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By L. Connor. Palmer College of Chiropractic.

In addition 200mg nizoral amex antifungal inhaler, the commanders were requested to designate a guideline champion and a facilitator to lead the implementation activities purchase 200mg nizoral fungal rash. Preferably, this in- dividual was a primary care physician who was an opinion leader and had a strong commitment to the successful implementation of the guideline. The facilitator was to guide the implementation team in developing an implementation action plan and then to provide support to the champion and team in coordinating and managing the implementation process. This individual needed experience fa- cilitating group decisionmaking processes as well as to be able to or- ganize work processes and to work with data for quality management and monitoring activities. Command Support and Accountability Commanders at the demonstration MTFs had agreed to participa- tion in the low back pain guideline demonstration. Over the life of the demonstration, however, the support of the MTF commanders ranged from moderately strong to absent, and some commanders appeared to be ambivalent or passive toward the guideline work. This change did not alter the positive (but still passive) com- mand support of the guideline at one MTF. The new commander at the other MTF had yet to be briefed or see a copy of the low back pain guideline by the time of our second visit. All the commanders designated guideline champions, facilitators, and implementation teams, and they authorized the teams’ par- ticipation in the two-day off-site conference that initiated the demonstration. When implementation activities began, none of the participating MTFs provided the leaders and members of the 46 Evaluation of the Low Back Pain Practice Guideline Implementation implementation team with dedicated time to devote uniquely to carrying out the guideline action plan. Team members continued to be responsible for their existing job functions, and time spent on actions to implement the low back pain guideline was added to those responsibilities. Nor did MTF commands request regular reporting, and hence, accountability, on implementation progress. Indeed, at one site, the commander gave the explicit signal that implemen- tation of the guideline was not a priority for him, and staff acted accordingly, undertaking virtually no actions to introduce new practices for managing low back pain patients. Implementation team members responding to the RAND survey perceived that complying with implementation would not reap rewards for them and failing to comply would have no ad- verse consequences. Two out of every three respondents said there would be a "good" to "very good" chance that a staff member would be noticed if she or he did not cooperate with guideline implementa- tion, but an overwhelming majority (94 percent) of respondents indi- cated they had "no risk" or "slight risk" if they did not cooperate. Similarly, a majority of respondents indicated that there was "no" to "little" chance that management would praise a staff member for co- operation with the guideline. The Champions The participating MTFs varied widely in their initial choices of champions to lead the low back pain guideline implementation ac- tivities, and the champions changed during the demonstration pe- riod. Three of the sites initially designated primary care physicians as champions, and the fourth site designated a specialist. All were clearly respected by their colleagues, and with one exception, they were committed to the successful implementation of the guideline. At some of the sites, the champions played more passive roles while the facilitators took on greater leadership roles. The champions re- ported that lack of "protected time" allocated for implementation of the guideline hampered their ability to be available and effective in leading implementation actions. They estimated that about one- third of their work time was needed for the first few months to per- form this role effectively, but most were unable to do so. Infrastructure for Guideline Implementation 47 At two sites, the champions did not change during the demonstra- tion, which provided continuity of leadership. At another site, the first champion was a colonel and was replaced by a newly arrived captain (several ranks below colonel). This change effectively down- graded the role of the champion, such that the new champion (who was committed to the role) was unable to achieve desired practice changes. A similar change occurred at the last site, where the cham- pion was replaced by a younger, lower-ranked physician. These changes reflected the low commitment at the two facilities to im- provement of practices for treatment of low back pain. The Facilitators The demonstration MTFs selected individuals with a variety of back- grounds to serve as facilitators, supporting the MTF teams in their planning and execution of implementation actions. One of the MTFs did not designate a separate facilitator—the champion took on this role. For the remaining MTFs, one designated a military person as facilitator, one had a team of two facilitators (one military and one civilian), and the third had a civilian facilitator.

Other painful conditions buy 200 mg nizoral mastercard antifungal wipes for cats, particularly painful swelling of the knee(s) or ankle(s) cheap 200 mg nizoral overnight delivery fungus gnats in grass, can result through problematic patterns of walking. It is possible that orthopaedic doctors, recommending conventional orthopaedic exercises for such conditions, may not fully realize that having MS could mean that such exercises fail to work. It is likely that the swelling/pain of one joint may be easier to remedy through what is called an ‘assistive device’ (e. Several muscles contract simultaneously, both those assisting movement and those normally countering it. These muscles will feel very tense and inflexible – this is because what is medically called their ‘tone’ increases, and movement becomes more difficult, less smooth and possibly rather ‘jerky’. Spasticity is quite a common symptom in MS and is often very painful: it can occur in the calf, thigh or buttock area, as well as the arms and, occasionally, the lower back. Spasticity can lead to ‘contractures’, where the muscle shortens, making disability worse. There are a number of ways of managing spasticity in MS: • Use your muscles as much as possible in everyday activities, and undertake regular stretching exercises to help reduce muscle shortening. Devices to assist in the management of spasticity There are specific devices that may be useful for people with MS when spasticity occurs regularly in key muscle groups, and exercises alone do not appear to deal with the problem. What are called ‘orthoses’ – in effect braces – keep the hand, wrist or foot in an appropriate position or prevent ranges of movement that may result from, or cause, spasticity. A particularly useful brace may be one that places the ankle in a good position in relation to the foot (called an ankle–foot orthosis – see also Chapter 8) and thus lessens the possibility of local muscle contractures, as well as lessening the stress on the knee. It is important that all orthoses are specifically suitable for the individual concerned, as of course body shapes and sizes vary considerably. Drugs There are several drugs available to help muscles relax, and ensure that as few of your activities as possible are affected. It is difficult to target spasticity specifically, so some people may need medication occasionally, in the day or at night, and others may require more continuous medication. It is difficult to get the balance and the dose right, and this often has to be done on a trial and error basis. One of the most common and effective drugs for spasticity is baclofen (Lioresal), but it can have side effects; some people find it hard to tolerate high doses. Normally this drug is taken by mouth, but other ways of administration are being developed to help people with more severe symptoms. Other muscle relaxants, such as the widely used diazepam (Valium) can also be used, but they may have general sedative effects, causing drowsiness; this is why diazepam might be particularly helpful at night. People are also worried about whether they might become dependent on these drugs in the longer term. There are some newer drugs in the process of being introduced, which on their own, or in combination with the more established drugs, may target the spasticity more specifically: • Dantrolene (Dantrium) tends to reveal and possibly exacerbate any muscle weakness that may be present, and its effects should be carefully monitored. Some other drugs work best for specific muscle groups in the body – such as cyclobenzaprine HCl, which is useful for the back muscles, although it may work for other muscle groups as well. In relation to chronic spasms, which may result in a complete arm or leg being extended or stiff, carbamazepine may be used, although baclofen can be very helpful. Cortisone can sometimes be used to assist short-term control of such spasms – although it is not for long-term use because it has a range of side effects. It is possible that any or all of the drugs above may become less effective over time and thus one of the possibilities is to stop taking the drug concerned for a period of time before starting it again. There are other drugs undergoing trials at present in relation to the control of spasticity. One of the most promising is cannabis (or, in practice, combinations of cannabinoids – the chemical constituents of cannabis). There may be occasions, especially later in the course of MS, when treatment needs to be more robust to reduce very severe spasticity. This might take the form of injections, directly into the nerve or muscle concerned, with phenol or alcohol or, more recently, botulinum toxin, which damages the nerve and produces what some call a ‘nerve block’ preventing the spasticity from occurring. Spasticity and surgery Surgical intervention may be tried in relation to spasticity if other means of control fail. Nerves controlling the specific muscles of the leg may be deactivated using what is called a ‘phenol motor point block’. Other techniques may help spasms in the face – indeed botulinum toxin (Botox), which is increasingly being used for cosmetic purposes, may help small but very irritating facial spasms.

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