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Synonyms Idiopathic parkinsonism plus dementia Symptoms and course Symptoms of dementia associated with Parkinson’s disease will vary from person to pregnancy options purchase femcare 100mg overnight delivery person menstruation lower back pain order femcare 100 mg free shipping. Jellinger et al: J Neural Transm 109 (2002) 329-339 13 Alzheimer Europe Rare Forms of Dementia Project 3 menstruation starter kit buy 100 mg femcare otc. Synonym Lobar atrophy women's health clinic north vancouver buy cheap femcare 100mg, fronto-temporal atrophy Symptoms and course Damage to the frontal and temporal lobe areas of the brain will cause a variety of different symptoms. Behaviour may be sexually suggestive, though a loss of interest in sexual acts themselves is also common. Genetics There is a family history in about half of all cases of fronto-temporal degeneration. After several years, this disease develops into fronto-temporal dementia with severe language disorder. A less common variety begins with impaired word finding and progressive deterioration of naming and comprehension, with relatively preserved articulation. Symptoms and course this begins with loss of knowledge about the world, which often presents as problems with language. Although people can still speak fluently they lose the words for certain items and also lose the knowledge of the meaning of the word. For example, someone may not only forget the word "hippopotamus" when shown a picture, but also loses all the knowledge they once had about this. Caregiver problems People with primary progressive aphasia are fighting against a condition in which they will continue to lose their ability to speak, read, write, and/or understand what they hear. In patients with semantic dementia, the loss of brain tissue was mostly confined to the left side of the brain and particularly to the front portion of the left temporal lobe. Semantic impairment, hypoperfusion of the temporal cortex, bilateral but with a left predominance. The Parkinsonian features are related to movement disorders such as rigidity, reduced speed and uncontrolled movemements, including those of the eye (supranuclear palsy). Symptoms and course Clinical presentation is extremely variable, according to the type of mutation on tau gene, and heterogeneous inside a same family. Some have with rigidity, bradykinesia, supranuclear palsy and saccadic eye movement disorders. Symptoms usually start between 40 and 60 years of age, but may occur earlier or later. Ongoing research / clinical trials these mutations have generated the concept of “tauopathies”, since the cause of the disease is tau mutations. This could be linked to difficulty in identifying emotions shown by their relatives. These symptoms include loss of memory, lack of spontaneity, difficulty in thinking or concentrating, and disturbances of speech. Other symptoms include gradual emotional dullness, loss of moral judgment, and progressive dementia. However, levels of normal tau protein are dramatically decreased, suggesting that this fronto-temporal dementia is also a tauopathy (“tau-less tauopathy”: Zhukareva et al, 2001). Typically, during the initial stages of fronto temporal dementia, memory will still be intact, but the personality and behaviour of the person will change. They may talk to strangers, make inappropriate remarks in public and be rude or impatient. However sometimes difficulties in organisation and concentration may lead to an apparent memory problem. Tiny, cramped handwriting and some changes in personality are often other indicators of the disease. From a broad survey of various countries in the Western World, the probability of the disease being passed from one generation to the next within a family is extremely low. Levodopa and anticholinergic medications may provide temporary reduction of symptoms. A randomised, multicentric, double blind, placebo controlled, stratified, parallel group study. Symptoms include signs of parkinsonism such as poor coordination, akinesia (an absence of movements), rigidity (a resistance to imposed movement), and disequilibrium (impaired balance); and limb dystonia (abnormal muscle postures). Other symptoms such as cognitive and visual-spatial impairments, apraxia (loss of the ability to make familiar, purposeful movements), hesitant and halting speech, myoclonus, and dysphagia (difficulty swallowing) may also occur. A degeneration affecting many subcortical nuclei and spreading into the neocortex in the frontal and parietal areas with an aggregation of tau protein in affected areas within neurons and in astrocytes. Belongs to the 4R tauopathies (aggregation of tau isoforms with 4 repeats) (Sergeant N. Causes and risk factors Neuron degeneration likely associated with dysfunction of tau protein. Argyrophilic grain disease: widespread hyperphosphorylation of tau protein in limbic neurons. The disorder is characterized by postural (or orthostatic) hypotension—an excessive drop in blood pressure when the patient stands up, which causes dizziness or momentary blackouts. For the majority of patients, blood pressure is low when the patients stand up and high when the patients lie down. Other symptoms that may develop include impaired speech, difficulties with breathing and swallowing, and inability to sweat. Diagnostic procedures the diagnosis is mainly based on the specific clinical manifestations (postural or orthostatic) hypotension, rigidity, balance, coordination, impaired speech, excessive drop in blood pressure, and in general autonomic/urogenital failure. Medications to elevate blood pressure, such as salt-retaining steroids, are often necessary, but they can cause side effects and should be carefully monitored by a physician. An artificial feeding tube or breathing tube may be surgically inserted for management of swallowing and breathing difficulties. The symptoms of lower motor neuron disease are muscular weakness, atrophy, fasciculation, cramps, slurred speech (dysarthria), difficulties in swallowing (dysphagia) and difficulties in mastication. On examination there are almost always lower motor neuron signs together with upper motor neuron signs. Significant bulbar and respiratory weakness soon occurs in about one half of the patients. Causes and risk factors the aetiology is likely multifactorial involving both genetic and environmental factors. In some of these families, there is clear evidence of autosomal dominant inheritance and rarely of autosomal recessive inheritance. Heredity was discounted because the spouses of many patients were also affected, and no environmental causes or virus were found. Twenty percent live five years or more; up to ten percent will survive more than ten years. Electromyographic demonstration of denervation in at least three limbs confirms the findings of lower motor neuron abnormalities. Magnetic resonance imaging may show high signal intensity in the corticospinal tracts. In one retrospective analysis, patients who received riluzole remained in a milder stage of disease longer than did controls. Transgenic mouse models have been developed expressing these aberrant mutants that develop a form of motor neurone disease the progress of which can be slowed by riluzole. Studies in these mice have provided evidence for a role for excitotoxic, apoptotic and oxidative processes in the development of pathology. The mice can be used for testing molecules targeting these processes as potential therapies, to allow the most promising to be evaluated in humans. However, with the exception of studies with riluzole, the results of these have been disappointing. Mutations in Cu/Zn superoxide dismutase gene are associated with familiar amyotrophic lateral sclerosis. Ataxias by Giuliano Binetti General outlines the word "ataxia" comes from the Greek word "ataxis" meaning "without order" or "incoordination. Initially this latter feature may be mild, with just extensor plantar responses, but almost invariably a pyramidal pattern of weakness in the legs occurs, which sometimes leads to paralysis. Nystagmus is seen in only about 20%, but the extraocular movements are nearly always abnormal. The dominant ataxias are a clinically and genetically complex group of neurodegenerative disorders. Mild or moderate dementia may occur but it is usually not a prominent early feature.

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If you are • Joint and Muscle Pain experiencing this problem women's health clinic nyc 100 mg femcare with visa, talk to menopause headaches generic femcare 100mg visa your doctor about medications that may help control it menstrual joy discount femcare 100 mg on line. It is a areas that involve joints may end up not using those joints mixture of the cough suppressant dextromethorphan to breast cancer untreated buy 100 mg femcare free shipping their full capacity. Lack of use can cause stiffness and and quinidine, which is used to treat heart arrhythmias. Range-of-motion exercises are designed to It is expected to be available by prescription in early prevent these joint problems. However, there are still a number of common pains • Cognitive and Behavioural Changes that can develop. A firm seat on a regular chair or wheelchair ments such as holding a pen to write, or cutlery to eat, will relieve strain on the hip joints. There are a variety of products designed to assist • Leg and foot Swelling you with weakened grip strength. If your lower limb mobility is reduced, you may experi If these weaknesses continue to develop, you can lose ence mild leg and foot swelling, which is best reduced by your ability to hold even lighter weight articles. Getting moving the toes and ankle, if possible, and by elevating dressed and undressed becomes more and more difficult, the leg and/or using an elastic stocking. If your fingers get cold you will probably be sur stretch it until the pain is eased. Severe or frequent cramps prised by how much harder it is to do such things as undo should be discussed with your doctor. With you may have discomfort in your lower back, neck and respect to moving about, some may need a cane or a walk shoulder blade region. Special cushions, chair backs, lum er at first, then a manual wheelchair, followed by a power bar (lower back) and cervical (neck) rolls are available to wheelchair to assist in maintaining a certain level of inde help you to maintain correct sitting posture. Also, there are raised chairs and toilet seats essary for you to sit in a reclined position or to use a neck which are easier to get up from, and portable hoists to collar to maintain proper positioning. Your occupational move a person Regarding eating, there are eating utensils therapist can assist you in choosing the right device. Choosing the best assistive equipment for your If you experience weakening leg and ankle muscles and situation involves many considerations, including an unexpected fatigue, tripping and falling become problems. It is advised that When these problems occur you should consider using leg you get advice from a healthcare professional such as an and ankle splint devices (ankle foot orthoses-AfOs) that occu. Some people are self-conscious about having to use walk ing aids, or see it as an announcement that their condition is worsening. See Section 5 Assistive Equipment and However, you must also think about preventing injuries Section 4 Adapting to Changes in Mobility and that will inhibit your independence further, or cause seri Maintaining Independence sub-section. Partners should realize that touching is as important as Sexual desires and abilities may not be affected by the dis sexual performance in reducing tension and maintaining ease process, except for the physical limitations imposed emotional intimacy. Preservation of personal integrity by physical discomfort, muscle weakness, fatigue or low should be an overriding concern. If you are both willing, you could isfying a demand not met by conventional approach explore different sexual techniques, role flexibility, and es. Unfortunately, many of the peo ple pushing these claims are making a lucrative living at the Cranio-Sacral: expense of people who are looking for hope. A cranio-sacral massage is a very light and gentle massage the following information provided takes a look at mas of the back of the head and neck. They can warm up limbs, which often of most massage treatments ranges between $40 and $75 feel cold because of inactivity, low circulation and for sessions up to an hour in length. Though touch therapies are usual ments are not covered by provincial healthcare plans, but ly given by a caregiver or therapist, self-massage can also be very beneficial. It is important to talk to your doctor may be covered in whole or in part by private or group before receiving massage therapy. For the most beneficial massage, body oil is used to lubricate the • Meditation skin, which aids in soothing and relaxing the muscles. Massage involves systematically stroking, kneading and Meditation is a way to relax and revitalize both mind and body, and can be practised in many ways. It required and should be done so under medical consul has been practised over the centuries by many different cul tation. Referring to the results of pressing the soft tissues of the body with fingers and the researching meditation in his book the Relaxation palm of the hand, working on the muscles, ligaments and Response, (Avon Books, N. A complete massage covers the entire body, that meditation creates an overall awareness of relaxation inducing a state of warmth and relaxation. Breathing and heart rate slow massage of parts of the body, such as arms, legs or shoul down, blood pressure drops, and there is an increase of ders is also beneficial and will help improve circulation. One type of meditation involves concentrating on some Shiatsu is a Japanese system of touch therapy and is given thing, such as your breathing, a candle flame, a religious using fingers, thumbs and hands. The forearm, knees, and object, or even rolling surf, while peacefully and silently feet can also be used, applying pressure to specific points repeating a mantra, a special word or sound. The other type of meditation also involves repeating a mantra, but Reflexology: the objective is to relax your mind entirely. When thoughts come into your mind, you try to relax, observe the Reflexology is based on the theory that pressing and mas thoughts and let them flow, without participating in the saging certain points in the feet will affect the whole body thought process. Many meditation teachers suggest that, for the best results, meditation should be done twice new Regulations in Canada: a day, for about twenty minutes, with your eyes closed. Two common problems for Health Canada, designed to balance the need for those new to meditation are being unable to relax as their safety and efficacy with consumer choice. The new regulatory framework incorporates an It takes daily practice and time to develop the ability to evidence-based approach that assesses products for safety achieve a state of conscious relaxation. The Standards of Evidence developed are clearly defined criteria concerning the amount of evidence There are several other techniques to help clear the mind, required to support each claim (five levels ranging from and achieve a state of relaxation, including music therapy "well-designed systematic reviews and meta-analysis of and visualization therapy. Your stronger the claim, the stronger the supporting evidence nurse, social worker, occupational therapist, or other men needs to be. As a consumer, you will now be able to tell tal health professional may also be good resources for what level of evidence is available which will help inform your choice. Also con other so-called complementary or alternative medi sider the cost of the product. If it is very expensive, but cines (natural health products) have become so popular there is little if any scientific evidence to support the over the last few years, it is appropriate to say a few things claims, you may want to reconsider. If you find something that helps you feel better or makes your life a While extensive and rigorously controlled research is little bit easier, let your doctor know done for pharmaceutical drugs before they can go to about your progress. Also, it is well known that animal and plant by-products have provided the basis for many successful drugs. Strengthening – moderate resistance exercises, for ways to stay as functionally mobile as you can to con example, Thera-Band tinue to accomplish the everyday activities you are • may decrease disuse atrophy accustomed to doing. Aerobic – exercises for example stationary cycling these strategies aim to promote physical comfort, pre and walking) vent injury, and help maintain independent living. Once the and limbs supply of motor neurons that control a particular mus • To help manage pain and stiffness due to spasticity cle has degenerated, it cannot be regenerated by exer and increase tone cise or anything else. Exercise programs should be Exercise will help to keep your body as flexible as pos recommended by an occupational therapist or physical sible and your joints mobile. Exercise should not cause pain limb are exercised in a particular order before the next and excessive fatigue or shortness of breath. You may wish to break up your assist the muscle through the movement, or you may exercise routine into parts to avoid fatigue. If you be shown a way to do a self-assisted range of motion experience fatigue, consult your therapist for a exercise. Your therapist can tine through the day or on alternate days to avoid train your caregiver(s) to do these exercises properly. If you continue to experience fatigue, con sult your therapist for a change in your program. You may find that you can do some exercises Participate in an active exercise program. A you to make decisions about the type of exercise physiotherapist can prescribe an exercise program that that is most suitable for you. They will demonstrate the exercises to ensure that they will be performed correctly. Ask for Prioritize your exercises based on how effective diagrams of the exercises to help you and your caregiv they are for you in terms of injury and pain pre er remember the techniques. Ask your therapist which exercises are It is important that all exercise be performed in moder the most important ones to do if you have a busy ation.

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Learn to women's health clinic sf discount 100 mg femcare mastercard recog nize the sure signs of apprehension: raising of the head pregnancy 37 weeks buy femcare 100mg visa, ears pulled back menstrual natural remedies buy femcare 100mg without prescription, eyes widening and becoming intense women's health center frost street order femcare 100 mg on line, skin twitching, tail swishing, swinging of the rear toward you, stamping of feet, breathing short and hard, and biting. Sure signs of relaxation and enjoyment, however, include: eyes half-closed, head down, ears to the side, heavy sighs, relaxing of the lower lip, and nuzzling. After a few sessions, the horse will accept your efforts without any trouble and start to enjoy massage. Some horses with trau matic histories (abuse, accidents) may be more resentful of mas sage than others, tensing up all over. Sometimes there can be a fear of being touched, or “touch-shyness,” simply because humans 40 the Horse and Massage Therapy 41 have not spent much time bonding with a particular horse. In some cases, touch-shyness in one area of the body (for exam ple, the head or back) can indicate an underlying condition. When dealing with an extreme case of phobia or restlessness, consult your veterinarian or homeopath. Be especially aware of the horse’s temperament and character when approaching him; be particularly careful with stallions. Most geldings, mares and foals, however, respond very positively to their first treatment. As a rule, use the relaxation routine in chapter 6 prior to giving any massage at any time to any horse. With each session you will build your horse’s trust while allaying his instinctive fears. As the horse relaxes during the session, his head will go down and his breathing will become deeper and slower with occasional sighing. Depending on the nature of the massage you use, the horse might go to sleep or perk up and be ready for exercise. How the Horse Responds Like humans, horses have both visual and auditory aspects to their mental makeup. Many factors in the horse’s life will influence his psychological and physical behavior. Visual and auditory tendencies will vary in relationship to: age, sex, environment (people, stabling), experiences, and training. Such an animal communicates pri marily through motion, expressing his emotions by physical reac tions and movements. Body language signals are important, particularly since horses like to be touched when they want to be touched. Demonstration through gesture is more important than talking, but it is good to maintain a soft-spoken contact with him as you massage his body. This type of horse is less body-expressive than the visual horse but is willing to please. The auditory horse always loves to be touched, but also likes serenity and time alone. The auditory horse can be massaged anywhere; because of his nature, he copes with new environments easily. Due to the auditory horse’s sensibility, you need to pay extra attention to your approach during your massage. Keep in mind that both visual and auditory conditions will appear in a horse’s make-up during different periods of his life. The one condition may change to the other gradually over a long period of time, or the change may be quite rapid. As part of the relaxation mas sage routine, the head massage routine in chapter 6 gives you a good opportunity to evaluate the horse you are working on. Duration of a Massage For your first massage, and especially if it is the animal’s first mas sage, the relaxation massage routine in chapter 6 is highly recom mended. Use your own judgment and modify the time in relation to the horse’s tempera ment and the feedback signs he gives you. The first massage is a very special time in which you should really emphasize a soft, mindful, and caring contact to gain the animal’s trust. On your first full-body massage, again proceed gently in a very relaxed manner, avoiding awkward rhythms and deep pressure, until you have gained the horse’s confidence. After several sessions you can increase the duration of your massages to 45 or 60 min utes, up to an hour and a half if the animal permits it. The head massage routine in chapter 6, which complements the relaxation routine, can take anywhere from 10 to 30 minutes. Again, some animals love having their faces touched; some simply do not, but with patience and perseverance you might win them over. A maintenance massage routine (chapter 6) can be done any time to keep the animal’s muscles fit; it should last 30 or 40 min utes in the early practices, and increased to 60 or 90 minutes later on. A recuperation routine (chapter 6) should be used after the horse has exercised in order to prevent stiffness or tying up. The Horse and Massage Therapy 43 It is not unusual to spend an hour and a half on a thorough maintenance routine with a horse accustomed to massage. The expression “being massaged to death” is very appealing but not very realistic; most horses will become nervous, almost agitated, after an hour-long massage. But some animals can easily take a two-hour, gentle, in-depth maintenance massage. This may sound exhausting for the masseur or masseuse, but with practice and the use of efficient techniques mentioned later (chapter 5), he or she will quickly develop good endurance. But after 5 to 10 massage sessions, most horses will love to be massaged; they will lower their heads and go into relaxation very quickly. When dealing with an injury, consult with your veterinarian before any massage is considered. Depending on the case, once the injury is past the acute stage, a massage treatment should last from 20 to a maximum of 60 minutes, including hydrotherapy and stretching time where applicable. The severity of the case and the degree of inflammation symptoms (heat and swelling) present will dictate the nature and course of treatment. Chapter 5 presents sev eral massage techniques that are commonly used for injury treat ment. Always keep in mind that injured tissues are extremely painful; you must not overwork them. As the inflammation decreases, you can proportionally increase the duration of your massage sessions. When working on any one specific area—for example, the hindquarters or back—do not work for more than 10 to 15 min utes; otherwise you could overwork the tissues. For the same reason, do not spend more than 5 to 10 minutes on a small area such as the poll or stifle. Consider the state of the tissues and the horse’s tolerance at the time of treatment. And always relieve any inflammation by following the massage with lots of drainage and cold hydrotherapy (chapter 4). Plan and evaluate your treatment mentally before you start, keeping track of time as you move around the body. When to Massage Your Horse Basically, any time is a good time to massage your horse, but you want to choose the moment when your horse will be most recep tive. Depending on your goals and the situation at hand, you need to find the optimum time in order to achieve the best results. For example, you can massage right after grooming, after exercise, or when putting your horse away for the night. You can massage for a few minutes over a small area, such as the back, right after unsaddling. In any case always observe these guidelines: Always do a “health” check to ensure that there are no pre vailing contraindications prior to massaging the animal (page 47). When you want to deliver a good massage, it is best to wait for the horse’s “moment. If your ani mal seems to have an auditory-dominant nature, he will probably prefer a massage when everything is quiet, usually in the evening or perhaps during the day when the other horses are out. As men tioned earlier, if your animal is more visual, he will prefer a mas sage in familiar surroundings; within normal limits, noise will have little effect on him. The type of training and lifestyle your horse is used to will also play a role in determining good times for massage; i.

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The patient speaks freely pregnancy zone trusted 100 mg femcare, but what he says is so littered with paraphasias as to breast cancer 4th stage treatment order femcare 100 mg overnight delivery make it almost impossible to pregnancy insurance buy femcare 100 mg line understand women's health lose weight safe 100 mg femcare. He speaks freely with well-formed sentences and normal prosody (melody), at times making no mistakes; he then gets stuck ‘ and then for an extent for a week I was a problem with poising voicing’. He appears to understand what is said to him, but has great difficulty identifying and touching parts of his face in sequence. In summary, he has a fluent aphasia with impaired comprehension and repetition and he makes paraphasic errors. The patient reaches out and grasps the hands which are offered to him (even though he has been asked not to) and is unable to let go. Video 99 Fronto-temporal dementia and marked grasp and snout reflexes, as well as foot stereotypies. This patient flexes her head and opens her mouth to an approaching finger even when asked not to. The patient follows the light with her eyes, even though it circles uncomfortably. The patient stacks three pairs of spectacles on his nose, one at a time, as each is offered to him. When the examiner raises his hand with two fingers extended, the patient incorporates the posture into his own gestures. He also imitates left arm raising, both arm raising, right fist clenching and left leg raising, while continuing the conversation. This patient is unable to copy accurately the akinesia test for Parkinsonism, flexing the interphalangeal joints, as well as the metacarpophalangeal joints. The patient is able to obey a simple sequence of pointing commands (showing that her comprehension is reasonable), but is unable to mime cutting a loaf. Video 107 Rapidly progressive cognitive decline, apraxia, ataxia, myoclonus and spasticity secondary to Creutzfeldt–Jakob disease. Video 108 Psychogenic, distractable tics, precipitated by severe life stressors and triggered by suggestion and application of a tuning fork. Video 109 Intermittent tremor and intermittent multidirectional, conjugate gaze determined to be psychogenic nystagmus and opsoclonus. Video 110 Psychogenic convergence spasm manifested by dysconjugate gaze and miosis and episodic left side ‘involuntary’ muscle contractions, triggered by a powerful suggestion and application of a vibrating tuning fork. Neurological Clinical Examination this book and extensive video library provide a practical guide to the clinical neurological examination, an essential tool in the diagnosis of common and unusual neurological conditions encountered in the outpatient clinic and hospital ward. Each chapter covers a different condition and uses a step by step approach, selecting those aspects of the clinical examination which are most likely to lead you to the correct diagnosis. Neurological • Gain instant access to over 100 free video clips from your desktop or via smart phone or tablet • Generously illustrated with clear diagrams Clinical • Tables are used to list the various causes of particular signs • Key features of the neurological examination which help in reaching the correct conclusion are listed as Tips Primary care physicians, neurologists and trainees preparing for certifying Examination examinations will nd this book an invaluable learning companion and essential tool for the diagnosis of neurological disorders. Introduction Guarantees Boston Scientific Corporation reserves the right to modify, without prior notice, information relating to its products in order to improve their reliability or operating capacity. The purpose of this form is to maintain traceability of all products and to secure warranty rights. Return one copy to the Boston Scientific Customer Service Department, keep one copy for patient records, provide one copy to the patient, and save one copy for the physician. Patient Identification Card Please ensure that the patient receives a completed temporary identification card following surgery. Permanent cards will be mailed directly to the patient following patient registration. The Stimulator is controlled by a handheld Remote Control, and can be interfaced with a Clinician’s Programmer using the Bionic Navigator™ Software. Page 2 of 66 Physician Manual 92093580-01 Safety Information Warnings Unauthorized Modification. System integrity could be compromised and harm or injury to the patient could occur if the medical devices are subjected to unauthorized modification. Special precautions should be taken for patients who are prone to hemorrhage including patients with coagulopathy, with high blood pressure, or who are using prescribed anticoagulants. Whenever possible, the current amplitude and pulse width should be programmed such that the charge density is below 30 µC/cm2 per stimulation phase. To maintain safety limits, the software will display a warning when the level of stimulation exceeds 30 µC/cm2 per stimulation phase; however, the software allows the stimulation to be adjusted above this level by the physician. Set and verify the maximum and minimum amplitude levels allowed by the Remote Control to ensure that current levels remain safe. Patients should be counseled to avoid or exercise care around: • Theft detectors such as those used at department stores, libraries, and other public establishments. The patient should proceed with caution, ensuring to move through the center of the detector as quickly as possible. If the patient must pass through the security screener, they should move quickly through the device staying as far from the physical device as allowable. The high energy fields produced by these systems may interfere with the operation of the Remote Control and its ability to control stimulation. Failure to use either the Charging Collar or an Adhesive Patch while charging, as directed, may result in a burn. If the patient experiences pain or discomfort, they should cease charging and contact their physician. Chemical burns may result if the Stimulator housing is ruptured or pierced, exposing the patient’s tissue to battery chemicals. Consider adjustment of stimulation, discontinuing stimulation, adjusting medication, and/or psychiatric referral. Stimulators, such as the Vercise™ Stimulator, may interfere with the operation of implanted devices such as pacemakers, cardioverter defibrillators, or medication delivery pumps. Performing activities that would be dangerous if treated symptoms were to return, or instances in which stimulation changes occur, should be avoided. The implanting physician should be experienced in the subspecialty of Stereotactic and Functional Neurosurgery. Contamination inside the ports may be difficult to remove and can cause high impedances, preventing electrical connectivity which may compromise the integrity of the stimulation circuit. Excess wire on top of the Stimulator may increase the potential for tissue erosion or damage during Stimulator replacement surgery and may interfere with charging. To ensure proper charging, orient the Stimulator parallel to the skin surface and at a depth less than 2 cm below the skin. The etched writing “This Side Up” must be facing out of the pocket towards the patients skin. Suboptimal placement of the Stimulator may result in the inability to recharge and/or a revision surgery. If stimulation cannot be turned on after charging, the Stimulator may have changed orientation or rotated; patients should contact their physician to arrange an evaluation of the system. If a patient notices a change in appearance of the skin at the Stimulator location, such as the skin becoming thin over time, they should contact their physician. Before tightening Setscrews, always test impedance to confirm electrical connectivity. If the Stimulator stops working even after complete charging (up to four hours when properly aligned), patients should be instructed to turn off the Stimulator and contact their physician immediately so that the system can be evaluated and appropriate medical care given to manage the return of symptoms. Temporarily, there may be some pain in the area of the Stimulator as the incisions heal. If there is excessive redness around the wound area, it should be checked for infection. While interference caused by cell phones is not anticipated, the full effects of interaction with cell phones are unknown at this time. During the two weeks following surgery, it is important for the patient to exercise extreme care so that appropriate healing will secure the implanted components. Instruct the patient to restrict head movements, including extension or flexion of the neck and rotation of the head, until healing is complete. Patients should avoid receiving massage therapy near the implanted system components. Patients should avoid activities that could potentially involve large amounts of electromagnetic interference. Devices that contain permanent magnets, such as speakers, should not be placed near the Stimulator because they may cause the system to turn on or off. The following medical therapies or procedures may turn stimulation off, cause permanent damage to the Stimulator, or may cause injury to the patient: If any of the procedures below is required by medical necessity, the procedure(s) should be performed as far from the implanted components as possible.

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