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Because the understanding and use of language is quite good in people with MS buy cheap diclofenac gel 20 gm on-line, in a single or occasional interview or consultation, it may be hard for a doctor to pick up more subtle but still important cognitive prob- lems. As we have suggested, it is far more likely that those who are with you, and see you everyday, will notice these things first. People with MS have found that cognitive problems can be one of the main reasons why they have to go into residential care or why they become unemployed. Tests Formally, the range and extent of any cognitive problems can be measured and monitored through what are known as ‘neuropsycho- logical tests’, usually given by a psychologist. They would involve some verbal and written tests focusing on things like your memory and your ability to solve problems of various kinds. These tests are becoming more sophisticated and you may be given a group (often called a ‘battery’) of tests that could take perhaps an hour or more to do. Your performance on these tests is then compared to those of normal healthy adults, and it is assumed that, unless there are other explanations, a much lower performance on one or more tests is due to MS. These tests are only given routinely in some clinical centres at present and, because this is still one of the developing areas of research and clinical practice in MS, you may need to attend specialist centres to obtain such an assessment. Because some medications may affect your performance in tests, you should make the person who is testing you aware of what medication you are currently taking. For example, many of the tests used for people with MS require a degree of coordination and manual dexterity, and this may be compromised by other effects of MS. Also, a problem in one area of cognition can affect performance in a test in an unrelated area, or it may be difficult to compare tests involving spoken responses with tests involving written or manual responses. Emotional state Your emotional state may affect your cognitive performance, but the exact relationship and mechanism is not yet clear. Some studies have shown that depression seems to be related to cognitive performance, and others have shown the opposite. Heat Heat, or getting hot, may affect your cognitive performance, as it may influence other symptoms from time to time. Although little research has been undertaken on heat and cognition, on the basis of research on other symptoms it would be reasonable to conclude that if, for example, your memory could have been affected in this way, it would be likely to return to normal with a reduction in the temperature. Medication Medication may also affect cognition, particularly those that have cen- tral nervous system effects, such as sedatives, tranquillizers, certain pain killers and some steroid treatments.

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Whilst statistically it is probably correct that most of your symptoms will be related to the MS buy cheap diclofenac gel 20 gm on line, many will not. It is easy for both of you to say ‘Oh, that’s another symptom of MS’ and not realize that, like other people, you can have other everyday problems. It is important that both are recognized in relation to pain as well as other symptoms. If GPs do confuse MS and non-MS symptoms, this is not through incompetence – even specialists sometimes have similar problems. Most GPs have so few people with MS on their patient lists – often only one or two – that, because of all the other pressing demands on their time, they have not been able to study, and experience, all the many twists and turns of the disease. Try a little persistence if you feel that your symptoms are not being treated as carefully as you wish; you can always ask for a second opinion if necessary. Sensations Initially strange and sometimes uncomfortable sensations of many kinds are typical effects of MS. A person can feel these symptoms but the doctor may to be able to find clear physical evidence of why particular symptoms are caused. Doctors often regard these symptoms as relatively benign because, although they may be irritating, they do not, on the whole, tend to result in major problems in daily functioning. Many people with MS get to know the situations in which these sensations occur and adjust their everyday lives as much as possible to avoid those situations. Medically, this is often called ‘dysaesthesia’ and results from abnormalities in the sensory pathways in the nervous system. Unfortunately, ordinary pain medications do not usually have much effect on this kind of sensation. Antidepressant medications such as amitriptyline may be used for relief if it becomes too problematic, or other remedies, such as antiepileptic drugs (gabapentin and carbamazepine), may be used to try and alter conduction along the nerve fibres, which has produced the sensation. Depending on where the damage occurs, you may feel all sorts of unusual sensations in those areas.

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Our analyses focused on patterns of service delivery and pain medi- cation prescriptions during the conservative treatment period diclofenac gel 20 gm online. We tested six hypotheses, stating that increased use of conservative treatment for acute low back pain patients will lead to a decrease during the first six weeks of care in the 1. These hypotheses are based on the assumption that an MTF effec- tively introduces and maintains the new approach of conservative treatment, which involves reducing the amount of services and medications provided to patients during the early weeks of low back pain. Therefore, we expect to observe the hypothesized changes in clinical practices only in those MTFs that proactively implemented ______________ 2The guideline leaves the actual timing of specialty referrals to the judgment of the clinician, depending on the severity of pain and presence of other symptoms during the conservative treatment period. Summary xvii the new practices, and we also expect to observe effects that are re- lated to the particular intervention strategy of each MTF. For exam- ple, there should be a reduction in referrals to specialty care only for those MTFs that defined specialty referrals as a priority and actually undertook actions to reduce inappropriate referrals. A Systems Approach to Implementation A systems approach was applied in the AMEDD practice guideline implementation demonstrations, an approach that was amply sup- ported by lessons from the demonstrations. The demonstrations highlighted that two main dimensions need to be addressed to en- sure successful changes in practices by MTFs and other local facili- ties: (1) build local ownership or "buy-in" from the staff responsible for implementing the new practices, and (2) ensure that clinical and administrative systems are in place to facilitate staff adherence to the guideline. Drawing on published literature and the experiences observed in the AMEDD demonstrations, we identified six critical success factors that strongly influence how successful an MTF will be in integrating new practices into its clinical and administrative processes (Chodoff and Crowley, 1995). In the evaluation, we assessed the performance of demonstration participants on these factors: (1) visible and consis- tent commitment by the MEDCOM leadership at all levels, (2) ongo- ing monitoring and reporting of implementation progress in carrying out an action plan, (3) implementation guidance to the MTFs by MEDCOM, (4) identification of an effective physician guideline champion at each MTF, (5) dedicated time and adequate resources for the guideline champions, and (6) rapid integration of new prac- tices into a clinic’s normal procedures. The DoD/VA low back pain guideline was introduced in the Great Plains Region in November 1998 at the demonstration kickoff con- ference. The asthma guideline demonstration began in the Southeast Region in August 1999, and the diabetes guideline was introduced in the Western Region in December 1999. The guideline implementa- tion process used in the demonstration consisted of (1) the practice guideline and metrics, (2) a guideline toolkit of materials to support the MTFs’ implementation activities, (3) a kickoff planning confer- ence at which demonstration MTF teams developed their implemen- xviii Evaluation of the Low Back Pain Practice Guideline Implementation tation strategies and action plans, (4) MTF implementation activities following the kickoff conference to carry out the teams’ action plans, (5) information exchange among the teams to share experiences and build on each other’s successes, and (6) monitoring of implementa- tion progress by both MEDCOM and the participating MTFs. Each demonstration was followed by Army-wide implementation of its guideline, beginning with the low back pain guideline in spring 2000. The Demonstration Sites Each demonstration was located in a different region to maximize the training and exposure of MTF personnel to the practice guide- lines and implementation methods in preparation for systemwide implementation.

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