Little Charlie

Posted on Posted in Brain Science, Continuing Education, Pain, Psychology

By Mary O’Brien, M.D.

Do you know what “Mitochondrial Deficiency Syndrome” is?  Most people don’t.  Unfortunately, that doesn’t stop them from weighing in on the case of little Charlie Gard.  Charlie is an 11-month old baby with a rare and devastating genetic disorder that precludes normal functioning of mitochondria.  Mitochondria are intracellular organelles that generate ATP (adenosine triphosphate).  In essence, ATP represents energy at the cellular level.  Without ATP, cells, especially brain and muscle cells, cannot function.  The most sensitive and vulnerable cells in the body are those of the cerebral cortex.  Little Charlie cannot see or hear or move or swallow or vocalize or think.  No one can know with absolute certainty, but he probably cannot “feel” anything at this point.  The word tragic is utterly inadequate.

The global media frenzy surrounding this heartbreaking situation is revealing and deeply disturbing.  Controversy sells, and unfortunately, the less people know, the more adamant and emotional they often become.  Those of us who have dealt with life and death situations for decades can help by elevating the level of conversation.  Some timeless principles are useful:

  • Embrace humility.  Never be afraid to say “I don’t know enough about this situation to have a well-informed opinion.” That would be refreshing.
  • Exercise the intellectual discipline to learn the facts involved.  In medicine, every patient is unique.  Arguments for or against life support or experimental treatments are pointless absent actual knowledge.
  • Resist the temptation to become emotional.  Unbridled emotions cause far more problems than they solve.  Try to be the voice of reason.
  • Try not to confuse or conflate the issues.  People in nearly every media outlet have tried to make the case about socialized medicine, cost control, parental rights, the British court system, the European Union, or theology.  The case of Charles Gard is about medical ethics.
  • Focus on principles, not personalities.  There is a colossal difference between saving life and prolonging death.  Remember, there is never a moral imperative to render futile care.

Primum non nocere.  (First, do no harm.)  There’s a reason that Solomon prayed for wisdom.

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Arthritis and Diet

Posted on Posted in Continuing Education, Elder Care, Homestudy, Pain, Seminars, Webinars

older-black-woman-rubbing-her-hands-arthritisThere are more than 100 different types of arthritis, and, therefore, no single diet will work for every person with arthritis.  However, studies have found that green tea, green leafy vegetables, dried plums, and kiwi fruit are all vitamin-rich and have powerful antioxidant properties.  Diets which include large quantities of fruits and cruciferous vegetables have been shown to have a beneficial effect on preventing the development of rheumatoid arthritis.  In addition, it is clear that carrying extra weight can put significant stress on the joints, and even a small reduction in weight can have an effect on the severity of arthritis symptoms.  Studies have shown that losing weight can significantly ameliorate the effects of osteoarthritis.  Significant weight gain prior to age 35 — as well as excessive alcohol consumption — has been linked to the development of gout.

Other contributing factors are certain foods and nutritional supplements (vitamins, minerals, and omega-3 fatty acids) which may play a role in preventing and reducing symptoms in some types of arthritis, such as gout, osteoporosis, osteoarthritis, rheumatoid arthritis (RA), and reactive arthritis.  Fish oil, particularly when ingested in conjunction with a diet low in arachidonic acid, reduces inflammation in some patients with rheumatoid arthritis.   Regular intake of fish has been shown to have a beneficial effect.  Consumption of excessive dietary fat, however, appears to exacerbate arthritis symptoms.

WEIGHT LOSS AND THE ARTHRITIS PATIENT

Weight loss for overweight arthritis patients is very important for several reasons.  First, as mentioned previously, loss of even a few pounds can significantly reduce stress on weight-bearing joints.   Research demonstrates that exercise and combined weight loss — as well as exercise regimens — result in decreased pain and disability and increased performance levels in patients with osteoarthritis.  Biomechanical data suggest that exercise in combination with diet may also result in improved gait when compared with exercise alone. Secondly, patients of all ages who have arthritis are much healthier, have an improved sense of well-being, and are less likely to suffer arthritis-related depression when they follow a nutritious, well-balanced diet.  The Arthritis Foundation recommends following a balanced diet that includes plenty of fruit, vegetables, and whole-grain products, while limiting consumption of sugar, salt, and saturated fat (i.e., a diet low in fat, high in fiber, and low in sugar).

By Mary O’Brien, MD

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Neck Pain: An Introduction

Posted on Posted in Continuing Education, Elder Care, Homestudy, Pain, Seminars, Webinars

Rear view of a young man holding her neck in pain, isolated on white background, monochrome photo with red as a symbol for the hardening

By Raj Hullon, MD

Almost everyone has experienced neck pain of some sort during his or her lifetime — and for good reason.  One of the most common causes of such pain is poor posture.  Simple activities such as reading, especially in bed — or sleeping on a pillow that may either be too low or too high — can cause neck pain.  Other activities that can cause neck pain include bending over a desk for hours, maintaining poor posture while watching TV, and positioning a computer monitor either too high or too low.  The key is always to maintain the neck as close to a neutral position as possible.

The best medical care, however, begins with a crucial question:  What is the most serious problem this could be?  Neck pain can be referred from multiple anatomical structures as a result of developmental processes in the embryonic stage.  Serious cardiovascular, neurologic, infectious, or neoplastic etiologies must be considered before attention is focused on common musculoskeletal disorders.

Chronic neck pain is prevalent in Western societies, with about 15 percent of women and 10 percent of men suffering from it at any given time.  People with physically demanding jobs requiring neck flexion and awkward lifting are at high risk of developing chronic neck pain.  It is also common among health care professionals, particularly affecting nurses who are constantly involved in handling tasks that involve reaching, lifting, and pulling.  Dental professionals who work long hours bending over their patients also suffer from neck pain because of postural demands.

The pain is often muscular or ligamentous in origin and is usually self-limited although the pain can be persistent.  Pain is transmitted through nerve endings in the various ligaments and muscles of the neck, vertebral joints, and the outer layer of the intervertebral discs.  When these structures are irritated, strained, or inflamed, pain is felt in the back of the neck, may spread toward the shoulders, and is commonly felt between the shoulder blades.

The natural healing processes result in improvement in almost all cases.  In fact, the pain from serious neck injuries such as fractures, dislocations, and most cervical spine surgeries often resolves after a few weeks or months.  There is usually little if any correlation between neck pain and the degenerative changes that are commonly seen on X-rays.

Neck strain or sprain is the most common type of injury to motor vehicle occupants treated in U.S. hospital emergency departments.  Whiplash injuries can be serious in certain situations.  Severe damage to the spinal cord can be fatal.

Sports and athletics are also common sources of injury to the neck region and should be a particular concern for the younger adult population.

Another common offender is carrying unbalanced loads, such as a heavy briefcase, luggage, or a shopping bag. A careful history is often required to identify such factors as playing a role in neck and shoulder pain.

 

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About Systemic Lupus Erythematosus (SLE)

Posted on Posted in Continuing Education, Elder Care, Homestudy, Pain, Seminars, Webinars

bhmkclteeodsgq5wrqwaSystemic lupus erythematosus (SLE) is an autoimmune disease that can cause damage to the heart, lungs, kidneys, joints, skin, brain, and blood vessels.   It is characterized by flare-ups, and symptoms, ranging from mild to severe, including extreme fatigue, chest pain, anemia, swelling in legs and near the eyes, painful joints, fever, skin rashes, hair loss, and kidney problems.

At least 1.5 million Americans suffer from lupus.  The ratio of female to male is 9:1 according to the Lupus Foundation of America.   African-American women are far more likely to be affected than are Caucasian women.   Recent research points to a strong genetic role, but environmental and hormonal factors seem to be involved in lupus as well.

Diagnosis can be difficult and may be delayed because the onset of symptoms is hard for patients to pinpoint and because the wide variety of symptoms overlap with many other conditions.  To diagnose lupus, the clinician takes a careful history, performs a physical exam, and orders anti-nuclear antibodies and other laboratory tests.

Although lupus can be life-threatening, some 80 to 90 percent of sufferers can expect to live a normal lifespan if they are carefully monitored and treated.

Management of lupus is directed at preventing flare-ups, treating symptoms, and preventing or slowing damage to organs.  According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), the principal medications include:

  • NSAIDs to reduce inflammation.
  • Anti-malarials such as hydroxychloroquine (Plaquenil®) to prevent flare-ups.
  • Corticosteroids such as prednisone (Deltasone®), hydrocortisone, methylprednisolone (Medrol®), and dexamethasone (Decadron®, Hexadrol®) to reduce inflammation.
  • Immunosuppressive agents such as cyclophosphamide (Cytoxan®) and mycophenolate mofetil (CellCept®) to inhibit an overactive immune system.  Belimumab (Benlysta®) is a B-lymphocyte stimulator protein inhibitor that was approved by FDA 2011 for patients with lupus who are receiving other standard therapies.  It may reduce the number of abnormal B cells thought to be a problem in lupus.
  • Methotrexate (Folex®, Mexate®, Rheumatrex®), a disease-modifying antirheumatic drug, may be used to help control the disease in some patients.

Other treatments may include hormonal therapies such as dehydroepiandrosterone (DHEA) and intravenous immunoglobulin, which may be useful for controlling lupus when other treatments haven’t worked.

A variety of self-care and complementary approaches can be useful, including exercise, diet, the avoidance of sun exposure, and skin protection.  Patients are advised to recognize early signs of a flare-up and get immediate medical attention.

Findings from prospective human studies have strengthened the evidence of a connection between lupus and vitamin D status.  There is evidence that increased vitamin D levels (via supplementation) may help reduce inflammation.  A reasonable dose would be 2000 IU of vitamin D3 on a daily basis.  Vitamin D levels are easily checked.

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A Brief History of Pain

Posted on Posted in Continuing Education, Homestudy, Pain, Seminars, Webinars

first-aid-908591_640By Dr. Mary O’Brien, MD

Early humans explained the mystery of pain by associating it with evil, magic, and demons. Relief was the responsibility of sorcerers, shamans, priests, and priestesses, who treated their clients with herbs and rituals.

On stone tablets, ancient civilizations recorded accounts of pain and the treatments used, including pressure, heat, water, and sun. The Greeks and Romans were the first to advance a theory of sensation, the idea that the brain and nervous system were involved in the perception of pain. During the Middle Ages and into the Renaissance, evidence began to accumulate supporting these theories. Leonardo da Vinci and his contemporaries came to see the brain as the central organ responsible for sensation, with the spinal cord transmitting sensations to the brain.

In the 19th century, pain came to dwell under a new domain—science—which paved the way for advances in pain therapy. Physician-scientists discovered that opium, morphine, codeine, and cocaine could be used to treat pain. In the late 1800s, research led to the development of aspirin, to this day the most commonly-used pain reliever. Before long, anesthesia—both general and regional—was refined and applied during surgery.

Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. There are two basic categories of pain, acute and chronic, and they differ greatly.

Acute pain usually results from disease, inflammation, or injury to tissues. This type of pain generally comes on suddenly—for example, after trauma or surgery—and may be accompanied by anxiety or emotional distress. The cause of acute pain can generally be diagnosed and treated, and the pain is self-limiting—confined to a given period of time and severity. In some instances, it can become chronic.

Chronic pain is widely believed to represent a disease in and of itself. It persists over a longer period of time than acute pain and is resistant to most medical treatments. Chronic pain often persists longer than three months, or longer than expected for normal healing. It can be made much worse by environmental and psychological factors. It can—and often does—cause severe problems for patients, as pain signals keep firing in the nervous system for weeks, months, or years. There may have been an initial mishap such as a sprained back or serious infection, or there may be an ongoing cause of pain such as arthritis, cancer, or infection. However, some people suffer chronic pain in the absence of any past injury or evidence of illness.

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The Zika Virus: A New Warm Weather Worry

Posted on Posted in Pain, Seminars, Webinars

mosquito-542156_640It’s odd to think about mosquitoes in the middle of winter. However, in Brazil, it’s not the middle of winter.  The Zika virus, a potentially devastating illness, has captured medical headlines around the world.  Carried by mosquitoes, the Zika virus has been documented in Central and South America, the Caribbean and several southern states.  Apart from causing miserable flu- like symptoms, this unusual and worrisome virus can cause catastrophic birth defects.  In fact, as of January 31, 2016, the Brazilian government has traced over 3,000 birth defects to Zika virus exposure in utero.

Patients with Zika infection may experience high fevers, severe musculo-skeletal pain and profound malaise.  Symptoms are often similar to those caused by another warm weather mosquito-borne culprit, Chikungunya virus.  The word, “Chikungunya,” is a tribal word describing the acute, contorted, bent-over posture of people doubled-over with pain, as the illness strikes.  An intense, maculo-papular rash on the trunk and extremities is often present early on. Encephalitis, myocarditis, and hepatitis can develop.  The most recent outbreak of Chikungunya virus flared up in October, 2013 on the island of St. Martin.

Researchers believe the current outbreak of Zika virus can be traced to large crowds and warm weather at the most recent World Cup events.  The illness has now been confirmed in 24 countries. Nearly 40 cases are being evaluated in the United States, however, all of these cases are apparently related to exposure while traveling.

Zika virus in the expectant mother can result in severe birth defects, neurologic deficits, and even anencephaly in newborns.  The Brazilian government has taken the unprecedented measure of warning women not to get pregnant until the situation is controlled.  This is an extreme policy designed to prevent extreme tragedy.  The best advice for everyone combines current science and common sense:

  • Women who are pregnant or may become pregnant should avoid travel to endemic areas of infection.
  • Be careful around upcoming Mardi Gras and Carnivale celebrations.
  • If travel is essential to these areas, avoid camping, “jungle expeditions,” dense tropical vegetation, standing water, or other obvious exposures to mosquitoes.
  • Minimize outdoor exposures at dawn and dusk.
  • Keep arms and legs covered and use insect repellants properly.
  • If symptoms develop, seek medical attention promptly and give a precise travel history.

For now, staying informed and exercising common sense and good judgment is everyone’s best bet.

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Stress: The Silent Stalker of the Heart

Posted on Posted in Continuing Education, Elder Care, Homestudy, Pain, Seminars, Webinars

heart-915562_640Despite the many advantages of today’s technological progress, chronic stress persists as a major problem. Stress is not only uncomfortable, it can cause major damage to the circulatory and immune systems, leading to hypertension, arrhythmias, increased coagulation, and atherosclerosis.

Stress also exacerbates coronary heart disease (CHD), myocardial infarction (MI), and heart failure. Various stressors have been found to raise the risk of heart disease and even increased mortality due to heart disease—especially chronic work-related stress, marital strain, bereavement, and social isolation. Acute emotional stress may trigger myocardial infarction and a phenomenon known as stress myocarditis.

Stress, by virtue of its effects on adrenaline release, triggers myocardial ischemia, promotes arrhythmogenesis, stimulates platelet function, and increases blood viscosity. In some individuals, the intrinsic effects of stress include exaggerated heart rates and blood pressure responses. Emotions that often come with stress, namely anger, hostility, anxiety, and depression, bring a heightened risk of cardiovascular disease, coronary heart disease, and cardiac events, and — in those with heart disease — poor prognosis.

Depression is related to greater risk for developing coronary heart disease (CHD), poor prognosis in CHD, and higher mortality in those with CHD. It is also associated with arrhythmias, higher risk of acute coronary syndrome, and poor prognosis after myocardial infarction.

Those who are depressed are less likely to make lifestyle changes important for heart health. Mood disorders such as depression and anxiety may also affect lipid metabolism. Twenty percent of individuals who have cardiovascular disease or a previous history of MI have been found to have major depressive disorder (MDD). Psychosocial stressors can be both a cause and a consequence of cardiovascular disease events. Stress management might reduce future cardiac events in patients with cardiovascular disease.

Unless medications are required, patients can often make lifestyle changes that markedly decrease chronic stress. Some recommended strategies include:

  1. exercising on a regular basis.
  2. meditating for one or two 20- to 30-minute sessions a day. Studies show meditation can have lasting effects on blood pressure and heart rate.
  3. taking a vacation or a long weekend off.
  4. writing about stressful events.
  5. participating in a support group.
  6. regularly doing deep breathing exercises.
  7. using progressive muscle relaxation, which reduces muscle tension by relaxing individual muscle groups.
  8. practicing yoga, tai chi, or qi gong, all forms of exercise and meditation that are effective in reducing stress.
  9. spending more time outdoors.
  10. disconnecting from electronics and social media.
  11. listening to soothing music or silence.
  12. engaging in creative endeavors or hobbies.

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Essentials of Hypothermia

Posted on Posted in Continuing Education, Homestudy, Pain

 

tyrol-69661_640Surviving hypothermia after being left for dead in the wilderness makes an interesting story line in the movies.  In real life, hypothermia kills over a thousand people each year in the United States alone.  Knowing how to recognize it and treat it (or better yet, prevent it) can save lives.

Systemic hypothermia involves a core body temperature below 35 degrees Celsius.  Accurate measurement is crucial and the core temperature probe must be able to measure as low as 25 degrees Celsius.  Resuscitative measures must always be continued until the patient’s core temperature is clearly over 32 degrees Celsius (unless there are obvious fatal injuries).  As every physician, nurse, and first responder has been taught, “you’re not dead until you’re warm and dead.”

Susceptibility to hypothermia is increased by extremes of age, heart disease, exhaustion, hunger or malnutrition, dehydration, hypoxia, immobility, intoxication with drugs or alcohol, low body mass, contact with moisture or metal, and loss of consciousness.  Even in the movies, victims of hypothermia try desperately to stay awake and keep moving.

Clinical signs and symptoms of hypothermia vary based on the patient’s underlying status.  In general, however, there are four stages:

  • Stage I- CBT (core body temperature) is between 32 degrees Celsius and 35 degrees Celsius.  The patient is shivering and may be losing good judgement and coordination; still conscious and hemodynamically stable.
  • Stage II – CBT is between 28 degrees Celsius and 32 degrees Celsius.  Shivering stops, pulse slows, and pupils dilate.  Reflexes slow and “cold diuresis” develops as a result of renal dysfunction and low levels of ADH (antidiuretic hormone). Eventually, this will lead to hypovolemia and shock.  The patient becomes increasingly confused and lethargic.
  • Stage III-CBT is between 24 degrees Celsius and 28 degrees Celsius. Vital signs may still be present, but the risk of cardiac arrest increases dramatically, and the patient is now unconscious.
  • Stage IV – CBT is less than 24 degrees Celsius.  Vital signs are absent.  There is coma, loss of reflexes, asystole or ventricular fibrillation and rigor mortis. The patient appears dead but may still be salvageable.

The cornerstone of treatment in hypothermia is rewarming.  Rapid assessment with support of airway, breathing, and circulation must occur almost simultaneously.  All cold, wet clothing should be removed and replaced with warm, dry clothing and blankets.  The patient’s head should be covered and every effort must be made to prevent additional heat loss.  In general, raising core body temperature by 1 degree Celsius per hour is safe.  Giving warmed IV fluids (normal saline at 45 degrees Celsius) may be helpful.

Great care and caution must be used when moving or transporting a hypothermic patient.  The combination of vasoconstriction, hypovolemia, and return of cold peripheral blood to the central circulation can cause ”core temperature after drop.”

This phenomenon, combined with lactic acidosis, can precipitate potentially fatal arrhythmias known as “rescue collapse.”  This is where real life must break with the movies.  Dramatic scenes where the rescuer frantically rubs and massages the victim’s extremities may be riveting, but they’re also wrong.

Preventing hypothermia is much easier than treating it.  When in doubt, rely on the old adage: Keep warm, keep dry, and keep moving.

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The Mystery of Pain: Acute vs Chronic Pain

Posted on Posted in Brain Science, Continuing Education, Pain, Psychology, Seminars, Webinars

By Michael Howard, Ph.D.

Early humans explained the mystery of pain by associating it with evil, magic, or demons. Relief was the responsibility of sorcerers, shamans, priests, and priestesses, who treated their clients with herbs and rituals.

Ancient civilizations recorded on stone tablets accounts of pain and the treatments used, including pressure, heat, water, and sun. The Greeks and Romans were the first to advance a theory of sensation, the idea that the brain and nervous system were involved in the perception of pain.pain

During the Middle Ages and into the Renaissance, evidence began to accumulate supporting these theories. Leonardo da Vinci and his contemporaries came to see the brain as the central organ responsible for sensation, with the spinal cord transmitting sensations to the brain.

In the 19th century, pain came to dwell under a new domain—science—which paved the way for advances in pain therapy. Physician-scientists discovered that opium, morphine, codeine, and cocaine could be used to treat pain. In the late 1800s, research led to the development of aspirin, to this day the most commonly-used pain reliever. Before long, anesthesia—both general and regional—was refined and applied during surgery.

Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. There are two basic categories of pain, acute and chronic, and they differ greatly.

Acute pain usually results from disease, inflammation, or injury to tissues. This type of pain generally comes on suddenly—for example, after trauma or surgery—and may be accompanied by anxiety or emotional distress. The cause of acute pain can generally be diagnosed and treated, and the pain is self-limiting—confined to a given period of time and severity. In some instances, it can become chronic.

Chronic pain is widely believed to represent a disease in and of itself. It persists over a longer period of time than acute pain and is resistant to most medical treatments. Chronic pain often persists longer than three months, or longer than expected for normal healing. It can be made much worse by environmental and psychological factors. It can—and often does—cause severe problems for patients, as pain signals keep firing in the nervous system for weeks, months, or years. There may have been an initial mishap such as a sprained back or serious infection, or there may be an ongoing cause of pain such as arthritis, cancer, or infection. However, some people suffer chronic pain in the absence of any past injury or evidence of illness.

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What is Fibromyalgia?

Posted on Posted in Continuing Education, Homestudy, Pain, Seminars, Webinars

alone-62253_640By Nikita Katz, M.D., Ph.D.

The word “fibromyalgia” is derived from the Latin roots “fibro” (connective tissue), “my” (muscles), “al” (pain), and “gia” (condition of).  As a syndrome, fibromyalgia is composed of a specific, often complex, set of signs and symptoms that complicate diagnosis and treatment. Before official recognition as a disorder by the American Medical Association (AMA) in 1987, fibromyalgia was considered a “wastebasket” diagnosis, but lately there has been a “paradigm shift,” and fibromyalgia is being recognized as a true illness and a major cause of disability.

Fibromyalgia is a disorder characterized by chronic widespread musculoskeletal pain with associated fatigue, insomnia, and multiple somatic complaints such as stiffness, headache, and chest pain, with no evidence of disease.  It occurs mostly in women but does occur in men.  Most of the pain involves several tender points in the body, which are targeted areas where people with fibromyalgia feel an exaggerated sense of physical pain upon the slightest application of pressure. Fibromyalgia is neither degenerative nor progressive, and there is no inflammation.  In fact, it used to be called fibrositis, but the name was changed to fibromyalgia when evidence showed no inflammation in the disease process.  It is non-articular, meaning it does not involve the joints, and there is no swelling in the joints or tissues.  Descriptions of conditions consistent with what we now call fibromyalgia have been found in the medical literature as far back as the early 17th century.

Although there is no cure for fibromyalgia, several treatments can alleviate the multiple symptoms of this complex disorder, thus making it easier for patients to live a near-normal life.  Treatments include pharmacological interventions, dietary counseling, alternative medicine, relaxation techniques, and moderate exercise.  Many authors recommend combined management of fibromyalgia rather than just one treatment alone.

Fibromyalgia is not a life-threatening, deforming, or progressive disease.  Although lack of proper treatment may lead to the illusion of disease progression, this illusion is not supported by scientific evidence.  Compensation of sleep deprivation and physical reconditioning should, at least in some patients, lead to reversal of the disease or improvement of function and reduction of pain.

Numerous modalities available can reduce pain and other debilitating symptoms; these include electrotherapy, cryotherapy, and therapeutic heat. The clinician should teach patients how and when to use therapeutic modalities as part of their maintenance program. A multidimensional clinical approach including behavioral therapy, exercise, and pharmacological intervention is essential.

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