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It reportedly allows providers to explain appropriate exercises and preventive be- havior faster to the patient generic wellbutrin 300 mg on-line. However, a physical therapist conducted a survey of low back pain patients referred to him and found that none of the patients had received or seen any educational material for low back pain. Thus, there is substantial uncertainty regarding the extent to which patient education is being provided in the pri- mary care clinics. The patient education video was not used at Site C because of an in- sufficient supply of video players to show the video regularly, and most staff thought they had only one tape available. It turned out that several copies had been received, but they had not been dis- tributed. Alternatively, closed circuit television could be used for this purpose, and this possibility is being considered. Metrics and Monitoring The original plans by Site C for monitoring progress in guideline im- plementation have been hampered by time constraints, breakdowns in the ADS, inaccurate and untimely ADS coding, and difficulties in accessing the CHCS data. By the time of our final visit, Site C had fo- cused on measuring two metrics: • presence of documentation form 695-R in medical charts • number of MRIs ordered. MEDCOM documentation Positive comments about the original form included form 695-R the following: helps efficiency by seeing patients faster, a useful reminder of red-flag conditions, the pain scale is useful to assess progress, helps process new Army re- cruits efficiently to make a decision whether to con- tinue training or release from service. They also felt the form was not useful for patients presenting with multiple problems. Patient education brochure Generally liked, but some felt it did not do much good with their patients. It should include an explanation to patients of why taking an X ray was not indicated. Key elements card Both cards are useful as reminders, most particularly for young providers and those who do not see many low back pain patients. As noted above, the presence of form 695-R in charts had increased from 4 to 20 percent between our two site visits to the MTF.
Scharff and de Varela (Chapter 9) describe how object relations therapy would be applied to couples wellbutrin 300mg low cost. Shifting from more traditional approaches of working with couples to postmodern thinking, Rosen and Lang (Chapter 10) introduce key aspects of doing narrative therapy with couples. In the first of several integrative approaches to working with couples, Bradley and Johnson (Chapter 11) present emotionally-focused therapy, an inte- gration of collaborative client-centered, gestalt, systems approaches, con- structivist thinking, and understandings derived from attachment theory and the empirical literature. Cheung (Chapter 12) proposes the integration of strategic family therapy and solution-focused approaches to working with couples. In Chapter 13, Pitta describes integrative healing couples therapy that uses psychodynamic, behavioral, communication, and sys- temic theories in understanding the couple’s functioning. Concluding this part, Nutt (Chapter 14) describes feminist and contextual approaches to working with couples. Section III approaches couples’ interventions from the perspective of common presentations in therapy. Thus, Watson and McDaniel (Chapter 15) describe the work with couples who are confronting medical concerns. The interface of the biological and the emotional provide the framework for their work in medical settings. In Chapter 16, Harway and Faulk consider how a history of sexual abuse in one member of the couple may affect the overall couple’s functioning and may lead to difficult therapeutic concerns. Holtzworth-Munroe, Clements, and Farris (Chapter 17) discuss the implica- tions of intervening with these types of couples. Stanton (Chapter 18) reviews key elements of couples therapy for the treatment of addictive be- haviors.
This stress may cause "slippage" of the discs discount wellbutrin 300 mg with amex, com- pressing one or more of the nerves as they leave the spinal cord and resulting in pain in the part of the body that is innervated by these nerves. Obviously, heavy lifting and inappropriate turning and bending compound the problem. These movements irritate the spinal nerves, causing the muscles on the side of the spinal column (the paraspinal muscles) to go into spasm; it is this spasm that causes low back pain. If a spinal nerve is significantly irritated, the pain may extend down to the muscles in the leg that are served (innervated) by that nerve. If the problem is one of poor walking posture, the pattern should be corrected; if spasticity contributes to the problem, it must be less- ened. Local back care with heat, massage, and ultrasound waves fre- quently are helpful, and exercises designed to relieve back muscle spasm may be recommended. Physical therapists and chiropractors who are sensitive to the problems associated with MS may speed 98 CHAPTER 15 • Pain healing. Drugs designed to relieve back spasms also may be used, often in conjunction with nonsteroidal antiinflammatory medica- tions (for arthritis). If the problem is the result of a severely damaged disc, surgery may be needed to relieve the spinal irritation. A person with MS and back pain should avoid severe spinal manipulation or spinal adjustments (rapid twisting or pushing of A person with MS and back pain should avoid severe spinal manipulation or spinal adjustments (rapid twisting or pushing of the spinal column). It is critical that a correct diagnosis of the cause of any type of pain be made to ensure that it is properly treated. Diagnostic studies that include magnetic resonance imaging (MRI) and computed tomograph- ic (CT) scanning may be needed to pinpoint the cause of the pain. Other types of musculoskeletal problems of an orthopedic nature are commonly seen in MS. Ligament damage may result if there is too much knee hyperextension during walking. Many orthopedic specialists are unfamiliar with MS and do not understand why this related problem occurs. As a result, they may recommend exercises such as "quad sets" to increase the strength of the weak leg.