By: Charles D. Ponte, BS, PharmD, FAADE, FAPhA, FASHP, FCCP, FNAP
Another study compared a brief cognitive intervention with aerobic exercise of 45 sessions (Storheim et al 2003) and reported no significant differences between the treatments with regard to antibiotics for acne bad for you order vibramycin 100mg without prescription either disability or prospectively measured pain (although antimicrobial laundry soap purchase 100mg vibramycin otc, retrospectively antibiotics for acne and side effects discount 100mg vibramycin with amex, the exercise group reported a greater pain reduction and were more satisfied with their care) antibiotics bad for you 100 mg vibramycin with visa. There is strong evidence that brief interventions provided by a physiotherapist, or a physician and physiotherapist, and encouraging a return to normal activities, are as effective in reducing disability as routine physiotherapy or aerobic exercise (level A) Effectiveness of minimal contact/brief educational interventions versus other treatments One high quality study (Cherkin et al 2001) compared the effectiveness of acupuncture, therapeutic massage, and self-care education for persistent back pain (N=262). Self-care intervention consisted of a book and 2 video-tapes (one on self management and the other demonstrating exercises). After 1 year, self-care was no different from massage or acupuncture, in terms of pain and disability. There is limited evidence that brief self-care interventions are as effective as massage or acupuncture in terms of reducing pain and disability (level C). Cost-effectiveness No full cost-effectiveness analyses alongside the trials were found. One high quality trial (Karjalainen et al 2004, Karjalainen et al 2003) reported lower costs from low back pain in the mini intervention group (A) compared with a mini intervention plus a work site visit (B) or usual care (C): A=4670 Euros, B=5990 Euros, C = 9510 Euros. Safety Unknown (no studies were found on this issue) Subjects (indications) In particular, sick-listed people with a high perceived risk of not recovering may benefit from appropriate advice and information in a brief educational intervention provided by a physician and physiotherapist. It should be noted that many of the studies have been carried out with patients who were more at the subacute end of the subacute-chronic spectrum (especially the Scandinavian ones that provided moderate evidence that brief educational interventions addressing concerns and encouraging a return to normal activities are better than usual care in increasing return to work rates). It is difficult to define how intense or how extensive a brief intervention should be. It may be that a stepped approach as recommended by Von Korff (2001), where patients are initially offered a minimal intervention to address their worries and concerns, is all that is needed for the majority, while more intensive interventions may be required for those with on-going activity limitations. The brief/minimal interventions varied considerably in how they were applied, for example whether they were face-to-face or not. One common factor appeared to be the focus on return to normal activities and work. More research is needed to investigate which approach is most effective for any particular group of patients. Internet interventions, used as “minimal contact/brief educational interventions”, are unlikely to reach all back pain populations. Individual beliefs and communication skills of the care provider, as related to active management, are likely to influence the credibility and the effectiveness of the delivery. The option of brief or minimal contact interventions should be made more widely and explicitly available to patients, helping them to avoid more intensive and perhaps unnecessary treatments. The use of brief or minimal contact interventions for chronic back pain appears to be a promising area for further research, particularly as this approach could result in significant cost-savings if it proves to be as effective as more intensive treatment. Evidence Summary • There is moderate evidence that brief interventions addressing concerns and encouraging a return to normal activities are better than usual care in increasing return to work rates (level B). We do not give recommendations on the specific type of brief educational intervention to be undertaken (face-to-face, Internet-based, one-to-one, group education, discussion groups, etc. The latter may be best determined by the available resources and the preferences of both the patient and therapist. The emphasis should be on the provision of reassurance and positive messages that encourage a return to normal activities. Buhrman M, Faltenhag S, Strom L, Andersson G (2004) Controlled trial of Internet based treatment with telephone support for chronic back pain. Karjalainen K, Malmivaara A, Mutanen P, Roine R, Hurri H, Pohjolainen T (2004) Mini-intervention for subacute low back pain: two-year follow-up and modifiers of effectiveness. Karjalainen K, Malmivaara A, Pohjolainen T, Hurri H, Mutanen P, Rissanen P, Pahkajarvi H, Levon H, Karpoff H, Roine R (2003) Mini-intervention for subacute low back pain: a randomized controlled trial. Psychological components may be involved in back school programmes and multidisciplinary treatment programmes, but these are dealt with in their own separate chapters. Cognitive and behavioural interventions are commonly used in the treatment of chronic (disabling) low back pain. The main assumption of a behavioural approach is that pain and pain disability are not only influenced by somatic pathology, if found, but also by psychological and social factors. Consequently, the treatment of chronic low back pain is not primarily focused on removing an underlying organic pathology, but at the reduction of disability through the modification of environmental contingencies and cognitive processes. In general, three behavioural treatment approaches can be distinguished: operant, cognitive and respondent (Turk and Flor 1984) (Vlaeyen et al 1995). Each of these focuses on the modification of one of the three response systems that characterize emotional experiences, that is behaviour, cognitions, and physiological reactivity. Operant treatments are based on the operant conditioning principles of Skinner (Skinner 1953) and applied to pain by Fordyce (Fordyce 1976) and include positive reinforcement of healthy behaviours and consequent withdrawal of attention towards pain behaviours, time-contingent instead of pain-contingent pain management, and spouse involvement. The graded activity programme is one example of operant treatment for chronic low back pain (Lindstrom et al 1992a). Cognitions (the meaning of pain, expectations regarding control over pain) can be modified directly by cognitive restructuring techniques (such as imagery and attention diversion), or indirectly by the modification of maladaptive thoughts, feelings and beliefs (Turner and Jensen 1993). Respondent treatment aims to modify the physiological response system directly. Respondent treatment includes providing the patient with a model of the relationship between tension and pain, and teaching the patient to replace muscular tension by a tension-incompatible reaction, such as the relaxation response. A large variety of behavioural treatment modalities are used for chronic low back pain, because there is no general consensus about the definition of operant and cognitive methods. Furthermore, behavioural treatment often consists of a combination of these modalities or is applied in combination with other therapies (such as medication or exercises). One of these randomised patients with evidence of disc degeneration at L4-5 and/or L5-S1 to either lumbar fusion or a cognitive intervention with exercises. Another randomised airline workers sick-listed with back pain to a behavioural graded activity group or usual care (Staal et al 2004). The trial dealt with an exercise programme (and is accordingly dealt with in the section on Exercise Therapy) but it used behavioural therapeutic principles which aimed at helping sick-listed workers to unlearn pain behaviours through graded activity/exercise, i. Quality Assessment the Cochrane review (van Tulder et al 2000, van Tulder et al 2004) and additional trials (Brox et al 2003, Spinhoven et al 2004, Staal et al 2004, van den Hout et al 2003) were all considered high quality. It found that behavioural therapy did not significantly increase function (pooled effect size was 0. There is strong evidence that behavioural treatment is more effective for pain, functional status and behavioural outcomes than placebo/no treatment/waiting list control (level A). There is strong evidence that a graded activity programme using a behavioural approach is more effective than traditional care for returning patients to work (level A). Effectiveness of cognitive-behavioural treatment vs other treatments One low quality trial (Turner et al 1990) found no difference between behavioural therapy and exercise therapy in relation to pain or depression after 6 or 12 months. Effectiveness of cognitive-behavioural treatment vs fusion surgery One additional, high-quality trial of patients with chronic low back pain and evidence of severe disc degeneration at L4-5 and/or L5-S1, randomized to either lumbar fusion or a cognitive intervention with exercises, found that there was no significant difference between the groups in relation to their improvement in the primary outcome measure, disability (Oswestry), at the 1-year follow-up (Brox et al 2003). There is moderate evidence that the addition of cognitive behavioural treatment to another treatment has neither short nor long tem effects on functional status and behavioural outcomes (level B). Two were high quality trials (Kole-Snijders et al 1999, Turner and Clancy 1988) and five were low quality trials (Nicholas et al 1991) (Bru et al 1994) (Turner 1982) (Turner and Jensen 1993) (Newton-John et al 1995). Catastrophising decreased and perceived control over pain increased at one year in both groups. However, the exact nature of the contribution of the treatment to these changes remained unclear. However, at baseline, people in the problem-solving group had had fewer days sick leave and more had returned to work than people allocated to group education. There is strong evidence that there is no difference in effectiveness between the various types of behavioural therapy (level A). Cost-effectiveness One study conducted a full economic evaluation of a behavioural treatment (Goossens et al 1998). The population consisted of patients with chronic pain including chronic low back pain. The study showed that adding a cognitive component to an operant treatment did not lead to significant differences in costs and improvement in quality of life when compared with the operant treatment alone. Economic endpoints were the costs of the programme and other health care utilisation, costs for the patient, and indirect costs associated with production losses due to low back pain. Compared with the common individual rehabilitation therapy the same effects could be reached at the same or lower costs with a short and intense standardised group programme (Goossens et al 1998). Safety Unknown (no studies found on this issue) Subjects In most trials included in the review, patients with severe, long-lasting chronic non specific low back pain were recruited. The study found no differences between the behavioural treatment and usual care (mixed physiotherapy techniques) at 1 year, for any of the clinical outcome measures (functional status or pain) (Ostelo et al 2003).
Changes in posture are considered in some chiropractic approaches as a measure of outcome bacteria kits for science fair buy vibramycin overnight. Other assessments such as leg length analysis tween 80 bacteria cheap generic vibramycin uk,(70-94) palpatory and strength challenges(95-130) are also employed to bacterial 16s rrna universal primers purchase vibramycin on line amex assess states of muscular responses to antibiotics xorimax vibramycin 100mg discount neurological facilitation. Spinal distortions and resultant neurological interference may create postural or neurological reflex syndromes which result in a functional change in apparent leg length. This information is also combined with skin temperature assessments(131-138) and/or electromyography(139-167, 175-180) as well as technique-specific examination procedures to evaluate the integrity of the nervous system. Orthopedic and neurological tests are indicated only when relevant to the assessment of vertebral subluxation, or when determining the safety and appropriateness of chiropractic care. It is recognized that research will continue to evolve the most efficacious applications of assessment techniques described in this document. However, the literature is sufficiently supportive of their usefulness in regard to the chiropractic examination to warrant inclusion as components of the present recommendation. Clinical Impression An appropriate interpretation of case history and examination findings is essential in determining the appropriate application of chiropractic care within the overall needs of the patient. The clinical impression derived from patient information acquired through the examination process is ultimately translated into a plan of corrective care, including those elements which are contraindicated. Initial Consultation the initial consultation serves the purpose of determining how chiropractic care can benefit the patient. It is during this interchange that the practitioner presents and discusses examination findings with the patient. Additionally, during the initial consultation, the practitioner should take the opportunity to present his/her practice objectives and terms of acceptance. The terms of acceptance provides the patient with 72 information regarding the objectives, responsibilities and limitations of the care to be provided by the practitioner. This reciprocal acknowledgment allows both practitioner and patient to proceed into the plan of care with well-defined expectations. While not limited to the following, it is suggested that the initial consultation include the following parameters: 1. Description of chiropractic: Chiropractic is a primary contact health care profession receiving patients without necessity of referral from other health care providers. Traditionally, chiropractic focuses on the anatomy of the spine and its immediate articulations, the existence and nature of vertebral subluxation, and a scope of practice which encompasses the correction of vertebral subluxation, as well as educating and advising patients concerning this condition, and its impact on general health. Professional responsibility: To assess the propriety of applying methods of analysis and vertebral subluxation correction to patients; to recognize and deal appropriately with emergency situations; and to report to the patient any nonchiropractic findings discovered during the course of the examination, making referral to other health professionals for care or for evaluation of conditions outside the scope of chiropractic practice. Such referral does not obviate the responsibility of the chiropractor for providing appropriate chiropractic care. Practice objective: the professional practice objective of the chiropractor is to correct or stabilize the vertebral subluxation in a safe and effective manner. The correction of vertebral subluxation is not considered a specific cure or treatment for any specific medical disease or symptom. Rather, it is applicable to any patient exhibiting vertebral subluxation, regardless of the presence or absence of symptoms and diseases. A biomechanical definition of spinal segmental instability taking personal and disc level differences into account. Biomechanical characterization (Fingerprinting) of five novel methods of cervical spine manipulation. A comparison between the 3-space isotrak and digital videofluoroscopy in the assessment of lumbar flexion. Biomechanical analysis by chiropractic radiography: Part I A simple method for determining x-ray projectional distortion. Moir contourography and infrared thermography: changes resulting from chiropractic adjustments. Normal magnetic resonance imaging and abnormal discography in lumbar disc disruption. Reliability of magnetic resonance imaging for morphometry of the intervertebral foramen. Magnetic resonance imaging of the cervical intervertebral foramina: comparison of two techniques. The accuracy of magnetic resonance imaging in determining the vertical dimensions of the cervical intervertebral foramina. Lumbar intervertebral foramen dimensions from thirty-seven human subjects as determined by magnetic resonance imaging. Moir topography in scoliosisNits accuracy in detecting the site and size of the curve. The moir contourographic analysis controversy: A question of validity in present-day clinical practice. Determination of a locus of instantaneous centers of rotation of the lumbar disc by moir fringes. The value of cineradiographic motion studies in the diagnosis dysfunctions of the cervical spine. Moir topography in scoliosis: correlations with vertebral lateral curvature as determined by radiography. Development and application of spect-eil indices for quantitative analysis in moir contourography. An intergrated video biofeedback/moir system for diagnosis and treatment: A preliminary report. Moir topography in scoliosis screening: A study of the precision of the method. Inter-examiner reliability using videofluoroscope to measure cervical spine kinematics: A sagittal plane lateral view). A comparative study of the efficiency of different types of school screening for scoliosis. Prevalence study of trunk asymmetries structural scoliosis in 10-year old school children. The neurophysiological evaluation of the subluxation complex: documenting the neurological component with somatosensory evoked potentials. Characterization of neurological insult in the low back utilizing somatosensory evoked potential studies. Intraoperative lower extremity reflex muscle activity as an adjunct to conventional somatosensory-evoked potentials and descending neurogenic monitoring in idiopathic. Paraspinal muscle somatosensory evoked potentials in low back pain patients with muscle spasm: A quantitative study of the effect of spinal manipulation. Intra and inter-examiner reliability of plumb line posture analysis measurements using a three dimensional electrogoniometer. An estimation of the clinical error for the metrecom computer-assisted goniometer. Anatomical and functional perspectives of the cervical spine: Part 1: the normal cervical spine. Validity of derived measurements of leg length differences obtained by use of a tape measure. The value of the forward flexion test and three tests of leg length changes in the clinical assessment of movement of the sacroiliac joint. Inter and intra-examiner reliability of leg length differential measurement: A preliminary study. Optoelectric measurement of changes in leg length inequality resulting from isolation tests. Precise measurement of functional leg length inequality and changes due to cervical spine rotation in pain-free students. Interexaminer reliability of relative leg-length evaluations in the prone, extended position. Reactivity of leg alignment to articular pressure testing: Evaluation of a diagnostic test using a randomized crossover clinical trial approach. Responsiveness of leg alignment changes associated with articular pressure testing to spinal manipulation: the 79 use of a randomized clinical trial design to evaluate. Reactivity of leg length to articular pressure testing: A randomized cross-over clinical trial.
In other words treatment for uti from e coli discount vibramycin 100 mg on-line, the time variable in S and 0 S dier only by 0 t = t + t0 this is sometimes included among the transformations that make up the Galilean group antibiotics you can give dogs purchase vibramycin amex. The existence of a uniform time bacteria in stomach buy vibramycin 100 mg low price, measured equally in all inertial reference frames antimicrobial treatments purchase vibramycin in united states online, is referred to as absolute time. As with the other Galilean transformations, the ability to shift the origin of time is reected in an important property of the laws of physics. All evidence suggests that the laws of physics are the same today as they were yesterday. Cosmology Notably, the Universe itself breaks several of the Galilean transformations. This is the time of the Big Bang (which, loosely translated, means “we don’t know what happened here”). Similarly, there is one inertial frame in which the background Universe is stationary. This is the afterglow of the reball that lled all of space when the Universe was much younger. Dierent inertial frames are moving relative to this background and measure the radi ation dierently: the radiation looks more blue in the direction that you’re travelling, redder in the direction that you’ve come from. There is an inertial frame in which this background radiation is uniform, meaning that it is the same colour in all directions. To the best of our knowledge however, the Universe denes neither a special point, nor a special direction. However, it’s worth stressing that this discussion of cosmology in no way invalidates the principle of relativity. Overwhelming evidence suggests that the laws of physics are the – 7 – same in far ung reaches of the Universe. It is the famous “F = ma”, which tells us how a particle’s motion is aected when subjected to a force F. The quantity in brackets is called the momentum, p mx Here m is the mass of the particle or, more precisely, the inertial mass. It is a measure of the reluctance of the particle to change its motion when subjected to a given force F. In this case, we can write the second law in the more familiar form, mx = F(x, x) (1. Newton’s second law doesn’t actually tell us anything until someone else tells us what the force F is in any given situation. In general, the force can depend on the position x and the velocity x of the particle, but does not depend on any higher derivatives. We could also, in principle, consider forces which include an explicit time dependence, F(x, x, t), although we won’t do so in these lectures. Finally, if more than one (independent) force is acting on the particle, then we simply take their sum on the right-hand side of (1. The single most important fact about Newton’s equation is that it is a second order dierential equation. This means that we will have a unique solution only if we specify two initial conditions. These are usually taken to be the position x(t0) and the velocity x (t0) at some initial time t0. However, exactly what boundary conditions you must choose in order to gure out the trajectory depends on the problem you are trying to solve. It is not unusual, for example, to have to specify the position at an initial time t0 and nal time tf to determine the trajectory. It carries over, in essence, to all other laws of physics, from quantum mechanics to general relativity to particle physics. Indeed, the fact that all initial conditions must come in pairs — two for each “degree of freedom” in the problem — has important ramications for later formulations of both classical and quantum mechanics. For now, the fact that the equations of motion are second order means the following: if you are given a snapshot of some situation and asked “what happens next It’s not enough just to know the positions of the particles at some point of time; you need to know their velocities too. However, once both of these are specied, the future evolution of the system is fully determined for all time. Broadly speaking, there are three directions in which Newtonian physics needs replacing with a dierent framework: they are 8 1 • When particles travel at speeds close to the speed light, c 3 10 ms, the Newtonian concept of absolute time breaks down and Newton’s laws need modication. The resulting theory is called special relativity and will be described in Section 7. As we will see, although the relationship between space and time is dramatically altered in special relativity, much of the framework of Newtonian mechanics survives unscathed. Here the whole frame work of classical mechanics breaks down so that even the most basic concepts, such as the trajectory of a particle, become ill-dened. Nonetheless, there are quantities which carry over from the classical world to the quantum, in particular energy and momentum. For now, we mention only that the equations which govern the dynamics of elds are always second order dierential – 9 – equations, similar in spirit to Newton’s equations. Eventually, the ideas of special relativity, quantum mechanics and eld theories are combined into quantum eld theory. Forces In this section, we describe a number of dierent forces that arise in Newtonian me chanics. We start by describing the key idea of energy conservation, followed by a description of some common and important forces. For now, suppose that the force on the particle depends only on the position, not the velocity: F = F (x). We dene the potential V (x) (also called the potential energy) by the equation dV F (x) = (2. The integration constant is now determined by the choice of lower limit of the integral, Z x 0 0 V (x) = dx F (x) x0 0 Here x is just a dummy variable. In this course we will only take derivatives of position x with respect to time and always denote them with a dot over the variable). While V (x) is called the potential energy, T = mx is 2 called the kinetic energy. We need only dierentiate to get dV dV E = mxx + x = x mx + = 0 dx dx where the last equality holds courtesy of the equation of motion (2. We will spend some time in this course shing them out of the equations and showing how they help us simplify various problems. An Example: A Uniform Gravitational Field In a uniform gravitational eld, a particle is subjected to a constant force, F = mg 2 where g 9. The minus sign arises because the force is downwards while we have chosen to measure position in an upwards direction which we call z. The potential energy is V = mgz Notice that we have chosen to have V = 0 at z = 0. There is nothing that forces us to do this; we could easily add an extra constant to the potential to shift the zero to some other height. The equation of motion for uniform acceleration is z = g Which can be trivially integrated to give the velocity at time t, z = u gt (2. The potential energy of the harmonic oscillator is dened to be 1 2 V (x) = kx 2 the harmonic oscillator is a good model for, among other things, a particle attached to the end of a spring. The force resulting from the energy V is given by F = kx which, in the context of the spring, is called Hooke’s law. The equation of motion is mx = kx which has the general solution r k x(t) = A cos(t) + B sin(t) with = m Here A and B are two integration constants and is called the angular frequency. We see that all trajectories are qualitatively the same: they just bounce backwards and forwards around the origin. The coecients A and B determine the amplitude of the oscillations, together with the phase at which you start the cycle. If we want to determine the integration constants A and B for a given trajectory, we need some initial conditions. For example, if we’re given the position and velocity at time t = 0, then it’s simple to check that A = x(0) and B = x(0).
Employment problems Restrictions There are a number of ways in which epilepsy can have an impact on employment antibiotics for uti zithromax order vibramycin no prescription. In the first instance certain occupations are barred by law to antibiotics for sinus infection augmentin buy cheap vibramycin on line the person with epilepsy because of the potential hazards to antibiotics for uti child order vibramycin now him or her or others if a seizure occurs in the workplace antibiotics over the counter cvs order generic vibramycin from india. These include working as an aircraft pilot, ambulance driver, merchant seaman, taxi driver, train driver, and in the armed services. Secondly, the stigma attached to epilepsy and the resulting prejudice on the part of the employers and co-workers limits employment opportunities for individuals with epilepsy. Thirdly, there are also some occupations in which difficulties may be experienced, although there are no statutory barriers concerning them, such as teaching posts involving physical education, science and technology in state schools, some nursing posts, work with young children and jobs in the prison service involving close contact with inmates. Certain positions also involve substantial risks if seizures are not fully controlled and therefore should not be recommended. To obtain individual must have suffered no seizures or had no treatment for seizures for ten years (see Chapter 54). The available evidence does not suggest any striking lack of efficiency at work in employees with epilepsy. One study of an electrical components firm recorded Unemployment reduced working speed but this was reported to be associated with an increase in precision, which was Quoted unemployment rates vary widely. Figures cited for vocationally active people with epilepsy considered a positive outcome. Elwes and co-authors reported an unemployment rate of 46% for people with epilepsy, as opposed to 19% for a control group10. Significantly longer Data on absenteeism do not indicate any markedly elevated rates in people with epilepsy and turnover rate periods of unemployment and higher rates of early retirement are also reported. Rates of underemployment are reported to be higher for people with epilepsy but these rates are more difficult Seizures at work to quantify. However, the majority of studies investigating employment and unemployment rates among If a seizure does occur at work, three factors affect the level of disruption: the severity, the suddenness and people with epilepsy have been based on highly selected populations or small samples. A severe seizure at work is likely to cause a good deal of disturbance and disruption, at least by Jacoby on a large cohort of people with relatively well controlled epilepsy, 71% of those of working to those in the immediate vicinity. A breakdown of employment rates by clinical and demographic known to have epilepsy. Influence of demographic and clinical characteristics on current employment status. At this time people who are keen to prove their worth and make a good impression may put themselves under the kind of % Currently employed Number of patients stress that makes seizures likely to occur, particularly if they have not disclosed their epilepsy. Male 79 213 Shift work Female 64 266 It has been suggested that adapting to shift work will increase the chances of suffering a seizure in people Age at which first education completed with epilepsy who may be particularly susceptible to persistent fatigue, sleep disturbance and disruption <16 67 340 of routine. If a patient has more seizures in the context of lack of sleep or occasional missed doses 17+ 81 139 of medication then they might be vulnerable if they undertake shift work, as might individuals with well Epilepsy was established nocturnal seizures. Individuals with photosensitive epilepsy are at risk, however this is a rare Yes 67 355 condition in adults with seizures. Most computers work at a frequency which does not tend to provoke No 70 139 seizures. Laptop computers are even less likely to trigger seizures than ordinary computers. Work Self-assessed health status involving computers has increased dramatically in recent years and this growth is of potential benefit to people with epilepsy. Working with computers is relatively safe and enables employment within the Excellent/good 75 398 home, which can overcome the problems of transport. Fair/poor 49 79 Neurological deficit Accidents at work Yes 70 406 the few studies looking at the experience of people with epilepsy at work tend to show that they have No 71 73 no more accidents at work than anyone else. Of course, this may be because they are less exposed Seizure type to potentially high-risk situations, such as working at heights or driving vehicles. It may also be that when accidents occur, particularly if they are relatively minor, they are less likely to be reported. In one study Partial 53 32 of a sheltered workshop employing people with epilepsy, the accident rate was considered so impressively Partial with secondary generalised 74 160 low that the company was awarded insurance premium reductions. In most work situations it should Generalised 70 286 be possible to minimise the risk of accidents. The ineligibility of people with disabilities for employees’ accident liability insurance has been used Components of these programmes include neuropsychological assessment, vocational training, interview incorrectly as a reason for not employing someone with epilepsy. Employers are obliged to take out techniques (including disclosure) and specialist placement and post-placement programmes. The majority of insurance policies will treat anyone with a disability on the same terms as the rest of the workforce providing that the duties allocated take the disability into account. Principles for employing a person with epilepsy: good seizure control, work-related aptitudes this can be obtained from Health and Safety Executives and the Employment Medical Advisory Service. Pension schemes Many employers may believe that new recruits to their pension schemes should have high standards Health care of health. If a person is suitable for employment then they are suitable for a pension scheme. Large company schemes are usually based on a group policy with no requirement for When assessing an employee or job applicant, the employer needs to understand some of the basic facts about individual health criteria to be met. The Health and Safety at Work Act (1974) requires person may require psychological support and education about epilepsy that both employers and employees declare factors which might prejudice the safety of employees and epilepsy is regarded as a relevant factor. A failure to declare can result in instant dismissal which would • In most cases recurrent seizures can be controlled completely with drug treatment not be considered unfair if brought before an industrial tribunal. Shortcomings of this legislation for people with epilepsy have recently Job suitability been highlighted12. The vast majority of jobs are suitable for people with epilepsy: Adequate assessment When assessing employment prospects, many factors need to be considered. Too often, most focus • When medical advice is sought about the suitability of particular jobs for people with epilepsy, is placed on seizure-related factors. While the timing, frequency and nature of attacks is important, the guidance given should take into account the known facts about epilepsy and seizures – blanket these may actually not be the most relevant. A person’s skills, qualifications and work experience will prohibitions should be avoided be crucial. In addition, some inquiry into a person’s understanding and attitude toward his or her epilepsy may be helpful. A prospective employee’s ability to present his or her own seizures in an appropriate and • In those jobs known to carry a high physical risk to the individual worker or to others, the way the reassuring way can do much to allay the employer’s concerns. A thorough neuropsychological assessment may help to identify any problems that may be amenable to intervention, perhaps via a change in medication, which should be taken into account • When a person with epilepsy possesses the right qualifications and experience, job suitability should when advising on career options. Counselling and training is vital to provide input on job presentation skills and the role of psychosocial factors. Most people with epilepsy do not have access to specialist epilepsy rehabilitation services and must rely on mainstream resources. For example, people with well controlled epilepsy and those in remission have employment rates similar to those of the general population without epilepsy6. Smeets and colleagues12 have recently provided a conceptual overview of the employment barriers experienced Recruitment and selection by people with epilepsy. The authors conclude that there is a need for specific vocational rehabilitation • When personal health information is required it should be processed separately from the job application that focuses on increasing self-efficacy and coping skills. However they also recognise the need for form and evaluated by a suitably qualified person longitudinal research to demonstrate that employment opportunities can indeed be improved through specified vocational rehabilitation interventions. However, according to the authors ‘education alone is not enough: • Suitability for a particular job should be decided by the employer before any implications arising from the problem of bridging the gap between knowledge and attitudes and behaviour also needs to be addressed the job applicant’s epilepsy are considered though exposure of persons without disabilities to those with them. Epilepsia When an employee has seizures for the first time, the employer should respond fairly by giving the employee 39, 776–86. In: F Edwards et al (Eds) Epilepsy and Employment: • If any special job restrictions are needed there should be clearly stated policies about how they are A Medical Symposium on Current problems and Best Practices, Royal Society of Medicine Services, London. Educating employers Negative attitudes regarding the employment of people with epilepsy is often the result of ignorance. To this end the Employment Commission of the International Bureau for Epilepsy has drawn up a set of principles aimed at employers to improve awareness and hopefully employment practice. Attention is drawn to four key areas: health care, job suitability, recruitment, and selection and assistance at work. Summary Employment serves a number of important functions, including providing a sense of self-worth, an identity and personal status.
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