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For the first time 160 mg super avana mastercard, then order 160mg super avana overnight delivery, the Introduction xiii market became a factor for the industry. These developments resulted in the introduction of marketing as a legitimate function in healthcare. By the mid-1980s, marketing departments had been established in most of the large healthcare organizations. Once introduced to each other, marketing and healthcare passed through a tentative getting-to-know-you period. By the mid-1980s, however, it was a romance in full bloom with the two being seen everywhere together. Healthcare organizations were spending feverishly on their newfound consort, and marketers rushed to take advantage of the sudden burst of interest. Those without formal depart- ments started developing marketing functions through other mechanisms. Hospitals were among the first to embrace marketing as a part of their operations. As new forces emerged in the industry, often led by entrepreneurs rather than clinicians, the use of marketing techniques proliferated. Innovative health- care programs, such as urgent care centers and freestanding diagnostic cen- ters, began using marketing as a means of attracting patients from the established sources of care. Unfortunately, in the early years healthcare executives did not see marketing for what it really was, and many expensive mistakes were made by the organizations pioneering healthcare marketing. Healthcare organi- zations failed to do their market research homework, rushed headlong into expensive media advertising, became obsessed with image rather than sub- stance, and failed to evaluate their hastily contrived marketing initiatives. As a result of these mistakes, by the late 1980s healthcare organiza- tions were slashing their marketing budgets, disbanding marketing staff, and generally scaling back this relationship. Healthcare did not want to break it off altogether, but it did not want to continue spending on ini- tiatives with uncertain benefits. Both parties—healthcare and marketing—could probably be blamed for the shaky initial relationship. The marketers that healthcare imported from other industries failed in their effort to convert existing marketing techniques to healthcare uses. The first rule of marketing, of course, is to know your market, and marketers did not. They were offering quick fixes and short-run answers in an industry that required long-term initiatives. By the early 1990s, healthcare executives realized that marketing did not consist of spending truckloads of money on mass-media advertising. Progressive healthcare organizations began to assess their marketing objec- tives in a more reasonable light. They began to try to understand the mar- ket, their customers, and their customers’ motivations. Sensitive issues that are not factors in other industries had to be addressed in healthcare. Furthermore, marketers were faced with the unique situation in which cer- tain consumers were "desirable" and others were not. Today, healthcare marketers have a much better understanding of the market and their customers. An appreciation for what works and does not work in terms of marketing initiatives has evolved. New techniques have been developed specifically for the healthcare market, and a core of professional healthcare marketers have emerged. The rest of this book will be devoted to the development of an under- standing of marketing as a field and its application to healthcare. The chap- ters introduce the reader to the concepts, methods, and data used in healthcare marketing, providing the information required for developing an appreciation of the role of marketing in healthcare along with the tools necessary to plan and implement marketing initiatives. The book provides sound grounding in basic marketing concepts, along with background on the factors that drive marketing approaches and consumer behavior in healthcare. It presents nuts-and-bolts information on the marketing process and its management. It also critiques the mar- keting techniques currently in use in healthcare and introduces emerging techniques being adapted for healthcare.

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According to stan- dards prepared under the auspices of the International Society of Electro- physiological Kinesiology (ISEK) discount 160mg super avana mastercard, the range of signal frequencies for surface EMGs is from 1 to 3 cheap 160mg super avana amex,000 Hz (Winter et al. In general, however, most of the power of the signal is in the range 50 to 150 Hz and certainly below 250 Hz (see Figure 4. For this reason a sampling frequency of 500 Hz would be more than adequate for surface EMG and will be within the capabilities of most data capturing systems presently in use. You can use needle or wire electrodes (Basmajian and DeLuca, 1985) and there are other possibilities, such as monopolar or bipolar surface electrodes. For a comprehensive review of these and other electrode types, refer to the texts by Loeb and Gans (1986) and Geddes (1972). The advantages of these electrodes are that they are simple to use, are noninvasive, and, if the skin surface is well prepared, will provide a good indication of the underlying muscle activity. Though in many applications in gait analysis this is not a problem, there are times when a deep muscle, such as tibialis posterior, may be suspected of some underlying pathology (such as spastic hemiplegia with a varus foot) and only deep, indwelling electrodes can be used. These electrodes are used more often to capture ECG (electrocar- diographic signals, but they also work well for EMG. A possible source of confusion here is that if the amplifier measures the difference between the two signals at its input stage, the need for a separate ground electrode is not that obvious. V V V2 The signals and1 2 are the input from the R2 electrodes placed on the muscle; the signal Vo R R 0 3 the output from the if = R1 R2 amplifier. R3 R then 0 [V - V ] V =o 2 1 R1 As mentioned earlier, one method for reducing motion artifact is to select electrodes such as the Ag/AgCl variety, which have low half-cell potentials. Another method of getting rid of most of these spurious signals is to take advantage of the fact that motion artifact noise is at the low end of the fre- quency spectrum (as seen in chapter 2, most gait signals repeat about once per second, i. By filtering out or removing any signals with a frequency less than 20 Hz, many of the problems caused by artifacts can be reduced. Also, as indicated previously, using a notch filter to eliminate 60 Hz background noise (sometimes referred to as “mains hum”) would be advis- able. Signal Processing Methods Some methods for processing EMG data have been recommended by ISEK (Winter et al. These include • full-wave rectification, in which the absolute value of the signal is taken; • a linear envelope detector, which consists of full-wave rectification fol- lowed by a low-pass filter (i. MUSCLE ACTIONS REVEALED THROUGH ELECTROMYOGRAPHY 52 Raw signal Rectified Figure 4. Notice Threshold that the threshold detection detector to determine if a muscle is on or off must Integrated be set arbitrarily. Voltage reset Time For the rest of this chapter, and in the software examples demonstrated in Chapter 5 and GaitLab, we have chosen to represent EMG signals processed by the linear envelope method. One of the fascinat- ing features of human gait, however, is that the central nervous system must control many muscles simultaneously. When you consider that this graph is for one side of the body only and that there is another set of muscles on the other side which are half a cycle out of phase, you realise just how complex the human locomotor apparatus is! This applies both to muscles with similar actions (such as tibialis anterior and extensor digitorum longus), as well as those with no immediately apparent connection (such as rectus femoris and gluteus maxi- mus). Wooden models of the pelvis and lower limbs were constructed and arranged in an expanded and sequential series depicting a single stride. Based on photographs of these models, drawings were made, and muscle groups were superimposed on the drawing of each model at each position. Then the level of the muscle activity was indicated by colour: red, highly active; pink, intermediate; and white, quiescent. The shading indicates the degree of activity: black, most active; stippled, intermediate; and white, quiescent. In addition, these muscle activity sequences have been colour-coded and animated in GaitLab. Tibialis posterior Adductor longus Adductor magnus Iliopsoas Sartorius Extensor digitorum longus Extensor hallucis longus Tibialis anterior Gracilis Semimembranosus Semitendinosus Biceps femoris (long) Biceps femoris (short) Stance phase Swing phase MUSCLE ACTIONS REVEALED THROUGH ELECTROMYOGRAPHY 54 Heel strike Foot flat Midstance Heel-off Figure 4. Toe-off Acceleration Midswing Deceleration Initial swing Preswing Midswing Terminal swing 55 DYNAMICS OF HUMAN GAIT A careful study of Figures 4.

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In-session and at-home exercises discount super avana 160mg without a prescription, including some reading and videos on the concepts and skills they were working on g generic super avana 160 mg online. Sessions at home where they would discuss their concerns about their children individually with each child and together as a family Discussion of this treatment plan continued during the fourth session, and the couple and therapist signed it and began to implement it. Progress The first treatment session (end of number 4) and the subsequent one (number 5) focused on the cognitive aspects of initial perceptions and expectations about the relationship. The couple was animated in dis- cussing how they met and were so excited about each other, and believed that the glow they felt would carry them through everything. They ac- knowledged that they assumed incorrectly that they did not need to plan their time more carefully; work on clear, direct communication; or develop negotiating skills. Their refrain was (commonly heard among clinical cou- ples) "Why should we have to work so hard on our relationship? The concepts of empathy and listening skills, the difference between feeling and thinking, and assertiveness were also discussed (cf. This was followed by behavioral rehearsal and role reversal, and as the couple took well to these ideas and techniques, they were urged to prac- tice them during the week, including a 30- to 45-minute session consisting of only "feeling talk" and active listening. During the eighth session, the feeling tone between Indira and José was notably more vital and positive. When I mentioned this, they responded that they realized that by facing their difficulties and working on them, they could move ahead and have more realistic expectations of each other. They identified and prioritized key problem areas and agreed to work on them one at a time. In the ninth session, they acknowledged their different perceptions regarding Elena and Roberto, but concluded that each of their perceptions were valid, and the couple could work with each other in addressing them. Because José felt strongly about Roberto’s choice of friends and Indira was most con- cerned about Elena’s "precociousness," they both agreed to have individual Cognitive Behavioral Couple Therapy 133 discussions with the child each was most concerned about and then to discuss the results as a couple. As it turned out, Indira was satisfied with Elena’s comments and assurance that she was not in danger and knew her limits. José was less confident about Roberto’s descriptions of his activities with his friends, and Indira agreed that the three of them would speak to- gether. Essentially, a mutually supportive process for problem solving was created, and they proceeded to work on their sexual relationship and divi- sion of home responsibilities for six additional sessions following the end of the contract, bringing the total to 15. As the treatment reached conclusion, the issue of behavior exchange, or quid pro quo, was highlighted as a means of integrating the cognitive, com- munication, and problem-solving dimensions. By progressing sequentially through these areas, Indira and José each came to feel that their partner was truly as invested in the relationship as they were. I pointed out that this sense of equity is essential to maintaining goodwill in the relationship, and for accepting differences and strengthening commitment. Further, I ex- plained that at any moment, the balance of responsibility may be 80%/20% when one partner shoulders most of the responsibilities while the other is ill, has extra work commitments, or may be caring for an aging parent. Such an imbalance requires open discussion and negotiation, with a clear sense that the balance of responsibility will be more nearly equal when the stresses of the 20% partner decrease. With this sense of equal behavior ex- change, clear communication, and good problem-solving skills, all aspects of a relationship can remain functional and satisfactory over time. CASE ANALYSIS In many respects, José and Indira are typical of couples who met each other at a relatively young age and who remain together for decades. They were very excited about each other and had a free and easy relationship until their lives became more complex. There was some remote pressure from Indira’s family and some culturally based expectations, although these were mediated by educational and geographic factors. Mostly, they are a typical middle-class, middle-aged, dual-career couple with predictable stressors. Initially, an open discussion between Indira and José was needed to clar- ify their perceptions and feelings about their relationship. Numerous as- sumptions had evolved over the years, and because they were unspoken, they led to misperception, confusion, and irritation. As these became ex- plicit, it was important for both partners to state their reactions of acceptance and commitment (or lack of them) to each other regarding major issues.

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