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Jeffrey A Brinker, M.D.

Jeffrey A Brinker, M.D.

  • Professor of Medicine
  • Joint Appointment in Radiology and Radiological Science


Nodal counts and lymph node ratio impact survival after distal pancreatectomy for pancreatic 558 buy purim 60caps on line godakanda herbals. Available at: adenocarcinoma: is there a survival difference for R1 resections versus generic 60caps purim mastercard herbs that help you sleep. Microscopic margins ratio as an important prognostic factor in pancreatic ductal and patterns of treatment failure in resected pancreatic adenocarcinoma buy online purim herbals that prevent pregnancy. Am J French multicentre prospective evaluation of resection margins in 150 Clin Oncol 2014;37:13-18. Neoadjuvant treatment for resectable pancreatic cancer: time Oncol 2016;114:336-341. Neoadjuvant therapy of pancreatic versus gemcitabine for resected pancreatic cancer: a phase 3, open-label, cancer: the emerging paradigm Comparison of flourouracil with additional levamisole, higher-dose trial and literature review. Available at: folinic acid, or both, as adjuvant chemotherapy for colorectal cancer: a. Resection of borderline resectable pancreatic cancer after neoadjuvant chemoradiation does not 568. Weekly high-dose leucovorin depend on improved radiographic appearance of tumor–vessel versus low-dose leucovorin combined with fluorouracil in advanced relationships. Neoadjuvant therapy may radiotherapy for patients with borderline resectable pancreatic cancer: a lead to successful surgical resection and improved survival in patients with meta-analytical evaluation of prospective studies. Preoperative capecitabine study of neoadjuvant gemcitabine and oxaliplatin with radiation therapy in and concurrent radiation for borderline resectable pancreatic cancer. A systematic review and gemcitabine plus radiotherapy versus gemcitabine, 5-fluorouracil, and meta-analysis of survival and surgical outcomes following neoadjuvant cisplatin followed by radiotherapy and 5-fluorouracil for patients with chemoradiotherapy for pancreatic cancer. J Gastrointest Surg locally advanced, potentially resectable pancreatic adenocarcinoma. Acta Oncol 2013;52:1231 study of induction fixed-dose rate gemcitabine and bevacizumab followed 1233. Available at: induction chemotherapy and neoadjuvant stereotactic body radiotherapy. Available at: by resection versus upfront resection for resectable pancreatic cancer: a. Preoperative and postoperative chemoradiation strategies in patients treated with 593. Neoadjuvant therapy is pancreaticoduodenectomy for adenocarcinoma of the pancreas. J Clin associated with improved survival in resectable pancreatic Oncol 1997;15:928-937. The cost-effectiveness of pancreaticoduodenectomy for adenocarcinoma of the pancreas. Arch Surg neoadjuvant chemoradiation is superior to a surgery-first approach in the 1992;127:1335-1339. Preoperative chemoradiation for patients with localized adenocarcinoma of the chemoradiation reduces the risk of pancreatic fistula after distal pancreas. Neoadjuvant/preoperative radiation therapy and chemotherapy for patients with localized, resectable gemcitabine for patients with localized pancreatic cancer: a meta-analysis adenocarcinoma of the pancreas: an Eastern Cooperative Oncology of prospective studies. Available at: surgical resection for resectable pancreatic cancer: a review of current. Pancreatic cancer treatment and research: an international expert panel discussion. Available at: chemoradiotherapy on surgical margin status of resected adenocarcinoma. Second pancreatectomy for recurrent pancreatic ductal adenocarcinoma in the remnant pancreas: A pooled 608. Available at: chemoradiation therapy with gemcitabine/cisplatin and surgery versus. Available resection for isolated pancreatic adenocarcinoma metastasis: an analysis at. Yield of clinical and radiographic surveillance in patients with resected pancreatic 619. Covered metal versus plastic stents for postoperative surveillance after curative treatment of pancreatic cancer: a malignant common bile duct stenosis: a prospective, randomized, cost-effectiveness analysis. Palliative biliary stents for Abdominal imaging after pancreatic cancer resection: a national study. Available at: metal stents with an anti-migration system improve patency duration. Available at: gastrojejunostomy versus duodenal stent placement for malignant gastric. Long-term outcome of biliary and duodenal stents in palliative treatment of patients with unresectable 630. Am J Gastroenterol stent placement in patients with malignant gastric outlet obstruction: a 2006;101:735-742. A gastrojejunostomy for the palliation of gastric outlet obstruction: a prospective randomized trial.

Current medications include a short-acting 2-adrenergic agonist by metered-dose inhaler as needed order purim 60 caps line herbals a to z. At the end of the examination generic purim 60caps amex earthworm herbals, he tells the physician discount purim 60 caps fast delivery jiva herbals, "I enjoy coming to see you because you remind me of my daughter. Unfortunately, since we only have a limited amount of time, we must now move on to your medical condition. A 9-month-old boy is brought to the office by his mother for a well-child examination. She says he also awakens and cries at least once nightly and settles back to sleep after drinking a bottle of formula. Which of the following is the most likely explanation for this patient’s sleep pattern A 32-year-old man comes to the office because of a 2-year history of abnormal movements of his hands that are worse when he feels angry or depressed. His maternal grandmother and mother, both now deceased, had similar symptoms with onset at the ages of 53 years and 42 years, respectively. He is unable to fix his gaze on one point or protrude his tongue for more than 30 seconds. This patient most likely has an anatomic abnormality in which of the following locations Every year, 34,000 women in Europe are diagnosed with cervical cancer, and 13,000 of them die. Since launch, more than 63 million subjects are estimated to have been vaccinated with Gardasil worldwide. Cumulative marketing exposure to Cervarix is estimated as being more than 19 million subjects worldwide. Therefore, Denmark asked the European Commission to initiate another in depth review. Cervical cancer is the second most common cancer in women worldwide, with approximately 530,000 new cases diagnosed each year and 275,000 deaths annually. In the European Union, about 34,000 new cervical cancer cases are diagnosed every year causing about 13,000 deaths per year. Of particular concern, the incidence of anal cancer has been increasing in both men and women over the past several decades. In Europe, the incidence rate of anogenital warts is estimated to vary between 150 and 170 per 100,000 person-year in the general population, and is generally found to be highest among 20-24 years old individuals. Prompt diagnosis and early treatment are considered best practice in order to avoid secondary physical problems associated with disuse of the affected limb and the psychological consequences of living with undiagnosed chronic pain. Since the condition is infrequent, and the range of symptoms can mimic a large number of other possible conditions seen by practitioners from various professional backgrounds, patients commonly experience a delay in diagnosis and the start of appropriate therapies. One suggested that 74% of patients experienced resolution of the syndrome, with symptoms lasting a median of 7 months. Aug;150(2):268-74 3 Sandroni et al, (2003) Complex regional pain syndrome type I: incidence and prevalence in Olmsted county, a population-based study. Limb signs (such as swelling, sweating and colour changes) usually reduce with time, even where pain persists. For those in whom pain persists, psychological symptoms (anxiety, depression), and loss of sleep are likely to develop, even if they are not prominent at the outset. Overall, given the complexity of the syndrome and likely differential practice in approaches to diagnosis and management across countries and centres, reported background incidence may differ between countries. These symptoms may include palpitations, light headedness, weakness, ‘brain-fog’, peripheral coldness and purplish skin discolouration and blurred vision. This wide spectrum of symptoms probably reflects that the syndrome has several distinct pathophysiological mechanisms. For those aged 12–19 years this increase should be least 40 beats per minute (Sheldon et al, 20156; see table 2). Studies on subjects from the general population have suggested that having a positive tilt-test in an adolescent patient – regardless of symptoms – is common (Singer et al, 20127, Zhao et 5 de Mos et al, (2007) the incidence of complex regional pain syndrome: A population-based study, Pain; 129, 12-20. A definition of a syndrome that combines unspecific symptoms with a diagnostic test that is frequently positive in the normal population underlines the difficulties of studying such a syndrome and trying to establish reliable incidence estimates. Anxiety, depression, and other psychiatric disorders can also add to the complexity of the syndrome. In adolescence, the majority of affected individuals report symptoms beginning within a year or two of the beginning of puberty, with worsening symptoms until the age of 16. Whilst each patient has a unique set of symptoms, it is said that their stories often sound familiar. A large number of patients initially become symptomatic following a significant febrile illness, often mononucleosis or influenza (Kizilbash et al, 2014). Many sufferers experience full recovery over time with or without treatment, but some have persistent symptoms. Ninety per cent of patients will respond to a combination of physical and pharmacotherapy (Grubb et al, 2006)11. Occasionally, some patients experience deterioration in their daily life activity over time to such an extent that they are unable to continue normal employment or educational activities. The level of overlap will likely depend on the selection criteria within each study, and it is unclear how these estimates can be generalised. Journal Cardiovascular Electrophysiology 17: 108-112 12 Lewis et al, (2013) Clinical characteristics of a novel subgroup of chronic fatigue syndrome patients with postural orthostatic tachycardia syndrome. Int Med; 273, 5, 501–510 13 Hoad et al, (2008) Postural orthostatic tachycardia syndrome is an under-recognized condition in chronic fatigue syndrome.

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Overarching term for persons with various identities and expressions that are Transgender associated with assignment of incorrect sex cheap purim online american express herbs to grow indoors. Legal purim 60caps lowest price vhca herbals, medical purchase purim online herbals supplements, and surgical processes that a transsexual person might experience to Transition correct the incongruence of incorrect sexual assignment. Individual patients might be in the process of transitioning to their preferred gender through medical. Physical therapists should determine if patients in transition are currently under medical treatment for this transition, which could occur prior to or in conjunction with surgical transition, and will be continued after surgical transition. If the patient is on hormone replacement therapy, physical therapists should use the transitioned gender to determine the reference value. If the patient is not receiving hormone therapy, physical therapists should use the patient’s biological sex to determine the reference value. For example, a transwomen on estrogen replacement therapy should have her lab values compared to normal values of females due to the effects of estrogen on her physiology, whereas a transman on testosterone should have his lab values compared to those of males due to the effects of testosterone on his physiology. The key factor is not whether the medical record assigns a patient a particular sex or whether the patient has undergone sexual reassignment surgery, but whether patients are taking hormone therapy that will affect their physiology and lab chemistry. Knowing the medical transition status of a transsexual person reduces the risk of misinterpretation of lab values and ensure correct application of normal reference values consistently. Age Considerations this outline was created to assist the clinician with lab value considerations for the general population. The clinician should be aware that “norms” are created for the healthy adult, and each patient’s lab values should be interpreted within the context of the patient’s current medical status. That is to say, when reading the value ranges in this section, be aware that considerations for mobility might vary based on the patient’s age and current medical condition. For example, an 18-year-old boy with a below-normal hematocrit might tolerate this lower level better than a 90-year-old male with the same low hematocrit. Thus, a clinician might be more willing to mobilize a patient with a below-normal value who is younger and has overall more reserve. Conversely, patients being treated for certain blood cancers can more safely participate in mobility with lower platelet levels vs. Please refer to the Academy of Pediatric Physical Therapy for more information, as normative values might differ from the adult populations. Congenital L ym phadenopathy Chronic inflam m ation Painfulinflam edjoints W hite Blood Cells Connectivetissue disease R outinetesttoidentify Anem ia thepresenceof Viralinfections Trending W eakness Sym ptom s-basedapproach when infection,inflam m ation, Chem otherapy Dow nw ard F atigue determ ining appropriatenessforactivity, allergens. M edicalteam m ightm onitorpatientswith pre-ex isting cerebrovascular,cardiac,orrenalconditionsfor ineffectivetissueperfusionrelatedtodecreased hem oglobin. Sicklecellanem ia hospitaliz edpatientswhoare Stresstobone hem odynam icallystableandasym ptom atic N ote:Values are sligh tly m arrow m aytransfuseat7g/dL decreased inelderly. M ightpresentwith L eukem ia tachycardiaand/ororthostatic N ote:Values are Bonem arrow failure hypotension. D ietarydeficiency M edicalteam m ightm onitorpatients Trending D iz z iness Pregnancy with pre-ex isting cerebrovascular, Dow nw ard Coldhands/feet H yperthyroidism cardiac,orrenalconditionsfor (anemia) Chestpain Cirrhosis ineffectivetissueperfusionrelatedto Arrhythm ia 18 R heum atoidarthritis decreasedhem atocrit. Shortnessof breath H em orrhage H igh altitude If <25% :Sym ptom s-basedapproach whendeterm ining appropriatenessfor activity;collaboratewith interprofessionalteam (regarding possibleneedfor/tim ing of transfusion priortom obiliz ation)13-15,18 11 3. Changesin sodium,potassium andcalcium altertheex citabilityof neurons,cardiac,andskeletalm usclesthatcanproducearrhythm ias,weakness,andspasm s/trem ors. Im portantforbone Trending U pw ard E x cessivevitam inD D ecreasedreflex es form ation,celldivision Cancer Constipation andgrowth,blood 20 21 R enalfailure N ausea/vom iting coagulation,m uscle contraction,and releaseof Anx iety neurotransm itters. Trending Dow nw ard E x cessivevom iting 21 Cram ping and/ordiarrhea 21 Twitching 13 E lectrolyteR eferenceValues Causes Presentation ClinicalIm plications Ventriculardysrhythm ia Bonedestruction– H eartblock H yperphosphatem ia tum or Asystole P hosphate (h igh levelof Im m obiliz ation Com a Sym ptom s-basedapproach when (P O 4) ph osph ate inblood) F racture L ethargy determ ining appropriateness Trending U pw ard E x cessivevitam inD M uscleweakness of activity. Increasedreflex es M usclecram ps21 D iaphoresis Increasedintakeof N /V M agnesium H yperm agnesem ia antacids/m agnesium D rowsiness Sym ptom s-basedapproach when (M g) (h igh levelof citrate L ethargy determ ining appropriateness magnesium inblood) R enalfailure W eaknessflaccidity 1,20,21 foractivity. F ever whendeterm ining D ecreasedcognition 1,20,21 Increasedprotein appropriatenessforactivity. R educedurineoutput D ark-coloredurine E dem a D ecreasedtoleranceto R enaldisease Backpain activity. E ndocrine GlucoseR eferenceValues Causes Presentation ClinicalIm plications D iabetesm ellitus21 D ecreasedtoleranceto 24 Sepsis 21 Glucose activity. Increasedacid other L ax ativeabuse K idneydisease Acidosis production intestinal Thiaz idediuretics Cardiac E x pectsom nolenceandfatigue. L iverF unction/H epatic P anel L iverF unction/H epatic PanelR eference R anges Causes Presentation ClinicalIm plications Assessestheliver’sabilitytoclearbilirubin,total protein,andalbum in. Severeinfections Congenitaldisorders S erum Album in Severedehydration H epatitis Clinicalfeaturesare Assessintegum entarydaily Chronic inflam m ation H alf-lifeof 21days. Infection 0-5m g/dL = severe L ow levelsoccurwith prolonged N utritionalcom prom ise 13 proteindepletion hospitalstay. Inflam m ation Trending Peripheraledem a L iverdisease 5-10m g/dL = m oderate Dow nw ard N on-healing wound Serum Album in:<3. Sym ptom s-basedapproach when determ ining appropriatenessfor S erum Bilirubin Cirrhosis Patientswith severe 1,18,19 activity. H epatitis diseasem ighthave Totalbilirubin Trending H em olytic anem ia fatigue,anorex ia, Adapteducationif decreased U pw ard J aundice nausea,fever,and, cognition. Criticalvalue:>12 Bileductocclusion M ighthaveloose,fatty Patientswith advanceddiseaseareat 13 Chem otherapy stools. H epatic encephalopathy Am m onia (N H 3) Confusion Cirrhosis L ethargy 13 Severehepatitis D em entia 15-60µg/dL R eye’ssyndrom e D aytim esleepiness M ightneedtoaltercom m unication Trending Severeheartdisease Trem ors andeducation,anddesignatepatient E valuatesliverfunction U pw ard K idneyfailure Breakdownof fine asanincreasedfallrisk,if andm etabolism. If theliver (peripheralnerve isdam aged,then im pair) increasedam m onialevels Speech im pairm ent arenoted. Therapistsshouldbeawareof thealteredvalues im plicationsfor each of theselaboratorym easureswhendevising aplanof carewith patientswhoarebeing consideredfor,orareon,thelistforliver transplantation. Physicaltherapistsshouldreview F K trough (Tacrolim us/Prograf test)toassessfortrends(spikes)whenevaluating patientsforsafeex ercise prescription.

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Appropriate chronic pain management may involve prescription medications order purim from india herbals for anxiety, which require knowledge of risks for adverse effects such as dependency and addiction purchase purim overnight delivery herbals world. Activity level and mood may vary depending on the intensity of chronic pain (good days and bad days) order 60 caps purim overnight delivery herbals and diabetes. Awareness of conditions and activities that contribute to injury, especially in the workplace, can prevent pain. Learning objectives and potential outcome measures for an educational campaign on safer use of pain medications Learning Objectives Increasing the number of people with chronic pain who report that they: 1. Talk with their clinician about their hopes and expectations and share activities of daily living or function that are important to them. Work with their clinician to develop a plan of treatment consistent with their goals. Know that analgesic medications can be an appropriate pain management option in selected and monitored patients and they are not the only option. Know their prescription medication is only for them and do not share it with others. Know how to understand and recognize expected and unexpected adverse effects such as dependency and addiction and to discuss risks with their doctor. They talk to their doctor before taking prescription medications in combination with other drugs, including alcohol, sleeping pills, or anti-anxiety medication. Have discussed with family and friends how to recognize and respond to overdose, including the use of naloxone. Encourage family and friends to utilize Poison Control Centers as a confidential resource and to report possible 24 opioid exposure and/or abuse by calling the Poison Help line Potential Outcome Measures Where possible, existing data sources should be employed to monitor measures such as:* 1. The risks of epidural and transforaminal steroid injections in the Spine: Commentary and a comprehensive review of the literature. J Pain 2011; 12(12): 1199–1208 9 International Association for the Study of Pain Declaration;. Suicidality in chronic pain: A review of the prevalence, risk factors and psychological links. The Prevalence of Chronic Pain in United States Adults: Results of an Internet-Based Survey. Population-based survey of pain in the United States: differences among white, African American, and Hispanic subjects. Trends in prescriptions for oxycodone and other commonly used opioids in the United States, 2000-2010. Drug Abuse Warning Network, 2007: national estimates of drug-related emergency department visits. Prescribing Opioid Analgesics for Chronic non-Malignant Pain in General Practice a Survey of Attitudes and Practice. Pain management by primary care physicians, pain physicians, chiropractors, and acupuncturists: a national survey. What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors Empathy decline and its reasons: A systematic review of studies with medical students and residents. In particular, chronic non-cancer pain was suggested as a treatable condition necessitating long-acting medications, without solid scientifc evidence supporting that practice. As a society, we are reaping the consequences of that change in prescribing habits with an increase in opioid dependency, accidental drug overdoses, and heroin use. The expectation on the part of the 1,2,3 public that there is a pill to be prescribed for any discomfort is harder to quantify but no less important. The message embodied in this document is that opioids are powerful drugs that can create calm and relief when used wisely but can cause great harm when prescribed injudiciously. Every encounter with a patient in pain will require the same analysis, and patient safety should guide all treatment recommendations. Practicing outside those parameters puts your patient, or your patient’s family, or the community at large, at risk. Too many pills prescribed for a given situation can create dependency in your patient, or if they are stolen or diverted, can feed the illicit habit of others. This is an iatrogenic public health crisis, and all of us in the healthcare profession have to assume 4 responsibility in fxing it. We continue to adjust our recommendations as information concerning safe practice evolves. Likewise, we have reduced the maximum safe methadone dose from 40 mg/d to 30 mg/d, refecting the increase in overdose deaths associated with methadone use for pain treatment. To achieve genuine and lasting practice change, our entire community has to be educated concerning our current understanding of the appropriate management of pain. All of us need to understand the science that underlies current best-practice recommendations. We felt the best approach would be to promote a grassroots efort, achieving regional, broad support for these guidelines. Providers would share common understanding, our patients would hear a consistent message, and the community at large would support these eforts. Our group process has evolved over the past fve years, but includes didactic learning, small group discussion, case presentations, and updates on community activities. We have done our best to incorporate and be consistent with recommendations in both these guidelines.

It was decided that six months was practicable to purchase purim mastercard herbs collinsville il fit with the time requirements of the participating therapists cheap 60 caps purim with amex wiseways herbals. A questionnaire was sent to purim 60 caps with mastercard herbalsolutionscacom patients comprising outcome measures at each follow-up time point. A postal method of data collection was selected over an appointment as it had been reported that participants with symptom resolution were less likely to attend follow-up appointments (Dawson et al. Six weeks was selected to represent the end of the intervention period, based on participants receiving up to six, weekly appointments. Six or fewer appointments had been identified in the literature as the mean number of appointments needed to achieve clinical effectiveness in neck pain (Klaber-Moffett et al. The 26 week follow-up represented a mid-point review that evaluated change between the short-term and long-term outcomes, to provide more detailed, longitudinal information on intervention effects. The 52 week follow-up was the primary end point in this trial, in-line with other cervicobrachial studies (Walker et al. Long-term outcomes have also been reported as being important to justify the efficacy of treatment modalities used in neck pain (Hurwitz et al. The effects of manual therapy on cervicobrachial pain in the short (6 weeks) and long-term (52 weeks) also reflects assessments of clinical interest in previous studies (Persson et al. This established how representative the study cohort was, to determine generalisability (Burgess et al. These variables had previously been identified (with a moderate level of evidence) to predispose or be associated with the development of cervicobrachial pain (Finocchietti & Trindade,1973; Kostova & Koleva, 2001; Kaki, 2006). Additional information included smoking status and occupational status, which have been associated (a low/ very low level of evidence) with cervicobrachial pain were collected (Finocchietti & Trindade, 1973; Krapac, 1989; Sauter et al. Details on absence from work due to cervicobrachial pain were included as a baseline measure for cost analysis. This test has been used as a prerequisite in studies investigating manual therapy intervention on neurogenic cervicobrachial pain (Allison et al. The test was defined as positive when symptoms were reproducible or when there was a reduction in elbow extension by greater than 10° compared to the asymptomatic side (Wainner et al. The Principal Investigator taught Assessment Physiotherapists how to perform and interpret the test. Assessment Physiotherapists practised the technique until they were able to demonstrate its application and could verbally 112 support what they would classify as a positive test. The method of applying the test was written on the assessment sheet as a reminder to all Assessment Physiotherapists on how to conduct the test. Follow-up training was done at six monthly intervals during the course of the trial. It was recognised that participants with a preference for one of the interventions might bias the trial positively if they believed that they had received the more effective treatment, or negatively if they believed that they had received the less effective treatment (Brewin and Bradley 1989; Klaber Moffett et al. Asking for patient preference at baseline enabled post trial consideration to be made on whether preference was associated with change on the primary outcome measure (Adamson et al. A high level of pain perception leads to increased disability and reduced function, having an adverse effect on health and wellbeing (Daffner et al. Consequently, pain has been the single most consistently used outcome across all studies evaluating effectiveness of intervention on cervicobrachial pain. Self-report outcome measures have been considered a clinically relevant and reliable means for assessing pain perception (Dworkin et al. This intensity scale has been used frequently to assess pain perception in research studies (Dworkin et al. Each scale comprised a 100mm horizontal line marked “no pain” at 0 and “worst pain imaginable” at 100 (hence, higher scores related to higher pain perception). Participants were asked to mark a cross on each scale to indicate the intensity of their pain. One scale represented worst pain in their neck and arm, and a second scale represented average pain in their neck and arm. This has been reported to be an important consideration when interpreting study findings (Balsham et al. Other versions of global rating of change scores 115 were considered, including those with fewer and more points; however the 13-point scale has been validated for use in upper limb disorders, has established clinically meaningful differences for this population (Jaeschke et al. Pain medication used a self-complete descriptive scale at follow-up to identify any change requirements to pain medication. Other methods for assessment were considered, including the ranking of pain medication according to the ‘pain ladder’ (Lawrie & Simpson, 2006; Sarzi-Puttini et al. There was moderate evidence, in the literature that cervicobrachial pain could negatively impact on 116 function and disability (Daffner et al. Function can be affected by personal factors whereas disability has a more encompassing affect from environmental factors (World Health Organisation, 2002). Function and disability can be assessed using condition-specific or generic outcome measures. Condition-specific measures provide more detailed information on limitations particular to that condition, whereas generic outcome measures can evaluate the effect of an intervention on overall well being (Guyatt et al. This was chosen because it was the only tool that evaluated symptoms in the neck and arm, collectively, making the content validity high for patients with cervicobrachial pain (Stock et al. Scores range from 0 to 100, with high scores indicating worse function/disability.


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