By C. Tuwas. Defiance College.

Although the prevalence is high order himcolin 30gm without a prescription, many people with knee or shoulder pain do not seek medical care (5) purchase 30 gm himcolin mastercard. Overall Cost to Society In the year 2001 discount 30gm himcolin with mastercard, knee symptoms and injuries were the primary reason reported by the patient for 1 generic 30 gm himcolin free shipping. Knee prob- lems, therefore, are in the top 15 most frequent reasons for consulting a physician, second only to back pain among musculoskeletal problems. Chapter 15 Imaging for Knee and Shoulder Problems 275 For knee and shoulder problems seen in outpatient settings, imaging uti- lization varies greatly by specialty. A study conducted in the United States observed that orthopedic surgeons requested radiography in 80% of first knee pain consultations and 78% of first shoulder pain consultations, whereas rheumatologists utilized radiography in far fewer knee (45%) and shoulder (36%) cases (8). Orthopedic surgeons were also more likely to refer for MRI of the knee (20% versus 6%) and, to a lesser extent, of the shoulder (4% versus 2%). The direct cost of health care for musculoskele- tal problems is about 1% of gross national product in several industrial- ized countries (9), although we found no convincing estimates of the total societal costs for knee and shoulder problems. Goals Among patients who seek medical attention for knee and shoulder prob- lems, the clinician’s task is to find the appropriate balance between phys- ical examination, diagnostic imaging, and arthroscopic investigation to achieve accurate diagnosis and initiate cost-effective therapy. Methodology Our initial search strategy identified systematic literature reviews of knee and shoulder imaging studies. We searched the Medline database using the PubMed interface for abstracts published between January 1966 and March 2004 with the search words knee and shoulder and the PubMed designation of a systematic review (systematic [sb]). From this group, we selected several key arti- cles reviewing the role of imaging (10–19). We then searched the articles cited by these systematic reviews to identify the relevant primary studies. For topics where no recent systematic review was available, we selected two seminal articles on the topic and searched for similar work using the related articles PubMed function. Where possible, we obtained and reviewed the full text of all relevant English-language articles identified. What Is the Role of Radiography in Patients with an Acute Knee Injury and Possible Fracture? Summary of Evidence: Acute knee trauma provides a common diagnostic quandary in accident and emergency departments. Fractures are present in 4% to 12% of patients presenting with knee injuries (20,21), and yet radi- ography may be requested in excess of 70% of cases (22). Several guide- lines are available to help clinicians target imaging at high-risk patients. There is strong evidence (level I) to suggest that the five criteria of the Ottawa knee rule (OKR) are highly sensitive at predicting fractures in adults and moderate evidence (level II) that this rule can be generalized to children older than 5 years of age. Further work is needed to evaluate the impact of the OKR on the cost-effectiveness of medical care. Supporting Evidence: Several groups have developed clinical decision rules to guide knee radiography requests following trauma in order to save costs 276 W. These decision rules focus var- iously on patient age, injury mechanism, inability to ambulate, and other clinical signs such as fibula head tenderness. The optimal threshold for radiography requests depends on the trade-off between the clinical and possible legal consequences of a missed fracture compared to the time, cost, and radia- tion exposure of radiographs. In practice, all of the decision rules place great emphasis on sensitivity at the expense of specificity. Other decision rules may have greater specificity, but they have not yet been validated by independent investigators. The OKR suggests that radi- ography should be performed on the acutely injured knee when the patient has one or more of the following criteria: (1) age 55 years or older, (2) iso- lated tenderness of the patella (no other knee bone tenderness), (3) ten- derness of the head of the fibula, (4) inability to flex the knee to 90 degrees, or (5) inability to bear weight both immediately and in the emergency department for four steps. Initial assessment of the interobserver reliabil- ity of the OKR suggested excellent agreement between physicians (27); however, more recent work evaluating the agreement between nurses and physicians has been less impressive (20,28,29). These variable results emphasize the need for thorough training and support for clinicians before implementing the OKR. Clinical decision rules for radiography of acute knee injury % Sensitivity Specificity Validation Rule Criteria for radiography (Ref. Patient does not need radiograph if: 100 (26) 34 (26) 26 (26) • Able to walk without limping • Twist injury without effusion Chapter 15 Imaging for Knee and Shoulder Problems 277 A recent systematic review found 11 studies evaluating the diagnostic accuracy of the OKR (10). Six of these studies were suitable for inclusion in a meta-analysis, of which four were considered to be of high quality (i.

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Tone and pitch Tone and pitch of the voice can make it more interesting and can introduce variety and motivational emphasis to the voice discount himcolin 30 gm without prescription. Using variety also engages the participants himcolin 30gm with visa, and the leader can use more expression to encourage the group discount 30 gm himcolin otc. Varying tone and pitch can be used with emphasis on different types of exercise and can main- tain the group’s interest and motivation buy 30gm himcolin free shipping. 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. The process of linking exercises requires the leader to move from one exercise to another or to move the group in different directions. To do this there are basic steps, and arm and leg patterns are added to increase exercise intensity (see Chapter 5). When starting to use cueing and linking of free mode of delivery it is best to keep the type of exercise simple and to limit the exercise combinations. The combinations of exercise can be, for example, basic steps with variety of upper body activity. Basic steps that can be repeated throughout include: • heel digs for 8 beats • step back for 8 beats • knee lifts for 8 beats • side step for 8 beats. To manage the tran- sition, the leader can bring the class back to a march between each combina- tion of 8 beats. To start the groups together there are different ways to achieve this, for example: • count down from four and start on the fourth beat Four, three, two and – • during group marching. The leader demonstrates the move and invites the group to join in When you are ready join in. It is important to remind the group that this type of exercise format is skilful and requires practice. Furthermore, it is important to point out that the exercises are not dancing (moving aerobically to a rhythm provided by the music). Tips for developing teaching skills Tips for developing teaching skills Watch experienced CR exercise leaders take classes. Gradually take more of the class and ask an experienced leader to give you feedback. As with any skill, the more leaders can practise the more proficient they will become. There are courses specifi- cally addressing group teaching skills at, for example, the ACPICR and Glasgow Caledonian University. Teaching CR well requires awareness and development of many facets in order to develop and maintain proficient exercise leadership skills. An exercise leader may be very knowledgeable on the theoretical aspects of CR, but this is of little use if leaders do not develop and refine their teaching skills to deliver the practical content. The quality of the teacher in health-related exercise is acknowledged as a key element in participants’ adherence to and enjoyment of CR. REFERENCES American College of Sports Medicine (ACSM) (2000) ACSM’s Guidelines for Exer- cise Testing and Prescription, 6th edn, Williams and Wilkins, Baltimore, MD.

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This shift from self-absorption to performing concrete and tangible tasks offered Sarah the time she needed to coalesce cheap 30gm himcolin mastercard, return to the group generic himcolin 30 gm mastercard, and join the discussion phase discount himcolin 30 gm visa. However order 30gm himcolin with amex, rather than focusing the discussion on Sarah’s metaphorical communication—something she would have no doubt enjoyed, as any at- tention is good attention—I elected to ameliorate the anxiety by focusing 253 The Practice of Art Therapy on relationship goals. Consequently, I asked each group member to re- spond to a closure directive in an orderly fashion. The directives were "Name one thing you are going to work on so that you can improve your relationships in future groups" and "Name one thing that you accom- plished in group that was good. Through the im- plementation of structured directives and media, I intentionally provided boundaries that I hoped would contain any residual anxiety. Additionally, before beginning group I asked each member to repeat her relationship goal of the previous week and charged each with working toward that ob- jective in this group. In this session the directive was to draw three lines on the cardboard tube (Figure 6. In the feedback stage of the group Sarah’s peers praised, and thus reinforced, behavior that was not regressive. Through the groups verbal statements Sarah was able to find a measure of self-esteem and regard through belonging to a larger group. In the last directive before the group was to combine all the projects, the girls were directed to "draw a wish. Throughout the discussion Sarah attempted to enter into the fantasy of the drawings rather than the reality of the present. Each time she reverted to these infantile productions I posed questions about the value of effective communication and contributing through cooperative interactions. By ac- centuating the here-and-now these process-oriented statements under- scored the reasons for Sarah’s failed relations and offered her the opportu- nity for a corrective experience. I then left the group with the task of making group decisions through lis- tening, leading, and collaboration. They sat quietly looking at the box, then looking at each other, then scrutinizing the media I had supplied, then looking at each other again. Eventually, one member took her pom- pommed pass-around assignment and attached it to the box. This then be- gan a flurry of activity, in which Sarah followed suit until she felt comfort- able enough to branch out and create the inside of the project (left side of Figure 6. In complete silence the group members moved around the room as they constructed the outside of Figure 6. When they were satisfied with their work, they took their seats and gazed at the once-disparate creations that now formed their group sculp- ture. Sarah was the first to offer one—"The House"—which the group rejected out of hand even though the members had identified the items on the inside as a tele- vision, table, shower, and so on. Sarah attempted to promote her title by again clarifying the contents both inside and outside, but to no avail. As the girls struggled with the collaborative effort of making a group decision, Sarah listened attentively and then offered the title of "The Haunted Mansion. As this group proceeded, Sarah’s interactions focused less on the self and more on reciprocal identification. This progress, the beginning stages of group identity, marked a nodal point of change, as all members to varying degrees began the process of mutuality. Empathy When using structured exercises toward empathic understanding, it is in- tegral that the client’s subjective here-and-now experience allow him or her not merely familiarity but also a means to get in touch with the personal identification of another. This awareness of feelings, emotions, and behav- ior spans the self and broadens into the larger community of group insight. In working with the low-functioning client, Michael Monfils (1985) has outlined three philosophical constructs as they relate to a theme-centered group. The first principle "promotes the autonomy and separateness of each individual but also emphasizes the fact that group members need one another and are connected" (p. The‘We’stands for the consciousness of the group members of the fact that they are a group, and the ‘It’ is the theme or focus" (p.

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