By N. Bozep. University of Tulsa. 2017.

Care must be taken that the i’s are dotted and the t’s crossed; that may be best done by a physician who is used to administering such chemotherapy agents (an oncologist or cancer doctor) discount 10 mg vasotec with visa. THE TREATMENT OF ACUTE ATTACKS The treatment of acute attacks has changed little in the past decade. Cortisone medication including methylprednisolone, dexamethasone, 21 PART I • The Disease and Its Management prednisone, and others continue to be commonly used to shorten the attack. These potent anti-inflammatory drugs diminish the swelling within the brain and spinal cord that is seen as cells of the immune system invade and attack the nervous system. They are clearly associated with osteoporosis, cataracts, psychological changes, skin acne, weight gain, and salt and water imbalance. Thus their effect on acute attacks must be weighed against potential problems from the treatment. General drugs that affect the immune system include azathio- prine (Imuran®) and methotrexate. Studies do not show them to be as effective for relapsing MS as the newer medications, but for some people with either relapsing or progres- sive MS they may help to control progression of the disease. They clearly are not for everyone with MS and must be selected and used with expert advice. The back- bone to MS management has been and continues to be the man- agement of symptoms. Everyone with MS should be aware of the many ways that the symptoms of MS can be managed, with the goal of improved quality of life. Symptoms in MS may be divided into those that are caused directly by demyelination within the brain and spinal cord and those that are not. If you lose myelin in the part of the brain or spinal cord that influences strength, you will develop weakness; if you lose myelin in the part that controls coordination, you will become uncoordinated; and if you lose myelin in the part that con- PART II • Managing MS Symptoms trols sensation, you will develop numbness, pain, burning, or itch- ing.

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It is instructive to consider that I did not stop prescribing physical therapy until twelve or thirteen years after I began to make the diagnosis cheap 10 mg vasotec amex. It took that long for me to fully break with all the old traditions in which I had been schooled. Conceptually, prescribing physical therapy contradicts what we have found to be the only rational way to treat the problem; that is, by teaching, and thereby invalidating, the process where it begins— in the mind. Further, it had become obvious that some patients had put all their confidence in the physical therapy (or therapist) and were having placebo cures (see “The Placebo Effect”), which meant that sooner or later they would be in pain again. The principle is that one must renounce any structural explanation either for the pain or its cure, or the symptoms will continue. Manipulation, heat, massage, exercise and acupuncture all presuppose a physical disorder that can be treated by some physical means. Patients are usually shocked when it is suggested that they stop the exercises and stretching they have been taught to do for their backs. Exercise for the sake of good health is of course something else, and it is strongly encouraged. Patients are given a list of twelve key thoughts, and it is suggested that at least once a day they set aside fifteen minutes or so when they can relax and quietly review them. By the end of the second lecture-discussion it is assumed that the information about TMS has been intellectually processed. Patients are then urged to give this information an opportunity to “sink in,” to be integrated, to be accepted at a subconscious level, for conscious acceptance, though essential as a first step, is not sufficient to reverse the TMS. Patients are instructed to give it two to four weeks and then call me if they have not made sufficient progress. If they have not, I arrange either to see them in my The Treatment of TMS 83 office or, more commonly, attend a small group meeting composed of patients like themselves (who have made little or no progress) or those having recurrences after having been free of pain for months or years. It is the purpose of these sessions to uncover the reason for the recurrence or lack of progress. SMALL GROUP FOLLOW-UP MEETINGS The first thing to ascertain is that the patient understands and accepts the diagnosis. He accepts 90 percent of the diagnosis but still has some concerns that the herniated disc demonstrated on the CT scan or MRI has something to do with the pain.

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