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Matthew Jay Ellis, MD

Associate Professor of Medicine
Assistant Professor in Surgery

https://medicine.duke.edu/faculty/matthew-jay-ellis-md

You may be asked to push contractions arrhythmia synonym purchase 10mg plendil with amex, the caregiver pulls on a hanstation than is safe for use of as hard as you can while forceps pulse pressure in aortic regurgitation 2.5 mg plendil amex. The doctor turns and/or pulls on the handles when anesthesia is used or to aid rotation and descent prehypertension uk buy plendil discount. Used only in bearing-down efforts are Usually requires regional or Forceps are used much less in second stage when the baby is at a low insuffcient 7th hypertension discount plendil online american express. Fewer doctors May be used to facilitate May bruise or tear vaginal are trained in their use. If forceps attempts are unsuccessful, a cesarean is done to Speeds delivery if fetus is in ensure the health of the baby. It compares the following factors that might be desired outcomes of pain relief options: less pain intensity, less likelihood that the laboring mother will turn to pain medications (unless that was her goal), higher satisfaction with pain relief, shorter labor, higher chance of spontaneous vaginal delivery (versus instrumental delivery or cesarean), and less use of Pitocin to augment a slow labor. Your heart rate, blood pressure, and breathing rate increase, and efects of oxytocin are neutralized. You can paint, draw, write, sculpt, or use any other medium to help you create this vision. Focus on this image during the weeks prior to birth, and your nervous system will respond, producing a state of relaxation. Plan to use this image in labor to help you release tension, reduce pain, and have a more efective labor pattern. She worked with her partner and childbirth educator to change her focus from the needle that she feared to the benefts a medication would bring to her if it were needed. Having made this plan, the woman was able to approach her birth with much less fear. She ended up having an uncomplicated birth at home and no needles were needed, but she was relieved to have made such a thorough plan, because it reduced her fear. Pregnancy, Childbirth, and the Newborn Pregnancy, Childbirth, and the Newborn Chapter 11: Labor pain and options for pain reLief Understanding Your Coping Style Mother-to-be: this work sheet will help you think about your normal responses to physical and emotional challenges, as well as possible reactions to unknown situations. Date(s) you practiced: Date(s) you practiced: Pregnancy, Childbirth, and the Newborn For the following practice sessions, time several pretend contractions. Ten take a one-minute break to discuss with your support partner(s), giving feedback on what was helpful and what was not. Ten practice another sixty-second contraction, while adapting the technique to your preferences. To help you better learn what techniques work best for you, you may also want to try using ice as a source of discomfort to cope with. Fill a plastic baggie with ice and hold it in your hands during each of your contractions. Working with the discomfort of the ice can help you understand what might be most helpful for working with discomfort in labor. Systemic Medications for Labor Pain and Distress Possible risks and/ Additional precautions/ Type and timing Drugs used Benefts and/or purposes or disadvantages procedures/interventions Sedatives/barbiturates secobarbital In smaller doses, they have To mother: Large doses may Note: Rarely used today (Seconal) a sedative effect: reduce cause dizziness and disoribecause of undesirable side given by injection or pill anxiety, irritability, and exentation and can slow labor effects. Tranquilizers Phenothiazines: Used to reduce tension, anxTo mother: May cause Should be discontinued beiety, nausea and vomiting. When given with barequipment on hand if baby (Compazine) narcotics (thus reducing biturates or narcotics, may is born soon after these are narcotic side effects). Benzodiazepines: are sometimes given after cesarean birth to reduce diazepam anxiety during the repair. Nausea, vomiting, Mother should begin inhaling mother, who holds an Causes mother to feel drowsiness and dizziness for just before a contraction oxygen mask to her drowsy, lightheaded, or some women. Pregnancy, Childbirth, and the Newborn Pregnancy, Childbirth, and the Newborn Systemic Medications for Labor Pain and Distress Possible risks and/ Additional precautions/ Type and timing Drugs used Benefts and/or purposes or disadvantages procedures/interventions Narcotic or morphine During active labor, To mother:2 May cause Usually, restriction to bed. Narcotic antagonists naloxone (Narcan) Reduce narcotic effects, To mother and baby: Continued observation of such as hallucinations, itchAbrupt reversal of narcotic mother or baby for return of given by injection into ing, respiratory depression depression may result in narcotic side effects. The if there is narcotic toxicity effects of narcotics may or to the newborn when return if narcotic antagothere are respiratory probnist wears off before the lems caused by narcotics. To mother: (Xylocaine) given by injections Relief of pain of crowning, Sting of injections. If given around the vaginal can be given by episiotomy, or stitching during second stage, opening midwife or physician after birth. Paracervical block mepivacaine Removes pain due to dilaTo mother: Routine: (Carbocaine) tion of cervix and pressure given by injections into in lower segment of uterus. Pregnancy, Childbirth, and the Newborn Local Anesthetics for Labor, Delivery, and Repair Drugs used/ Benefts and/ Possible risks and/ Additional precautions/ Type and timing who administers or purposes or disadvantages procedures/interventions Pudendal block same as paracervical Numbs vagina and To mother: Routine: block perineum. Narcotics or narcotic-like drugs that may be used include morphine (Duramorph), fentanyl (Sublimaze), and sufentanil (Sufenta). Benefts and/ Possible risks and/ Additional precautions/ Type and timing Drugs used or purposes or disadvantages procedures/interventions Spinal narcotic narcotic only Similar to epidural narcotic, Similar to epidural narcotic. Epidural narcotic narcotic only Decreases perception of To mother: Note: Rarely done. Routine: 2 cm until transition Frequently, nausea and Affects ability to move vomiting. Fetal heart rate changes For newborn if mother had (can be secondary to mafever: ternal fever or decreased blood pressure). Combined spinal spinal narcotics given Same benefts as spinal Similar to spinal narcotics, See above.

While some research inditorical framing has been criticized for connoting cates that oocyte donors generally feel adequately altruistic intentions when blood pressure chart mayo 2.5mg plendil visa, in many cases heart attack quick treatment order generic plendil on line, a cominformed about the physical risks associated with mercial transaction takes place [16] blood pressure medication safe for pregnancy generic plendil 5mg with amex. Despite the donation [23] prehypertension icd 9 buy generic plendil 5mg, others suggest that clinics and controversy, this chapter will utilize the terminoloocyte donor matching agencies provide inadeogy of oocyte donation owing to its commonality quate or incomplete information about risks assoin the literature. Researchers have also raised concerns that donors for their time and efforts [31]. The long-term health effects would be inappropriate because prospective of oocyte donation are largely speculative but donors may be unduly induced by the sum and dismay include increased risks to future fertility and count of the risks associated with donation [27]. However, because there is still a possibiland that compensation for donors with specific ity that long-term risks may be indentified in the idealized traits is higher than recommended [32 ]. The willingness of some donation, one of the more hotly contested ethical to increase compensation for donors with specific issues in the context of oocyte donation has been traits also stirs ethical concern that oocyte donathe compensation of donors. This may refiect the moral the genetic endowment of offspring with socially belief that the market has no place in the domain desirable oocyte donor characteristics any differof the family [29]. Thus, the question remains whether systems have justified compensating donors by choosing donors with socially desirable traits indicating that remuneration ensures an adequate runs the risk of objectifying future offspring by pool of prospective donors, who without compeninadvertently assigning them an explicit intrinsic sation would not otherwise consider donating, as value [34 ]. Some resulting children or treating them as property research assessing donor motivations suggests and may be at odds with the expectation that that these concerns may be well placed [23], yet recipients will love these much-desired children others have pointed out that there is no evidence unconditionally [3]. Steinbock has raised the addithat offering donors higher payments or compentional concern that recipients who invest a lot of sation in kind necessarily leads to exploitation or money in an egg donor with desirable traits may be undue inducement [14, 36]. Other ethicists have disappointed if a child does not live up to their argued that if women are to be compensated for expectations [3]. Some scholars have for donors, but Steinbock argues that there is no raised the additional concern that the growing plausible impact on resulting children regardless global demand for donor oocytes raises the of whether the donor was compensated [3 ]. They that parties involved in constructing oocyte donaargue that recruiting women from these settings tion carefully consider the interests of would-be for transnational oocyte donation may be ethically children [22 ]. However, donors also considers the impact of compensaextending gestational and social parenthood to tion schemes on recipients of donor oocytes. Of note has been the contentiousness increasing compensation for donors will make of extending oocyte donation to postmenopausal the cost of treatment with donor oocytes more women. The decision to knowledge of donation outcomes and disposition allow oocyte donation should be approached on a of oocytes. To lessen the risk of adverse psychologidonation for third-party reproduction engages the cal impact of donating their oocytes, researchers question of donor anonymity. The rationalities have suggested that clinics and agencies consider underpinning anonymous and identifiable donathe possibility of standardizing the delivery of tion pertain to perceptions regarding the effects of non-identifiable information regarding outcomes of the availability of information on the well-being of anonymous oocyte donation, particularly if a donadonors and donor offspring. Those supporting the shift towards disoocyte donation, as has been detailed previously, closure of parentage argue that secrecy creates a ethical debate pertaining to the roles of clinicians negative power dynamic between parents and chil. Ethicists tifying information about the donor once they argue that the business models of donor agencies reach the age of majority [46, 47]. Within oocyte donor offspring of their genetic origins [48], and donation, confiicts of commitment may also arise some gamete recipients and donor offspring when a physician or agency is serving two differhave advocated for establishing donor databases ent parties whose interests may confiict [52], if. Wilson because the recipient is the patient who bears Acknowledgments the authors thank Valarie Blake and the costs and provides income for the parties Julie Severson for their comments on an earlier version of this chapter. While these authors and does not necessarily represent the official confiicts may not pose as blatant a physical or views of the National Human Genome Research Institute or National Institutes of Health. Payment for egg donation and surroof professional consensus regarding the disclogacy. Participation in investigational fertility preservation research: a feminist research ethics still considerable room for engagement of the approach. In: Woodruff T, Zoloth L, Campo-Engelstein ethical consequences of promoting donor autonL, Rodriguez S, editors. Wanted: egg donors for donation has been available for nearly three research: a research ethics approach to donor recruitdecades, debates regarding the morality of the ment and compensation. The unbearable lightness of bringing into and regulatory contexts in which donation takes being. However, regardless of the context, the arguments and insights from religious traditions. Rabbis and reproduction: the uses of new reproductive technologies among ultraorthadox Jews confiicts of interest are issues likely to continue in Israel. Ethics Committee of the American Society for work in embryonic stem cell research. The Ethics Committee of the American Society for transaction of donor sperm and eggs. The Ethics Committee of the American Society for expectations and experiences during their first donation Reproductive Medicine. Financial compensation of anonymity and secrecy on the welfare of the child in oocyte donors. New reproductive technologies and the sions of parents of children conceived by donor family. Self-regulation, compensation, and the donors exploring their experiences, knowledge, and ethical recruitment of oocyte donors. The uterine rupture caused the baby intent of the gestational carrier getting pregnant to die and the wife to undergo a hysterectomy. Center in Cleveland, Ohio, found the proposal to be very interesting and challenging. The physicians contacted the couple and told them History they were, from a scientific standpoint, very interested in their proposal. They were, howthe first birth utilizing a gestational carrier ever, concerned about the ethical and legal occurred in April 1986 [1]. The wife nity to come to Mount Sinai to further evaluate had lost both of her fallopian tubes to ectopic their proposal. In 1981, the couple went to Bourn lawyer and brought a large amount of legal Hall in England to attempt in vitro fertilization documentation to Mount Sinai. The couple met with the Mount Sinai Ethics Committee and the Mount Sinai Institutional Research Board. The first gestational carrier became dis2008 18 % couraged and was not willing to attempt a third 2009 13 % cycle. The baby was born in April 1986 and made history not only as the first baby born by a gestagestational carrier services [2]. Gestational cartional carrier but also as the first baby to be rier services are utilized far less than the most utilegally handed over to a non-birth mother withlized third-party reproduction, oocyte donation. She graduated from Emory University Indications for Usage of Gestational in 2008 and currently lives in New York City. Carriers the indications for usage of gestational carriers Utilization of Gestational Carriers are listed in Table 5.

And what were her reasons for her wanting to meet me arteria supraorbitalis buy plendil without prescription, an unknown PhD student engaged in feminist activist researchfi To caution me about the possible consequences of speaking out and rocking the boat; to tell me that pharmaceutical companies have key opinion leaders in lots of areas of academia blood pressure 20090 buy plendil visa, to offer to be my examiner for my PhD viva voce in order to ensure that there was no pharmaceutical company-funded academic as part of the process who might discredit or fail my work hypertension jnc 7 guidelines discount plendil master card. She gave me a very clear account of what had happened to her and that she did not want my career to be jeopardised by my challenging the programme and advocating for the vaccine-injured young women and their parents wide pulse pressure icd 9 purchase 10mg plendil overnight delivery. These three events remind me of the importance of the research I have carried out. Indeed they are real, persistent and traumatic lives being felt and lived by the young women, their parents, families and wider circles. Based upon these events and my reflections on them, I will hold these in mind as I write my final conclusions of the research project. This is in part due to the fact that some vaccinations do indeed have a positive impact on infection rates and life-threatening diseases, but they also construct definitions of illness and create lucrative responses to these too. Furthermore I have explored the neoliberal framing of choice and argue that its relationships with post-feminism results in a pervasive precarity for young women. My journey through the research and thesis 258 writing has been a difficult one as a result of such sentiments and quick responses. Rather than the numerous downhearted sinking feelings, I instead would choose to remember my motivations for undertaking the research. What could follow would be an exploration of topics such as underage sex, teenage pregnancy and vaccine safety. It also piques the interest of the professional youth and community worker in me, and demonstrates the fact that there are more opportunities for political education to be embraced. I argue that my research speaks to scholars, youth and health practitioners, and activists alike. My obvious affiliation is with professional youth and community workers and sexual health practitioners. My research materials and arguments may also be of interest to feminist scholars with a focus on health and youth studies. It perhaps goes without saying that the engagement and arguments of this thesis began their journey 260 many years before; both through my professional and activist history. These research materials are presented as empirical facts; this is a political exercise and one which makes attempts at recalibrating the ways in which we consider experience and knowledge i. From my years of professional youth and community work I have several specific examples of advocating for young people against or alongside dominant competing agendas of what is deemed best for them, without necessarily asking or finding out from them. Such agendas and resultant policies are often based upon large-scale data sets of current trends in risks or problems in adolescence. But working directly with individuals and small groups often garners quite different perspectives on particular issues. Firstly, during my research I left the organisation and found employment elsewhere. This decision was based upon many reasons but also it settled my unease at feeling the tension between my critiques and the position of my employer. The process of engaging in a sustained, substantive piece of research has allowed me to go beyond the emotional unease and my activist responses, and introduce a more thoughtful process to engaging with information and knowledge to enable me to strengthen my critical thought. In turn this is allowing me to practice in new ways and to be able to highlight the concerns that have been solidified through the research, and advocate for social justice and political education in new ways and with access to new audiences. Their challenges are within the realms of how it is possible to practice femininity whilst also critiquing the vaccine. This comes about as a result of a postfeminist intervention being introduced under the guise of a feminist one. Examples of this have included them asking questions about vaccine-safety to the school nurses, feeling faint, getting sick and having declined/refused the vaccine. Thus they have practiced their sexual citizenship in ways which are both often hard to do and can be contrary to the strict norms of successful femininity. Whilst I feel pleased with the materials I was able to generate with those involved in my project, it was not without its difficulties. They include responding to , in my view, sometimes unjustified requirements of the ethics committee and related University demands. For example, having to gain consent from the youth projects to access and recruit young women rather than gain consent from them or their parents was a surprise to me. Although I satisfied the bureaucracy of the 262 ethics committee, I carried out the research in a way that allowed the participatory orientation to challenge the research ethics norms. This was largely due to my arguments that opportunities for outward expression are often limited for young women. The use of diaries was a way of enabling them to narrate and make sense of their worlds. The glimpses into the private individual worlds of these young women reflect elements of postfeminism in neoliberal times. Yet, the opportunities to create and display the diaries in the social space of the small group discussion at Wendy Chicken Shop school were different. Attending to this pharmaceutical framing, I argue that young women are deemed 263 to be at-risk and in need of intervention. This is, for me, a further example of the fallacy of choice that characterises the postfeminist times we are currently encountering. Pro-active choices are not being sought out by the young women and parents, instead they are being presented with an opportunity to make a decision based upon a limited number of options, limited information and a heavy burden of expectation. It is a key argument that the diagnoses that the vaccine-injured young women have received appear to be lazy and usual rather than in light of changing symptoms and emerging evidence. As highlighted in Chapters Four and Five, the parents have highlighted that to diagnose is a clinical priority; once something has been diagnosed or labelled, no further work appears required i. I argue that this practice of prioritising a diagnosis shifts attention away from the acceptance that the vaccine has a causal role in ill-health, and focuses instead on what practices can be done within the limits and boundaries of the clinical encounter. This resulted in the young women and their parents feeling ostracised from the programme in which they had previously had faith and optimism. By not accepting a more nuanced and experiential account of the infection, vaccine health practitioners are not recognising that young women and their parents can make rational decisions.

Examiners should develop policies and procedures for providing sexual assault care to the unconscious patient high blood pressure medication and zinc discount plendil 10 mg on line. Such care should respect the autonomy of the individual and be consistent with jurisdictional interpretations of emergency exceptions to informed consent arteria hypogastrica buy plendil overnight. Similarly blood pressure levels.xls purchase plendil uk, examiners should have policies for patients that present with altered mental status pulse pressure 44 buy plendil 5mg free shipping, which could be from alcohol or drug intoxication or for other reasons. At a minimum, if serious problems are ruled out, the patient will likely need to be observed until consent and cooperation can be obtained which will delay the start of the examination. In all cases, the medical forensic examination should never be done against the will of patients. Responders should not touch patients or otherwise perform exam procedures without their permission. Be sure jurisdictional policies address the scope and limitations of confidentiality as it relates to the examination process and with whom information can be legally and ethically shared. Individuals responding to the sexual assault victim need education on the basics of maintaining the confidentiality of their patients. They also should build their understanding of the scope and limitations of confidentiality of each agency and responder involved. In addition, individuals responding to sexual assault victims should be aware of the laws in their jurisdiction 88 pertaining to privileged communications. More than half of the states have laws in place providing some level of privilege to the communications of sexual assault/rape crisis and domestic violence counselors. In most states, counselors must complete a certain number of training hours to qualify for the privilege. Responders should be aware that victims in the military who choose restricted reports can confidentially speak with a sexual assault victim advocate, a sexual assault response coordinator, military chaplain, or other specified military professional. Jurisdictions should be careful in their local response to protect any privileges that are available to victims. This can be done by limiting who speaks with the victim at each stage of the process, who will be present during discussions and/or interviews, and who will be the recordkeeper or notetaker. In some jurisdictions, patients who are minors have fewer or more limited confidentiality rights than adults. For example, in some jurisdictions, minor patients have the right to grant or withhold consent to a forensic examination but not to keep the results of the exam private from their parent or legal guardian. It is important to convey to patients the scope and limits of confidentiality of this communication. These include communication between husband and wife, physician and patient, attorney and client, clergy and parishioner, and psychotherapist and patient. Confidential communication generated in the course of a counseling relationship has more recently been afforded some statutory protection. In general, victim-counselor privilege laws enable counselors (such as community-based victim advocates) to maintain confidentiality of information revealed to them. In addition to preventing counselors from testifying in court, many privilege laws extend protection to their written records. It is important that patients understand the scope and limits of confidentiality of these records. Patients usually need to make an official report by the end of the designated period of time or the evidence and information will be destroyed. They should have access to such documentation, and exam site and jurisdictional procedures for accessing this data should be conveyed to patients. Release of the information regarding the sexual assault to anyone other than the specified officials who may receive a restricted report will result in the loss of confidentiality for the victim and command and law enforcement will have to be notified of the sexual assault. Consider the impact of federal privacy laws regarding health information on victims of sexual assault. In such instances, jurisdictional policy would govern when such information could be released to the general public upon request. For example, maintaining confidentiality is often difficult in isolated or small communities where people know one another or word of a crime travels quickly. Special precautions must be taken in these situations to preserve confidentiality. Many sexual assault victims who come to health care facilities or other exam sites for the medical forensic exam choose to report the assault to law enforcement. Reporting provides the criminal justice system with the opportunity to offer immediate protection to the victim, collect evidence from all crime scenes, investigate the case, prosecute it if there is sufficient evidence, and hold the offender accountable for crimes committed. Equally important, reporting gives the justice system the chance to encourage victims to seek assistance to address their needs, identify patterns of sexual violence in the jurisdiction, and educate the public about such patterns. Service providers should discuss all reporting options with victims and the pros and cons of each, including the fact that delayed reporting may be detrimental to the prosecution of an offender. Victims need to know that even if they are not ready to report at the time of the exam, the best way to preserve their option to report later is to have the exam performed. Some victims, however, are unable to make a decision about whether they want to report or be involved in the criminal justice system in the immediate aftermath of an assault. Yet, they can benefit from support and advocacy, treatment, and information that focuses on their well-being. Recognizing that traumatic injuries heal and evidence on their bodies is lost as time passes and that they may report at a later date, victims can also be encouraged to have the medical forensic exam conducted. Victims who are recipients of compassionate and appropriate care at the time of the exam are more likely to cooperate with law enforcement and prosecution in the future. Except in situations covered by mandatory reporting laws, patients, not health care workers, make the decision to report a sexual assault to law enforcement. In the remaining jurisdictions, no report should be made without the consent of patients. All involved health care providers should be aware of the reporting requirements in the jurisdiction in which they work. In jurisdictions in which mandatory reporting by health care personnel is required, patients should be informed of the legal obligations of health care personnel, what triggers a mandatory report, that a report is being made, and the contents of the report. Patients should understand that even if health care personnel 93 make a mandatory report, they are not obligated to talk with law enforcement officials 92 Some jurisdictions mandate reporting for some or all violent crimes, requiring health care workers to notify law enforcement in cases involving a gunshot or knife wound, strangulation/choking, or other serious bodily injury. They vary, however, in whether they require acts of sexual violence without serious physical injuries to be reported. Health care personnel should be aware that these reporting laws may come into conflict with military policy allowing for restricted reporting for victims in the military. Victims may have these and other fears because they are from populations with differing sexual orientations or gender identities, or they are from racially or otherwise oppressed groups; they are inmates; or they fear being deported or refused citizenship (in the case of recent immigrants and refugees). Some recent immigrants or refugees may fear law enforcement because of past experiences of oppression by authorities in their countries of origin. In addition, many victims are not willing to deal with the humiliation, loss of privacy, and negativity they perceive would accompany reporting, an investigation, and prosecution.

Cardiovascular complications after acute spinal cord injury: pathophysiology blood pressure medication used for opiate withdrawal generic 5 mg plendil otc, diagnosis hypertension treatment guidelines 2013 plendil 10mg low cost, and management arrhythmia vertigo cheap plendil 10mg online. Trunk and upper extremity kinematics during sitting pivot transfers performed by individuals with spinal cord injury pulse pressure 25 purchase genuine plendil line. Effects of a simple electric system and/or a hinged ankle-foot orthosis on walking in persons with incomplete spinal cord injury. Level walking and ambulatory capacity in persons with incomplete spinal cord injury: relationship with muscle strength. A systematic review of the management of orthostatic hypotension following spinal cord injury. A systematic review of the management of autonomic dysreflexia following spinal cord injury. Outcomes after spinal cord injury: comparisons as a function of gender and race and ethnicity. A systematic review of functional ambulation outcome measures in spinal cord injury. Association between mobility mode and C-reactive protein levels in men with chronic spinal cord injury. Model of traumatic spinal cord injury in Macaca fascicularis: similarity of experimental lesions created by epidural catheter to human spinal cord injury. Sparing of sensation to pinprick predicts recovery of a motor segment after injury to the spinal cord. An evaluation of the factors affecting neurological recovery following spinal cord injury. Cervical spine injury is highly dependent on the mechanism of injury following blunt and penetrating assault. A typology of alcohol use patterns among persons with recent traumatic brain injury or spinal cord injury: implications for treatment matching. A clinical prediction rule for ambulation outcomes after traumatic spinal cord injury: a longitudinal cohort study. Epidemiology of pediatric spinal cord injury in the United States: years 1997 and 2000. Prediction of ambulatory performance based on motor scores derived from standards of the American Spinal Injury Association. Pain may be accompanied by upper extremity numbness, weakness, or hyporeflexia, and may be due to cervical disc herniation (younger patients), or foraminal encroachment or spinal stenosis (older patients). Patient Data fi General demographics fi Occupation/employment fi Hand dominance fi Living environment fi History of current condition fi Functional status and activity level (prior level of function) fi Medications fi Other tests and measurements (laboratory and diagnostic tests) fi Past history (including history of prior therapy and response to prior treatment) Specific Considerations fi Rule out red flags (require medical management). Incidence of disc herniation in patients over age 40 decreases due to dehydration of the nucleus pulposus. Subjective Findings fi Pain, numbness, tingling, paresthesias in upper extremity following cervical nerve root distribution, particularly with hyperextension and rotation. Objective Findings Objective findings may include: Scope of Examination Examine neuromusculoskeletal system for possible causes, or contributing factors to the neck pain. The condition may be induced by either traumatic or non-traumatic factors and may consist 138 of 937 of a new condition or an exacerbation of an existing one. Intensity of care is guided by the condition of healing tissue structures, generally including therapy visits supplemented by a home management program. Degree of abnormality should be specified at initiation of therapy, and periodically, to establish an objective response to therapy: 140 of 937 1. Activities of daily living, vocational activities) Practitioners are strongly encouraged to utilize peer reviewed, standardized tools to quantify Functional Limitations. Treatment Methods fi Depending on evaluation findings, you may use modalities to address pain. Expected Outcome Procedures/Modalities Such As Decreased pain and muscle fi Modalities are only used in the acute phase; spasm deep heating modalities should be avoided in the acute phase as they augment inflammation and may exacerbate radicular pain and nerve root injury. Expected Outcome Procedures/Modalities Such As Decreased pain and muscle spasm fi Modalities should be used sparingly on an as needed basis fi Mechanical/Manual Traction fi Soft Tissue and Connective Tissue mobilization Improvement in cervical and upper extremity fi Joint/segmental mobilization range of motion and strength fi Flexibility exercises fi Strengthening exercises fi Endurance training for neck and upper extremity fi Cervical spine stabilization exercises Improvement in body mechanics and fi Body mechanics training postural stabilization fi Postural stabilization activities fi Postural Control Ability to perform physical actions, tasks or fi Gradual tolerance of activities and activities related to self-care, home positions management, work, community and leisure fi Self-management of symptoms fi Teach home exercise program the following table lists procedures for Corrective/Rehabilitative Phase presentation. Expected Outcome Procedures/Modalities Such As Decrease referred symptoms fi Mechanical/Manual Traction fi Soft Tissue and Connective Tissue mobilization Improvement in cervical range of motion fi Joint/segmental mobilization fi Flexibility exercises Improvement in cervical and upper extremity fi Strengthening exercises-Active, Strength isometric, isotonic fi Endurance training for neck and 143 of 937 upper extremity fi Cervical spine stabilization exercises Improvement in body mechanics and postural fi Body mechanics training stabilization fi Postural stabilization activities fi Postural Control Ability to perform physical actions, tasks or fi Gradual tolerance of activities activities related to self-care, home and positions management, work, community and leisure fi Self-management of symptoms fi Teach home exercise program fi Functional training Note: Not all of the above modalities are appropriate for each individual case; they require the skill and judgment of persons properly trained and licensed for safe use. Home Medical Equipment fi Cervical traction fi Hot packs/cold packs Self-Care Techniques fi Postural advice, postural exercises fi Cervical isometric exercises, cervical stabilization exercises, flexibility exercises fi Aerobic conditioning fi Cold/heat applications, if needed, to relieve discomfort/stiffness fi Brief use of cervical collar, if necessary, in the acute stages to limit motion Alternatives/Adjuncts to Physical/Occupational Therapy Management fi Osteopathic Manipulation fi Chiropractic fi Physiatry fi Medication 144 of 937 Medicare References 1. Arkansas, Colorado, Delaware, District of Columbia, Louisiana, Maryland, Mississippi, New Jersey, New Mexico, Oklahoma, 145 of 937 Pennsylvania, Texas. Clinical prediction rules for physical therapy interventions: a systematic review. Prognostic factors associated with minimal improvement following acute whiplashassociated disorders. Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders, North American Spine Society, 2010. Physical Therapy of the Cervical and Thoracic Spine, 3rd ed, Churchill Livingstone, 2002 26. Effectiveness of specific neck stabilization exercises or a general neck exercise program for chronic neck disorders: a randomized controlled trial. Manual Therapy, Exercise and Traction for Patients With Cervical Radiculopathy: A Randomized Clinical Trial. Pain follows the distribution of one, or less commonly, more than one cervical nerve root. Patient History Patient history may include: Patient Data fi General demographics fi Occupation/employment fi Hand dominance fi Living environment fi History of current condition fi Functional status and activity level (prior level of function) fi Medications fi Other tests and measurements (laboratory and diagnostic tests) fi Past history (including history of prior therapy and response to prior treatment) Specific Considerations fi Rule out red flags (require medical management). Chance of disc herniation after age 40 decreases as the nucleus pulposus dehydrates. There is often a history of trauma involving extremes of extension, flexion, and/or rotation of the neck. Intensity of care is guided by the 151 of 937 condition of healing tissue structures, generally including therapy visits supplemented by a home management program. Treatment Methods fi Depending on the pain level, modalities to address pain may be utilized. Frequency 154 of 937 of therapeutic visits is gradually reduced over a short period of time, generally 1-4 weeks. Expected Procedures/Modalities Such As Outcome Decrease pain fi Physical modalities are only used in the acute phase; deep and muscle heating modalities should be avoided in the acute phase as spasm they augment inflammation and may exacerbate radicular pain and nerve root injury. Patient fi Avoid flexion education and fi Use of soft collar for the first few days home exercise fi Remain as active as possible program fi Teach home management program the table below lists procedures for Subacute Phase presentation. Expected Outcome Procedures/Modalities Such As Decrease pain and muscle fi Modalities should be used sparingly on an as spasm needed basis Restore flexibility, strength fi Studies support conservative treatment, such as and body mechanics of the the McKenzie approach and cervicothoracic cervical joint stabilization programs which includes cervical spine flexibility exercises, postural correction and strengthening, combined with aerobic conditioning. Ability to perform physical fi Gradual tolerance of activities and positions actions, tasks or activities fi Self-management of symptoms related to self-care, home fi Functional training management, work, fi Teach home exercise program community and leisure the table below lists procedures for Corrective/Rehabilitative Phase presentation. Expected Outcome Procedures/Modalities Such As Restore flexibility, strength fi Studies support conservative treatment, such as and body mechanics the McKenzie approach and cervicothoracic stabilization programs which includes cervical spine flexibility exercises, postural correction and strengthening, combined with aerobic conditioning. Ability to perform physical fi Gradual tolerance of activities and positions actions, tasks or activities fi Self-management of symptoms related to self-care, home fi Functional training management, work, fi Teach home exercise program community and leisure Note: Not all of the above modalities are appropriate for each individual case; they require the skill and judgment of persons properly trained and licensed for safe use. Home and Self-Care Techniques the patient can be taught to use medical equipment and administer self-care at his residence Home Medical Equipment fi Use of a cervical pillow while sleeping may be helpful fi Use of a cervical collar fi Theraband for therapeutic exercises fi Cervical traction unit fi Hot packs/cold packs fi Home electrical stimulation unit fi Gymball Self-Care Techniques fi Postural advice/postural exercises fi Cervical isometric exercises, cervical stabilization exercises, stretching exercises fi Aerobic conditioning fi Cold/heat applications, if needed, to relieve discomfort/stiffness fi Use of cervical pillow, if helpful 156 of 937 fi Brief use of cervical collar, if necessary, in the acute stages to limit motion fi Home cervical traction Alternatives/Adjuncts to Physical/Occupational Therapy Management fi Osteopathic manipulation fi Chiropractic fi Physiatry fi Medication Medicare References 1. Impact of continuing education interventions on clinical outcomes of patients with neck pain who received physical therapy. Physical Therapy of the Cervical and Thoracic Spine, 3rd ed, Churchill Livingstone, 2002 19. Nonoperative management of herniated cervical intervertebral disc with radiculopathy. Work conditioning, work hardening and functional restoration for workers with back and neck pain. Ziglar, Michele K, Current concepts in evaluating cervical spine injuries, Journal of Trauma Nursing, 2001. Because multiple factors can contribute to this syndrome, patients are considered to be suffering from a chronic pain syndrome. Patient History Patient history may include: Patient Data In addition to the standard information gathered, a complete understanding of the surgical procedure performed should be obtained from surgeon. Subjective Findings fi Pain, numbness, tingling, paresthesias in upper extremity following cervical nerve root distribution fi May complain of weakness in upper extremity, such as with grip strength fi May complain of difficulty with fine manipulation tasks, including handwriting, may be reported fi Headaches and neck pain may accompany upper extremity pain Objective Findings Objective findings may include: Scope of Examination Examine the neuromusculoskeletal system for possible causes, or contributing factors to neck pain.

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