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Aim: Outcome: To teach a skill Reader learns a skill How will your article help your reader learn a skill? You might want to give a sequence of instructions order singulair 10mg line asthma 24, explanations and practical examples purchase singulair pills in toronto asthmatic bronchitis 10. To share innovative or best prac- Reader is able to apply principles or tice model to own practice Check that your approach is innovative by researching information about cur­ rent practices purchase 5mg singulair with visa asthma definition nz. Have you proof that your model benefits your clients, service or organisation? To explain or provide an Reader increases knowledge and un- update on theory derstanding Engage your reader with the material by suggesting ways of following up the­ ory through independent study, real life experiences and by providing self-assessment exercises. Most journals will prefer that the theoretical aspects of your article are related to clinical practice. To challenge or stimulate debate Reader thinks, reflects or challenges back! Choose a controversial issue, challenge a traditional belief or take an unusual perspective on a topic. However, remember to support your arguments with facts, figures and examples. To disseminate research Reader increases knowledge of evi­ dence base and applies findings to practice Journals will be particularly interested in the results of your research and their implications for clinical practice. For example, you might want to write about the implications of a new piece of legislation for clinical practice. To entertain Reader enjoys Some journals accept items that are purely for the entertainment of the reader rather than for any academic or professional reason. A humorous piece, a collec­ tion of anecdotes or a historical piece, are just some examples. Once you are sure of this yourself it will be much easier to communicate it to your reader. Redraft it until you think you have a clear and succinct statement, for example, ‘to explain the signs and symptoms of depression, its causes, traditional classifications and manage­ ment options’. Answering these questions is particularly important if you are writing an article for members of another discipline. For example, an occupational therapist writing an article on poor hand–eye co-ordination for teachers will need to think carefully about the knowledge base of his or her readers. Add your target audience to your statement of purpose, for example, ‘explain to district nurses the signs and symptoms of depression, its causes, traditional classifications and management options’. Decide on the content Your statement of purpose or your objective forms the starting point for drafting the content of your article. Brainstorming using the keywords from your objective is a useful way of developing ideas. It may help this JOURNAL ARTICLES 281 process if you set yourself a series of questions. In the above example, you might want to ask some of the following questions. The key areas or concepts identified through this process will form your section headings. Even if these are not used as titles in the final article, they can act as markers for how you will organise your material. Creating a structure Forming a structure early on in your planning will help in refining your search for information. Here are some examples of different formats for presenting material in articles. Research papers Research articles or research papers are always written using the traditional scientific approach discussed in Chapter 13 ‘Research Projects’. An abstract consists of a short paragraph that summarises the research paper for the reader. Most are 200 to 250 words in length, although some journals may accept longer ones. A reader can use the abstract to quickly make a decision about whether the research findings are of relevance to him or her and therefore worth reading. On a database, an abstract may be the only information available to the searcher on the contents of a paper. Abstracts contain: ° a statement about the purpose of your research ° your hypothesis or your research question ° a description of your research design ° your rationale for choosing that design ° a statement about your methods and procedures that includes details of any special equipment and the selection and number of subjects ° a description of your data analysis ° your major findings ° your conclusions 282 WRITING SKILLS IN PRACTICE ° implications for further research or applications to practice. The organisation of the abstract very much reflects the structure of the re­ search paper, the standard format being: ° Introduction (this contains information about relevant literature, the purpose and rationale for your research and your hypothesis) ° Methods ° Results ° Discussion of results ° Conclusion. Other formats Example of a literature review: ° Introduction (reason for or objectives in conducting the review) ° Rationale for literature selection ° Critical analysis of the literature ° Results of your review ° Conclusions ° Implications for further research ° Applications to clinical practice. Example of a clinical update on skin diseases: ° Incidence of skin diseases ° Description of skin ° Effect on client (psychological aspects, physical factors, quality of life) ° Assessment (including a description of different skin diseases) ° Treatment ° Summary (a position statement). Example of a debate on clinical supervision: ° Introduction (definition of clinical supervision, statement on the purpose and terms of reference of the article) JOURNAL ARTICLES 283 ° Overview of the models of supervision ° Comparison of models of delivery ° Discussion of the benefits of supervision (supported by references to research). Example of a continuing professional development article on ‘depression’: ° Statement about the aims and intended learning outcomes for the reader, for example: ° describe the signs and symptoms of depression ° list common causes of depression ° differentiate between the four classifications of depression ° describe four treatments for depression ° Introduction ° Definition of depression ° Common causes ° Signs and symptoms ° Classification of depression ° Treatments ° Conclusion (applications to practice). A teaching article of this sort might suggest other complementary forms of study. In the above example, the reader might be asked to reflect on his or her own experience of depression, complete a self-assessment question­ naire on the basic facts, and make a list of symptoms noted in a client diag­ nosed with depression. A well-structured article will be organised and logical, and will only include information that is necessary to meet your aims. Researching your article Your next step is to carry out a thorough literature review of your intended subject area. See Chapter 7 ‘Writing As an Aid to Learning’ for information on searches. Writing your draft Your approach and style will very much depend on your readership. When you are writing an article for colleagues within your own discipline you 284 WRITING SKILLS IN PRACTICE will be able to assume a certain knowledge base. It will be appropriate to use well-known terminology without the need for extensive explanations. However, other groups of readers, despite being a professional audience, will not always have a specialist knowledge of your subject area. You will need to take this into account when introducing information and in your use of terminology. Be careful not to make your subject area too wide, as you must comply with the word limit set by the journal. Set yourself limits so that you are able to deal effectively with the information within the constraints of a short article. Constantly refer back to your objective to keep you on track with your task. Double-check the accuracy of facts and figures, particular the dosage for drugs. Continually monitor events so that your information remains as up-to-date as possible.

Physical therapists order 10 mg singulair free shipping asthma treatment by zubaida tariq, or PTs buy singulair with mastercard asthma definition spirometry, are health care professionals who evalu- ate and treat people with health problems resulting from injury or disease 5 mg singulair asthma symptoms baby coughing. PTs assess joint motion, muscle strength and endurance, function of heart and lungs, and performance of activities required in daily living, among other responsibilities. Treatment includes therapeutic exercise, cardiovascular endurance training, and training in activities of daily living. The median salary for a physical therapist is $51,000 de- pending on position, years of experience, degree of education, geo- graphic location, and practice setting. Physical therapists have developed an extensive battery of diagnostic as- sessment tools and therapeutic modalities. According to the 2001 Guide to Physical Therapist Practice, over 700 pages with meticulous detail, physical therapists follow “an established theoretical and scientific base” (S13). As did physical medicine and rehabilitation, physical therapy emerged from World War I and efforts to rehabilitate injured veterans. Physical therapy today is or- ganized around the “disablement model”: the effect of acute and chronic con- ditions on specific body systems, on performance of the whole person, and on people’s ability to perform desired and expected roles in society. Medical diag- noses connect directly to the disablement model since “disease and injury often may predict the range and severity of impairments at the system level” (S21). The disablement model includes four interacting domains: pathology and pathophysiology (diseases, disorders, or conditions); impairments (abnor- malities of tissues, organs, or body systems); functional limitations (difficulties performing physical actions, tasks, or activities); and disability (difficulties with self-care, home management, work or school, and community and leisure roles within the person’s social, cultural, and physical environments). The Guide to Physical Therapist Practice organizes evaluations of “gait, locomotion, and balance” around these four domains, defining gait as “the manner in which a person walks, characterized by rhythm, cadence, step, stride, and speed” (S64). In addition to eliciting detailed histories from pa- tients and simply observing them walk (with and without assistive devices), physical therapists employ various tools for measuring gait, such as dy- namometers, force platforms, goniometers, motion analysis systems, and videotaping. For arthritis patients, for example, physical therapists would observe gait, assess the mobility and integrity of joints, evaluate range of motion and pain, and query patients about the implications of their physi- cal limitations for daily activities (Cwynar and McNerney 1999). When asked their goals for a patient’s first visit, the seven focus group participants differed somewhat, depending on whether they practice in clinics or do home care. I try to get primary measurements addressing strength and tone and standing and balance—try to get an idea of what’s going on. I try to figure that out based on observation, timing, Physical and Occupational Therapy / 167 measuring distance, and then looking at strength and range of motion, try- ing to assess what’s limiting their ability to walk fast or far or safely. If somebody’s sitting in a chair telling you where things are rather than getting up and showing you, that’s a clue that things aren’t well. That would entail getting in and out of the elevator, reaching for the elevator buttons, walking the dis- tance to the hairdresser, getting her hair done, and then walking back. Anyway, we incorporated the pa- tient’s goals into the treatment plan for the long term. Louanne Mawby stayed in a rehabilitation hospital for three months following her stroke in her early forties: It was rough. Today, less than 5 percent of physical therapists work in rehabilitation hospitals (APTA 2001), and health insurers have cut the length of these 168 / Physical and Occupational Therapy hospitalizations dramatically. Decreasing reimbursement has stimulated interest in interventions that help people care for themselves. Certainly, physical therapists still actively administer some therapies, with patients as largely passive recipients: for instance, treatment for low-back pain includes ultrasound or microwave diathermy for deep heating, ice massage or vapocoolant sprays for thera- peutic cold, and even low-power cold laser treatments. Research shows that none of these interventions improves low-back pain in the short or long term. But these “passive modalities” remain popular for several reasons: “the patient’s expectations of traditional physical therapy, the laying of hands as therapists gives satisfaction... The demands of living daily with chronic conditions eventually prompt many people to take over managing their own care. The vast majority of persons with walking difficulties are not hospitalized for their underlying chronic conditions or are hospitalized only in later stages (e. Therapy must fit into their daily lives, so that it “en- courages functional independence, emphasizes patient/client-related in- struction, and promotes proactive, wellness-oriented lifestyles” (Guides to Physical Therapist Practice 2001, S97). Obviously, individual people have different needs and physical capabilities. He’s never going to im- prove, but we need PT to keep him at a stable functional status, to move his legs, get him out of the wheelchair. He spends a little bit of the day out of the wheelchair, which he never would have if he hadn’t gotten physical therapy. Other exercise programs involve people independently following phys- ical therapists’ instructions. Specific exercise regimens vary, such as to im- prove aerobic capacity or endurance or to enhance balance, coordination, flexibility, and range of motion. Depending on people’s needs, an explicit goal of exercise training is preventing falls or minimizing fall-related in- juries. Pool-based exercise programs use the buoyancy of water to ease people’s movements and support weight. Although physicians typically must write prescriptions for these devices to be reim- bursed, physical therapists often decide which equipment is appropriate, determine its exact specifications, and train people to use equipment prop- erly. Motivating change in people’s daily lives loomed large in the physical therapy focus group. Therapists, however, recognize their limitations in changing people’s lifestyles and physical environments. From the beginning, I spend a lot of time telling them, ‘I’m going to try to help you figure out why you’re falling, but then it’s up to you. This is what I think needs to be done; however, the ball’s in your court. If they do make this change, they’re probably going to have to change again. You can show them that they’re safer using a piece of equipment, for example, but they don’t see the benefit of it long-term. We had a group exercise program and tried to convince this wonderful woman who’s in her late eighties that she could do more if she bought a pair of pants. The concept of sweating and getting down on the floor and stretch- ing is difficult for some older people. Now we have a whole new group get- ting older that is going to be very different. They could be standing at their sink and washing their dishes and doing some exercise. Occupational therapy practitioners work with people of all ages who, because of illness, injury, or developmental or psychological impair- ment, need specialized assistance in learning skills to enable them to lead independent, productive, and satisfying lives. Occupational therapy can prevent injury or the worsening of ex- isting conditions or disabilities and it promotes independent func- tioning in individuals who may otherwise require institutionaliza- tion or other long-term care.

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By connecting the condition and specifics she was looking for with the word AND (for example buy singulair 5mg visa asthma treatment in jiva ayurveda, lupus AND rash cheap singulair 10mg on-line asthma definition medical dictionary, lupus AND etiology order singulair 4mg on line asthmatic bronchitis in children, lupus AND birth control pills), more relevant sites came up. If you use multiword phrases, place quotation marks around those phrases as well—certain databases have their own rules that must be followed. She was even able to determine that it was not a coincidence that her symptoms started when she began using birth control pills. Ayeesha wasted no time in going directly to a specialist in this area to verify the diagnosis and obtain the appropriate treatment. They discovered that 78 percent of the sites were authored by commercial organizations and 52. They concluded that consumers searching the Web for health information are likely to encounter consumer-oriented CAM advertising, which may not be supported by scientific fact. Is the sponsor an objec- tive source such as a nonprofit organization (like the Lupus Founda- tion or the American Heart Association), university, or government agency? Was the study published in a peer-reviewed journal, or is it simply being touted in a company’s press release? Pharmaceutical com- panies legitimately perform research as part of their development of new medicines. However, just because a site is a commercial one does not mean it doesn’t contain valuable and reliable information. Many for-profit hospitals and clinics have sites that advertise their facilities but also provide excellent information such as research results and treat- ment protocols. Look for sources on the Internet that list references to research studies or published books. Check the references periodically to make sure that they have not been made up by the author of the site. In our experience, most mystery malady patients have great suc- cess with “. Therefore, he directly went to a website for a certain uni- versity known for its excellent medical teaching facilities. When he clicked on the A-Z Health Encyclopedia and typed in fatigue he was led to the diagnosis of sleep apnea. He knew then he had to make an appointment at a sleep disorder clinic where this diagnosis was later confirmed and treated. Some sites volunteer to be inspected and monitored so they can receive a seal attesting to the accu- racy of the information they contain. Health on the Net (HON) is an organization that monitors health websites to ensure they are secure, confidential, and backed by legiti- mate sources. To validate the button’s authenticity, try clicking on it to see if it takes you to the HON website. A seal from the Utilization Review Accreditation Council (URAC) indicates the site has met URAC’s fourteen principles and fifty-three specific standards, including the use of credible sources, the ongoing updating of material, and security to ensure that no personal informa- tion can be revealed. To verify a site’s seal of approval, search URAC’s online directory at urac. The council does a full review of each accredited website once a year and conducts periodic reviews to verify that it remains compliant with the standards. We do not mean to imply that sites without seals of approval are necessarily inaccurate or dishonest. Commercial sites—those dot- coms and dot-nets—may seek seals to validate their legitimacy, whereas sites from respected nonprofit organizations, institutions, and govern- ment agencies may not feel the need for such validation. Abstracts of scientifically sound studies will include terms such as double-blind, ran- domized, case-controlled, or placebo-controlled. These terms indicate that the information is neither observational nor anecdotal. Anecdotal information and chat rooms can be helpful in pointing you in a spe- cific direction; they should not be relied on for factual data. Most health top- ics you might be searching for will have multiple rather than single studies. Be sure to read several studies on the same topic before taking the first one you find at face value. If several studies duplicate the same results, these results can probably be trusted. Medical Detective Work on the Internet 83 A single study could have turned out to be a dead end that no one continued to research, or it could be so new that the results haven’t yet been duplicated. So if it’s a single study, you can probably assume the results are not yet accepted by the scientific community. PubMed is a premier Internet site maintained by the National Library of Medicine and the National Center for Biotechnology Information. It allows public access to the NLM’s MEDLINE database, which houses articles from forty-five hundred journals from as far back as 1966. If you are unable to find a study mentioned there, the chances are better than not that the study was not published in a peer-reviewed journal. However, it is not essential for you to read the complete arti- cle or abstract. They (and you) need to read only the title and the conclusion section, which usu- ally contains short amounts of text. Possible Pitfalls in Internet Detective Work There are any number of problems in doing detective work on the Internet, which is why we always urge you to check the information you have found with your physician. Be careful of the following: E-Mailing a Physician Since it is difficult to understand the scientific language found in many med- ical articles, you can e-mail a physician on his or her website if this service is offered. But be aware that you may not receive an answer or you may get one that is not specific enough for you. Attorneys and malpractice insur- ance carriers have warned physicians about the amount of information they should give over the Internet. These physicians may be exposing themselves to liability, especially if the query is from someone who is not already one of their patients. The reason for this is because when a doctor responds to specific ques- tions, he or she creates a doctor-patient relationship. The physician now has a duty to this patient regardless of whether or not the patient has been seen personally in an office and regardless of whether or not monies have been exchanged. Keeping this in mind, you are highly unlikely to receive much help from e-mailing a physician or website for specific information about your particular condition. Remember, one of the qualities you examined in choosing your doctor (see Chapter 4) was your comfort level in bringing new information to him or her, so this a good time to exercise that prerogative. However, rare as it may be, you might get lucky using Internet con- sultation. For example, Steve, a forty-five-year-old independent contractor who was self-employed, thought that he was having chest pain from heart disease. He was afraid to go to the doctor because he didn’t have insurance to cover the office visit and expensive tests the doctor would probably want to order. By using the Internet, Steve was able to communicate his symp- toms to a physician at allexperts.

However buy discount singulair on line asthma symptoms diagnosis, their cable was not fastened by a crimping technique; it was fastened by knotting order singulair 4 mg without a prescription asthma prevalence definition. Causes of Failure There are a number of reasons why monofilament wire can fail as a cerclage material order singulair online from canada allergic asthma medical definition. Kinking is more likely to occur, and stress risers can easily be produced at the time of fastening of the wire with the various knotting and twisting techniques. However, failure of multifilament cable systems can still occur and could be the result of poor surgical technique (especially inadequate maintenance of instruments), biological factors such as poor bone bed (sometimes the trochanter is reattached to metal or cement rather than bone), and failure of the cerclage system itself. What are the contributory factors resulting in failure of a multifilament cerclage system? Tension There is always controversy as to whether tension in a cerclage system should be measured. Personally, I believe that measuring tension is of no value if the strength of the bone is unknown. The cerclage system could even cut into the bone while attempting to reach a certain level of tension. I would rather rely on my own feeling in judging the amount of tension required—rather like putting a screw into bone when one can sense that if you tighten it any more it will strip the bone. The ideal level of initial tension is therefore dependent on the strength of the bone and on tensioning to below the level at which the cable will cut through it. The other important consideration is that there is a definite tendency to overten- sion cables. Cable is strong and the tensioners are powerful instruments, and thus it is very easy for the surgeon to overtension a cerclage construct. It is also important to realize that a high initial tension will leave less reserve strength in the cable. Figure 3 illustrates a load-deflection curve of a cerclage construct with an arbitrary level of pretension. The reserve strength of this construct is the difference between The Dall–Miles Cable System 243 Fig. Load-deflection curve of a cerclage construct with an arbitrary level of pretension Fig. Tension release in a cerclage construct around a steel pipe versus one around the porcine femur over a period of time the yield point and the level of pretension. In other words, the higher the level of pretension, the lower the reserve strength. Furthermore, it should be realized that in tensioning cerclage constructs, after fastening there is always some loss of tension due to the viscoelastic properties of bone (Fig. For example, it often occurs at knots or twists in monofilament wire or where kinking has occurred. It is particularly inclined to occur at acute exit or entry points into the bone or fixation devices, or at sharp corners producing stress risers in both monofilament wires and multifilament cables (Fig. It is important to realize that in the clinical situation there is always cyclic loading of a cerclage construct as it is subjected to dynamic forces. Failure of fixation of the greater trochanter frequently occurs at stress risers such as acute exit points from bone. It is interesting that there have been no defined standards for fatigue testing of wire or cable. The first protocol for testing multifilament cables was devel- oped in 1994 by Schmotzer (Fig. It is a well known fact that fatigue strength is related to the toughness of the mate- rial (Fig. Changes in design and manufacturing technique can result in huge gains in fatigue strength for a small sacrifice in tensile strength (Fig. As a result of these studies and through changes in filament design and manufacturing techniques, Stryker has been able to substantially increase the fatigue strength of the Dall–Miles cables. A1/B1: thin black-hatched curve represents low-toughness material; A2/B2: thick black-hatched curve repre- sents high-toughness material. A1 and A2 represent the yield points; B1 and B2 represent the ultimate tensile strength; cross-hatched areas represent the material toughness. Significant gains in fatigue strength can be obtained for a small sacrifice in tensile strength. Tensile performance represented by solid columns; fatigue performance represented by hatched columns The Dall–Miles Cable System 247 approaches and should be combined with distal cerclage cables in these approaches. A trochanter grip plate is currently being developed to be used for extended trochan- teric osteotomy fixation. Allograft Fixation Cortical allografts have proved to be very useful in a variety of situations in revision total hip arthroplasty. Prophylactically, these are particularly indicated when severe cortical thinning has occurred, a cortical window or perforation is present, and in any situation where there is a significant risk of fracture. A longer stem should always be considered in addition to supportive allograft struts. They can also be used to support very thin femoral cortices when impaction grafting is the method of choice in revision arthroplasties. The cerclage cable can be applied around supporting mesh and/or supporting cortical allograft struts. Periprosthetic Fracture Fixation in Total Hip Arthroplasty Cable cerclage is particularly useful for primary or adjunctive fixation of peripros- thetic fractures. Intraoperative proximal fractures can be well controlled with cerclage cable. If a postoperative fracture is present in the proximal or middle stem regions and the stem is well fixed, cortical allograft struts fixed with cerclage cables can be used in the fixation of selected fractures. Seventeen patients united their fractures and returned to their preoperative functional status at an average of 4. Distal fractures can be controlled with a Dall–Miles plate, cerclage cables, and screws, but in the majority of cases additional cortical allograft struts should be used to strengthen the construct. Periprosthetic fractures associated with loose stems require revision of the stem (frequently to a long stem femoral component) with or without supportive cortical allograft struts (Fig. Treatment of Fractures Cerclage cables can be useful in a variety of situations, usually as an augmentation to fixation of primary fractures. The fixation of proximal femoral fractures can sometimes usefully be augmented by cerclage cable. This use could apply to head– neck replacements, gamma nails, and dynamic hip screws. Distal femoral fractures fixed with Zichel nails or blade-plates can also be aug- mented in certain cases with cerclage cables. The X-ray on the right shows appearance at 1 year postoperative a b Fig.