemical energy used in muscle contractions goes into per- forming work against external forces. The primary method of assessing energy expenditure during an activity is through the evaluation of exchange of oxygen and carbon dioxide. The amount of oxygen and carbon dioxide exchanged in the lungs normally should equal to that used and released by the body tissues in converting food energy into heat and mechanical work. The carbon and oxygen contents of carbohydrates, fats, and proteins differ dramatically, and therefore the amount of oxygen used during metabolism depends on the type of food fuel being oxidized. This value reflects the minimum amount of energy required to carry out the body’s essential physiological functions. The basal metabolic rate is di- rectly related to the fat-free mass of the body because preserving fat re- quires almost no energy expenditure. The other factors that affect the basal metabolic rate are surface area of the body (the larger the surface area, the higher the rate of heat loss across the skin), age (metabolic rate de- creases with age), body temperature, stress, and various hormones. The body’s ability to gauge muscle needs for oxygen during exercise is not perfect. At the beginning of exercise, the oxygen transport system (res- piration and circulation) does not immediately supply the needed quan- tity of oxygen to the active muscles. The oxygen consumption requires several minutes to reach the required steady-state level while the body’s oxygen requirements increase markedly the moment exercise begins. As a result, after the completion of the exercise, even though muscles are no longer actively working, oxygen demand does not immediately decrease. The amount of energy expended for different activities varies with the intensity and the type of the exercise. Some activities such as bowling or archery require only slightly more energy than when at rest. At the other extreme, sprinting requires so much energy expenditure that it can be maintained for only a few seconds. The energy expenditure per minute during high-speed running and crawl swimming is probably the highest among athletic activities, followed in order by handball, basketball, weight lifting, cycling, and so on. The oxygen consumed during an athletic activity increases in propor- tion to the effort.

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    In fact discount 400 mg quibron-t with amex, it is always important to ensure patients mention persistent vegetative state or similar that the patient and physician have a shared understand- dire scenarios 400mg quibron-t for sale. This question can be followed by asking ing of the conversation and its implications quality 400mg quibron-t. Similarly, what the patient would be willing to forgo to avoid such medical jargon should be avoided, one should always states. When doctors ask patients if they would want a particular treat- Choosing Surrogate Decision Makers ment, like a ventilator, patients will often state that the treatment should be provided "if it will help me, but if it Identifying who is to act as the patient’s health care won’t help me, don’t do it. Everyone responds to uncertainty differently, wish this to be a single individual or an entire family? For example, one may ask, between patient preferences and surrogate perceptions 294 J. Open-ended questions to initiate conversations the need for the patient to communicate with the selected about dying. The physician can admit that the discussion can be difficult and support the patient while being truthful. As a general by stating how helpful he or she has been in helping to rule, it is important for physicians to employ behaviors understand his or her preferences. Another way doctors that promote the sharing of concerns by patients and can provide support to the patient is to assure the patient to avoid behaviors such as reassurance that inhibit such that they will do whatever they can to meet their goals sharing. In this way, doctors can assure patients As patients respond to these questions, the physician that they will continue to care for them, even if they should continue to focus on the psychosocial and spiri- are in a condition in which they would not want life- tual aspects of their illness and not allow the biomedical sustaining treatment. A particular form of response that can be extremely effective at these times is the "wish state- Communicating about the Transition 67 ment. For example: of disease, the transition from a primary focus on life- prolonging therapy to a primary focus on palliation and PT: I’m going to get better. Such times of transition chemotherapy they’re offering at the university will involve the recognition of loss,redefinition of self-concept make the difference. Patients are MD: I wish that there was a treatment that would make likely to feel sadness, anger, and denial. Again, it is useful to identify the goals of these con- MD: There’s a lot that we can do. Let’s talk about what versations, which include eliciting emotional, psycholo- goals are most important for you right now. Of course, it is also important to help empathy toward the patient and to align herself with the patients acknowledge their illness and to make appro- patient’s hopes. Yet, at the same time it implicitly conveys priate health care decisions, such as enrolling in hospice. In this way, However, conversations should not be dominated by the the physician can address the patient’s denial without physician’s agenda, and patients must be given ample losing the therapeutic alliance. According to a recent study, patients facing terminal illness desire a physician who will talk in an honest and Dreaded Questions straightforward way, be willing to talk about dying, give bad news in a sensitive way, listen, encourage questions, Finally, it is useful to consider several of the questions and be sensitive to when they are ready to talk about that many physicians find most difficult to answer. Doctor–Patient Communication Issues 295 described in this chapter, and it is useful to keep several Bereavement additional points in mind. The loss of spouses, siblings, other family est in the patient’s ideas, and empathize with their con- members, and close friends is extremely common among cerns. Physicians can explore how the patient This response acknowledges that underlying such a has responded to the grief ("How have things been differ- question is tremendous emotion, most likely fear. The suggested overlook the frequently enormous practical ramifications answer above allows patients to speak about their fears of loss, such as financial difficulties or the possible loss of and worries.

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