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See also Dunfield (1996); Furnham and Bhagrath (1993); Furnham and Forey (1994); McGuire (1983); and Pawluch et al best cialis extra dosage 40mg impotence caused by medication. See Saks (1997b) and Coward (1989) for a critical assessment of the argument that holism is exclusive to alternative health care purchase cialis extra dosage 60mg otc erectile dysfunction prevents ejaculation in most cases. See also Fulder and Munro (1985); Furnham and Smith (1988); Glik (1988); Goldstein et al. What is understood to be alternative health varies dependent on who is giving meaning to the con- cept and in which social context that definition occurs. However, this does not mean that we can not discuss alternative health; rather, what is necessary is that we specify in what context meaning is invoked (Low 2001). In this case, the model of alternative health I discuss below is based on the subjective perspectives of Canadian lay users of alternative therapies. As I have demonstrated, the people who spoke with me sought out alternative health care to solve problems for which they found no redress in other quarters. While they were not shopping for an ideology when they ini- tially explored alternative therapies, once they began participating in alterna- tive approaches to health and healing, and through interaction with alternative practitioners and other users of alternative health care, they began to take on alternative ideologies of health. This belief system informs their alternative model of health, one that is made up of three conceptual categories: holism, balance, and control. Simply put, to be healthy is to be whole, which in turn is to be balanced, which in the end means being in, and subject to, control. ALTERNATIVE HEALTH AS PROCESS The people I spoke with see alternative health and alternative healing as concomitant ongoing processes. Health is not an achievable goal as such, but an ideal to which a lifelong healing journey takes one closer and closer. In other words, to be healthy is to be engaged in the process of healing. For example, Trudy said, “It was really more my own search for my own healing,” and Randal put it this way: 68 | Using Alternative Therapies: A Qualitative Analysis “I started my five-year search for this sort of healing, something that I’m con- stantly going to be working at. Nonetheless, these people do have a discernable model of health in mind, which they artic- ulate through the conceptual categories of holism, balance, and control. Holism Holism is the concept perhaps most often associated with alternative therapies (Furnham and Smith 1988; Lowenberg 1992; McGuire and Kantor 1987; Pawluch et al. Accordingly, it came as no surprise when all but three informants said they believe that an alternative model of health is a holistic model of health. For instance, Nora told me that alternative health “means that the person, their body, is functioning really well, in a natural way. Like many new age concepts, such as wellness or centred, the concept of holism is abstract and ambiguous. For instance, when I asked people to elaborate, most defined holism as the unity of mind, body, and spirit. Richard explained it this way: “Health is a state when you’re in line with your spiritual, physical and mental, and you’re pulling all your energies together. Balance Not only is alternative health a matter of the wholeness of the individual, but the person must also experience balance amongst the components of mind, body, and spirit (McGuire and Cantor 1987). Similarly, the people who participated in this research also emphasized the need for balance when discussing their beliefs about alternative health. For example, Trudy said, “I think ideally what well-being is, is a balance in heart, mind, body, and soul,” and Jane told me that “Health to me is not just physical, it’s mental and spiritual. If you’re a truly well person then all those things need to be balanced. For these informants, bal- ance is made up of two concepts: balance in the body and balance in the self. For almost half of the people who participated in this study, the concept of balance means balance within the bodily system. They said things such as, “My enzymes do change and you can tell when things start to get out of balance again” (Lucy); “If something happens you can re-balance yourself because there’s so many different systems in your body that you can balance it” (Richard); and “Having a balance in the body, it does make sense in a way to me” (Greg). Under certain alternative ideologies of health, illness is said to arise when the flow of bodily energy is disharmonious or has been dis- rupted (Glik 1988; O’Connor 1995). Likewise, for some of these people, balance in the body also means the unblocked flow of energy throughout the body.

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Simulated patients: these can also be used in very much the same way as for history taking cheap cialis extra dosage 60 mg without prescription erectile dysfunction on molly, with similar advantages generic 100mg cialis extra dosage with mastercard erectile dysfunction cures over the counter. However, the range of signs that can be simulated is limited, though not as much as you might think. For example, Barrows in his classic book showed that a wide range of neurological conditions can be simulated. In regard to other systems, conditions where pain is the main feature are particularly suitable. Also valuable are simulations of emergency situations such as perforation of a 83 viscus, myocardial infarction and subarachnoid haemorr- hage. Students can be trained to perform rapid assessment and acute management for conditions that otherwise would be impossible to programme. Simulated patient instructors are widely used, particularly in North America, to teach the pelvic examination. The main advantage of such an approach is that the instructor gives direct feedback on the students’ performance. The instructor is the only one who can say if the student has correctly palpated the ovaries and uterus or whether unnecessary discomfort has been created. The same approach has been used to teach rectal examinations in the male. Though not simulation, it is perhaps worthwhile remem- bering that self and peer examination is a valuable teaching technique for novice students. The learning of many basic manual skills is much better done in this way than using real patients. The use of instruments and basic equipment The student has to become competent with a variety of instruments and basic medical equipment other than the stethoscope. These include the opthalmoscope, the auroscope, the proctoscope, the laryngoscope, syringes, infusion apparatus, and endotracheal tubes. In most cases it is inappropriate for the first attempt to use them to be made on a patient, Students certainly appreciate the chance to practice their skills in a situation where they are not going to hurt a patient. TEACHING PRACTICAL AND LABORATORY CLASSES Practical and laboratory classes are often regarded as an essential component of science-based courses. However, they are becoming less prevalent in the medical curriculum as the pressures to free up time for other components in the course and decreasing resources force 84 a re-appraisal of their value. We have decided not to give detailed consideration to these important areas of teaching in this book but to refer those with responsibilities of this type to more specific resources. These are listed at the end of this chapter and include the non-medical version of our book entitled “A Handbook for Teachers in Universities and Colleges”. However, there is one particular type of practical teaching that we will mention, that is the research project, which is equally as likely to be managed by clinical teachers as by basic science teachers. Research projects Research projects have always held an important place in science-based courses. There is now a growing apprecia- tion of their value, albeit in a more limited and less technically demanding form, at various phases of the medical curriculum. Projects should provide the student with a real-life experience of research that is quite different to the more controlled laboratory exercises. They are strongly motivational to most students because of the high level of active participation, the close contact with super- visors and research staff, the lower emphasis on assess- ment and the greater degree of personal responsibility. Research projects can be undertaken individually, by groups, or by attachment to a research team in which the student accepts responsibility for certain aspects of an established project. It is recommended that departments using research projects should provide guidelines and training for supervisors. Several valuable publications are available that could be used or modified for this purpose (see Guided Reading at the end of this chapter). Alternative methods A combination of modern technology and interest in new teaching techniques has provided alternatives to the conventional approaches to practical work. Two that are now well established are computer-based methods and simulations. Computer-based methods The wide availability of computers and their everyday use in all areas of science and technology makes their integration into practical courses almost essential.

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Cross References Akinesia; Bradykinesia; Hypokinesia; Parkinsonism Klazomania Klazomania was the term applied to the motor and vocal tics seen as a sequel to encephalitis lethargica (von Economo’s disease) generic cialis extra dosage 60mg with mastercard erectile dysfunction natural treatment reviews, along with parkinsonism and oculogyric crises generic cialis extra dosage 200 mg on-line erectile dysfunction protocol download pdf. This observation helped to pro- mote the idea that tics were due to neurological disease rather than being psychogenic, for example in Gilles de la Tourette syndrome. Compulsory shouting (Benedek’s “klazomania”) associated with oculogyric spasm in chronic epidemic encephalitis. Acta Psychiatrica Scandinavica 1961; 36: 369-377 Cross References Coprolalia; Echolalia; Parakinesia, Parakinesis; Tic Kleptomania Kleptomania, a morbid impulse to steal, has been related to the obses- sive-compulsive spectrum of behaviors in patients with frontal lobe dysfunction. Journal of Neurology, Neurosurgery and Psychiatry 2001; 70: 279 (abstract) Cross References Frontal lobe syndromes Klüver-Bucy Syndrome The Klüver-Bucy syndrome consists of a variety of neurobehavioral changes, originally observed following bilateral temporal lobectomy (especially anterior tip) in monkeys, but subsequently described - 179 - K Knee Tremor in man. The characteristic features, some or all of which may be present, are: Visual agnosia (e. Journal of Neurology, Neurosurgery and Psychiatry 1993; 56: 311-313 Klüver H, Bucy P. Cross References Apathy; Hypermetamorphosis; Hyperorality; Hyperphagia; Hyper- sexuality; Visual agnosia Knee Tremor A characteristic tremor of the patellae, sometimes known as knee bob- bing, juddering, or quivering, may be seen in primary orthostatic tremor (POT; “shaky legs syndrome”). It is due to rapid rhythmic con- tractions of the leg muscles on standing, which dampen or subside on walking, leaning against a wall, or being lifted off the ground, with dis- appearance of the knee tremor; hence this is a task-specific tremor. Auscultation with the diaphragm of a stethoscope over the lower limb muscles reveals a regular thumping sound, likened to the sound of a distant helicopter. EMG studies show pathognomonic synchronous activity in the leg muscles with a frequency of 14-18Hz, thought to be generated by a central oscillator (peripheral loading does not alter tremor frequency). A number of drugs may be helpful in POT, including phenobarbi- tone, primidone, clonazepam, and levodopa, but not propranolol (cf. Archives of Neurology 1984; 41: 880-881 - 180 - Kyphoscoliosis K Brown P. Lancet 1995; 346: 306-307 Cross References Tremor Körber-Salus-Elschnig Syndrome - see NYSTAGMUS Kyphoscoliosis Kyphoscoliosis is twisting of the spinal column in both the anteropos- terior (kyphosis) and lateral (scoliosis) planes. Although such defor- mity is often primary or idiopathic, thus falling within the orthopedic field of expertise, it may also be a consequence of neurological disease which causes weakness of paraspinal muscles. Recognized neurological associations of kyphoscoliosis and scol- iosis include: Chiari I malformation, syringomyelia Myelopathy (cause or effect? Skeletal disease, such as achon- droplasia, is more likely to be associated with myelopathy than idiopathic scoliosis) Cerebral palsy Friedreich’s ataxia Neurofibromatosis Hereditary motor and sensory neuropathies Spinal muscular atrophies Myopathies, e. Some degree of scoliosis occurs in virtually all patients suffering from paralytic poliomyelitis before the pubertal growth spurt. Cross References Camptocormia; Stiffness - 181 - L Lagophthalmos Lagophthalmos is an inability to close the eyelid in a peripheral facial (VII) nerve palsy, with partial opening of the palpebral fissure. A sim- ilar phenomenon may be observed with aberrant regeneration of the oculomotor nerve, thought to be due to co-contraction of the levator palpebrae superioris and superior rectus muscles during Bell’s phe- nomenon. Cross References Bell’s palsy; Bell’s phenomenon; Facial paresis Lambert’s Sign Lambert’s sign is gradual increase in force over a few seconds when a patient with Lambert-Eaton myasthenic syndrome is asked to squeeze the examiner’s hand as hard as possible, reflecting increased power with sustained exercise. Cross References Facilitation Lasègue’s Sign Lasègue’s sign is pain along the course of the sciatic nerve induced by stretching of the nerve, achieved by flexing the thigh at the hip while the leg is extended at the knee (“straight leg raising”). This is similar to the maneuver used in Kernig’s sign (gradual extension of knee with thigh flexed at hip). Both indicate irritation of the lower lumbosacral nerve roots and/or meninges. The test may be positive with disc pro- trusion, intraspinal tumor, or inflammatory radiculopathy. Pain may be aggravated or elicited sooner using Bragard’s test, dorsiflexing the foot while raising the leg thus increasing sciatic nerve stretch, or Neri’s test, flexing the neck to bring the head on to the chest, indicating dural irritation. A positive straight leg raising test is reported to be a sensitive indi- cator of nerve root irritation, proving positive in 95% of those with sur- gically proven disc herniation. London: Imperial College Press, 2003: 362-364 Cross References Femoral stretch test; Kernig’s sign - 182 - Laterocollis L Lateral Medullary Syndrome The lateral medullary syndrome (or Wallenberg’s syndrome, after the neurologist who described it in 1895) results from damage (usually infarction) of the posterolateral medulla with or without involvement of the inferior cerebellum, producing the following clinical features: ● Nausea, vomiting, vertigo, oscillopsia (involvement of vestibular nuclei) ● Contralateral hypoalgesia, thermoanesthesia (spinothalamic tract) ● Ipsilateral facial hypoalgesia, thermoanesthesia, + facial pain (trigeminal spinal nucleus and tract) ● Horner’s syndrome (descending sympathetic tract), +/− ipsilateral hypohidrosis of the body ● Ipsilateral ataxia of limbs (olivocerebellar/spinocerebellar fibers, inferior cerebellum) ● Dysphagia, dysphonia, impaired gag reflex ● +/− eye movement disorders, including nystagmus, abnormalities of ocular alignment (skew deviation, ocular tilt reaction, environ- mental tilt), smooth pursuit and gaze holding, and saccades (lat- eropulsion) ● +/− hiccups (singultus); loss of sneezing. Infarction due to vertebral artery occlusion (occasionally poste- rior inferior cerebellar artery) or dissection is the most common cause of lateral medullary syndrome, although tumor, demyelination, and trauma are also recognized causes.

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