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American Journal of massage on human immune response in healthy adults Medical Science 299:313–318 (pilot study). Journal of Bodywork and Movement Lapp C 1997 Exercise limits in chronic fatigue Therapies 6(3):143–150 syndrome. American Journal of Medicine 103:83–84 Lukban J, Whitmore K, Kellog-Spadt S et al 2001 The Latha D, Kaliappan K 1992 Efficacy of yoga therapy in effect of manual physical therapy in patients diagnosed the management of headaches. Journal of Indian with interstitial cystitis, high-tone pelvic floor Psychology 10:41–47 dysfunction, and sacroiliac dysfunction. Urology 57(6 Lawler S, Cameron L 2006 A randomized, controlled Suppl 1):121–122 trial of massage therapy as a treatment for migraine. Lum C 1996 Hyperventilation and asthma: the grey Annals of Behavioral Medicine 32(1):50–59 area. An approach to the Lum L 1984 Hyperventilation and anxiety state examination and treatment of the lumbopelvic–hip [editorial]. 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Association between somatotypes and blood pressure International Journal of Neuroscience 115(3):495–510 Annals of Human Biology 31(4):466–476 Hodges P, Gandevia S 2000a Activation of the human Kasseroller R 1998 Compendium of Dr Vodder’s diaphragm during a repetitive postural task. Haug, Heidelberg, p 190 Physiology 522:165–175 Kirchfeld F, Boyle W 2000 Nature doctors: pioneers in Hodges P, Gandevia S 2000b Changes in intra- naturopathic medicine. Lancet Contraction of the human diaphragm during postural 338(8772):899–902 adjustments. News in Hodges P, Heijnen I, Gandevia S 2001 Postural activity Physiological Sciences 1:25–27 of the diaphragm is reduced in humans when Kollath W 1950 Uber die Mesotrophie, ihre Ursachen respiratory demand increases. Schriftenreihe fur Huey S, West S 1983 Hyperventilation: its relation to Ganzheitsmedizin Band 3. Journal of Abnormal Stuttgart Psychology 92:422–432 Kretchmer E 1921 Physique and character. 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Alternative Therapies in Health and Medicine Lindlahr Publishing, Chicago, p 16 11(4):44–52 Lindlahr H 1924 Iridiagnosis and other diagnostic Mesina J, Hampton D, Evans R et al 1998 Transient methods, 6th edn. Homotoxin-Journal Medicine 4:43–47 10:345–359 Newman Turner R 2000 Naturopathic medicine. Farrar, Letchworth Garden City Straus & Cudahy, New York Ng J, Richardson C, Kippers V, Parnianpour M 1998 Rhudy J, Meagher M 2000 Fear and anxiety: divergent Relationship between muscle fiber composition and effects on human pain thresholds. Journal of Orthopaedic relaxation intervention on sleep in critically ill patients. Biological Rolf I 1977 Structural integration: the re-creation of the Psychology 43(3):264 balanced human body. Viking Press, New York Noll D, Shores J, Gamber R et al 2000 Benefits of Salivon I, Polina N 2005 Constitution and reactivity of osteopathic manipulative treatment for hospitalized the organism. Modern Medicine of Australia Industrial Medicine 41(5):420–432 March:16–26 Shadduck R 1930 Body chemicals and their relationship Perlmutter D 1997 Parkinson’s disease – new to health. Townsend Letters Jan:48–50 Shanklin L 1950 The chemical types of people and their Pilkington K, Kirkwood G, Rampe H 2005 Yoga for foods. Williams & Wilkins, Baltimore Pryor J, Prasad S 2002 Physiotherapy for respiratory Southern Cross University, Naturopathic Nutrition and cardiac problems, 3rd edn. Cancer Nursing 28(5):390–398 100 Naturopathic Physical Medicine Tiker F, Gurakan B, Kilicdag H, Tarcan A 2004 Walsh M, Polus B 1998 A randomized placebo Dehydration: the main cause of fever in the first week controlled clinical trial on the efficacy of chiropractic of life. Watkins A (ed) 1997 Mind–body medicine: a clinician’s Plenum Press, New York guide to psycho-neuroimmunology. Immunopharmacology and Vodder’s manual lymph drainage, vol 1: basic course, Immunotoxicology 26(4):653–661 3rd edn. Massage Therapists Association of British relationship between iris constitution and angiotensin Columbia, Vancouver converting enzyme gene polymorphism. Simons 119 Asymmetry and range of motion issues 107 Is quality of movement palpable? This is no less the case in naturopathic Naturopathic assessment calls for physical medicine than in professions such as chiro- consideration of process 109 practic, osteopathy, massage and physical therapy, More examples of palpation accuracy where clinical decisions are frequently based on subjec- issues 109 tively gathered information, combined with objective evidence and the individual’s history and presenting The need for a wider evidence base 110 symptoms. Other variables 111 In manual medicine it is necessary for the practitioner Thoracic palpation accuracy 112 to be able to extract non-verbal information by means of Thoracic percussion: how not to conduct observation, touch and movement.
Neither good intention nor a profes- also communicate with the professionals willing sional level of understanding of medicine and to assume responsibility for pharmaceutical care malegra fxt 140mg overnight delivery erectile dysfunction test video. A large number and high frequency of drug order malegra fxt 140 mg mastercard erectile dysfunction in 40s,depending upon its pharmacokinetics and blood samples are usually needed to develop a pharmacodynamics buy cheap malegra fxt 140mg on-line erectile dysfunction doctor washington dc,has its own scientifically de- longitudinal record of dosing over an extended finable standard,and these are found from prop- period of time. For those few However,research experience suggests that pa- drugs that have exceptionally slow turnover (amio- tients rarely go to the length of opening the drug darone is an important example),periodic measure- package at the scheduled times but not actually ments of drug concentration in plasma may suffice, taking the medicine. To do this consistently,day and give comparable results to the use of low-dose, in and day out,throughout the whole course of slow-turnover markers,described below. The criteria for the measurement returned,unused tablets,cannot now be justified of compliance with electronic monitors in this case because of well-documented,high incidences of are: (a) the ratio of the number of administrations tablet dumping by poorly compliant patients observed to the number of intended doses; and (b) (Pullar et al 1989; Rudd et al 1989; Wakerhouse the mean intervals between the administrations (e. But what,precisely,are the advan- took 90% of the total doses with a mean interval tages of measuring compliance in the different between doses of 26 Æ 2 hours (h)). The study takes longer and is hard to manage,with relatively quick decision making Phase I Clinical Studies about whether or not to allow patients to continue in the study. However,subsequent normal volun- The other method is to enroll the patients into teer studies may examine the tolerability of repeat the study from the beginning and to follow their doses,even outside of a research facility,and the compliance during the whole trial. Furthermore, prospectively stratified in the statistical analysis, in studies of drug interactions,it is essential to using compliance as an independent variable (e. Again,run-in periods which would preselect pa- Data saved in electronic monitors may be trans- tients with good compliance could be used,but this ferred and collated in larger computers; the data moves away from the ordinary clinical situation. From these different analyses it should, for example,be possible to conclude whether,in a The central part of the compliance report is a large number of patients,good compliance im- quantitative and qualitative evaluation of the com- proves the efficacy of the product. Calendar compliance again,of course,entails additional displays should show the number of daily dose costs (the higher the number of patients,the longer units taken by the patient on ordinary monthly the duration of the trial),but will improve the qual- calendars. Understanding these tion of clinicians about the stages of treatment often subtle regimen behaviors may also help the when the patient is most likely to either forget his/ evaluation of reported effects (wanted and un- her tablets or deliberately discontinue treatment wanted). If desired,the distribution of medication cannot provide its full action,and the uncovered hours can also be charted,and charac- patient does not profit fully from treatment. These patients may unconsciously inexact,but they may form useful tools for feed- or consciously be responding to adverse events, back to the patient,illustrating his drug-taking too; in some cultures they may be reticent to tell behavior within the observation period,and their doctors about this,and in other situations allowing comparisons between observation periods patients may want to avoid being withdrawn from that can motivate an improvement in compliance. Non-compliance Calculation of the shortest and longest interval between two doses,the percentage of days with This patient takes the prescribed medication very correct number of doses taken,and the distribution irregularly. These limits are,for tients can be expected to have at least one such most drugs,undefined,although progress is being treatment-free phase within a 4 week treatment made with studies that define these limits. Health professionals have an import- Skewed Dosing ant role to play in helping patients comply properly and thus get the fullest possible benefit from their This uncommon type of patient continually prescribed medicines. The result is a high ardy and the costs of care rise,due to the needless fluctuation of the plasma levels and an inadequate addition of second or third agents,unnecessary therapeutic effect. This is especially true for the dose escalations,or repeated diagnostic tests to induction phase of preparations with a protracted ascertain the nature of a clinical problem that has onset of effect,but also for substances with a short been created simply by persistent,clinically unrec- half-life. Many studies have shown that patients undergo- ing long-term treatment in particular do not Skipped Dosing succeed in taking their medication correctly over a long period of time,and the scale of this problem The patient frequently omits a dose unit,e. The most frequent consequence scriptions filled then do not take the prescribed is therapeutic deficits occurring at intervals,which medication at all or do not take it correctly; 30% can lead to a considerable reduction of the overall of all prescriptions are used incorrectly and cause therapeutic success. Overall,it appears that there are four times The daily intake of the medication is not at a as many errors of dose omission than errors of regular,set time but with large temporal deviations excess dosing. Many patients fail to realize that The prevalence of suboptimal compliance in all it is important to take medication regularly and fields of chronic,ambulatory pharmacotherapy is that they can make hazardous mistakes in the well-established. The compliance of the patient is the Results to the Patient Enhances not only influenced by this array of different Compliance factors,but these factors are also under dynamic change. This step is and that the only way to compile a correct record wholly new,for prior efforts to improve compliance is to pay careful attention to the prescribed regimen have relied on patients (self-reported compliance), and link it closely to established routines in daily which is subject to errors due to imperfect memory, life. Despite the disciplinary aspect of the review,the If the results of treatment are unsatisfactory,the vast majority of patients regard the review as a following basic questions must be answered: logical extension of the interest of the prescribing physician in their care. Is the cause pharmacological,due to failure of tate communication between pharmacist and correctly taken drug to work as hoped,or is the doctor,increasing the attention to the patient cause due to inadequate compliance? Individualization of the treat- Many studies have clearly shown that the ment,adapting dose timings to the habits of the compliance of most patients deteriorates as treat- patient,and thus enhancing his compliance,can ment duration progresses. In the forefront is the treating physician, doctors often fail to recognize partial compliance who has to make sound decisions about the pre- or non-compliance in their patients. It seems highly unlikely Weber 1990; Matsui et al 1992; Matsuyama et al that a single type of electronically monitored pack- 1993; Cramer 1995; Feinstein 1990). Accurate understanding of compliance by ically monitored packages to emerge as the recog- physicians can reduce the probability that they will nized need for such information grows. Perhaps,with practice,the patient poor compliance will sooner or later attract serious develops a strong routine of drug intake,linked to attention from insurers and other payers for health some regular routine in his/her life. Prescription drugs,after all,are a principal the reminder device becomes superfluous,although interventional arm of modern medicine,and their it has served its purpose during the start-up phase actions are invariably dose-dependent. Stefan quences of missing an occasional dose of choles- Norell,a pioneer in this field,wrote in 1980: terol-lowering drug are,as far as anyone knows, negligible. Moderate±severe congestive heart failure radically change the medical and economic impli- appears to be one such situation (Kruse and Weber cations of compliance errors. When a strong routine past decade of research on patient compliance,it is exists,this device may be used then only spor- to put uppermost the question: non-responder or adically to check whether the patient is con- non-complier? An electronic dose organizer will help the eld- ing understanding of the medical and economic erly patients with multiple diseases and mul- advantages of correctly answering this basic ques- tiple medications,and may help them cope tion in situations where the wrong answer is very with the more complex regimens. That problem We should not forget,in this world of technol- has been solved by a variety of approaches,which ogy,that the patient should still come before,not integrate time-stamping,recording microcircuitry after,the technology. Technology by itself will not into a variety of drug packages,to record times solve all the problems created by erratic compli- when the package is used in the manner needed ance. Electronic professionals to identify,track,and potentially monitoring is an indirect method of measuring solve many of the issues created by partial and drug intake in ambulatory patients (Bond and poor compliance. It will not be helpful to over long periods of time,and has proved itself in have the patient forced into a world that he/she a variety of settings to be the superior method does not understand. Kruse W,Weber E (1990) Dynamics of drug regimen compli- Cramer J (1991) Overview of methods to measure and enhance anceÐits assessment by microprocessor-based monitoring. Van der Stichele R (1991) Measurement of patient compliance Urquhart J (1991) Therapeutic coverage: a parameter for ana- and the interpretation of randomized clinical trials. Adherence to oral tamoxifen: a comparison of patient self- Urquhart J (1994) Partial compliance in cardiovascular disease: report,pill counts,and microelectronic monitoring. The ethical aspects of this area of medicine are as Their relevance to pharmaceutical medicine is that: varied as the therapies themselves, and could be debated almost ad infinitum. Many patients in clinical trials will be using this short chapter is to alert pharmaceutical phys- complementary therapies (and we often omit icians to this topic, discuss the most commonly to ask on the case report form). There is no reason why comple- Even in the developed world, most good hospices mentary therapies may not be subject to evidence- will have complementary therapists on staff.
