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November 2011

DME: BRACING FOR CHANGE Durable Medical Equipment Helps Chronic Pain Patients PAGE 9

TENS UNIT A Drug-Free Alternative to Pain Relief PAGE 7

PLUS Ask the Expert: Electromyography (EMG) ༛S

November Cooking ༛S

Pain Management: Ultrasound Technology ༛S

Brace by BREG www.breg.com


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November 2011

WELCOME T h a n k he av e ns! The weather h a s cooled and we are finally ab l e to e nj o y the b eautif ul surro u n dings we live in without w o r r ying about dehydration. C o o l er weather often means i n c re ased activity. More folks w i l l be hitting the links, riding t h e i r bikes, taking walks and s p e n ding time outside doing what ev e r i t i s they love. W i t h cooler climates can come i nc rease d pai n. If you suffer f ro m arthritis or other joint p a i n , it may be aggravated b y b oth cool weather and i n c re ased activity. If you feel m o re pain than usual, take t h e t ime to rest, apply ice and he a t , c o nsi de r an over-thec o u n ter anti-inflammatory and m a k e an appointment to visit

one of o u r s p e c i a l i s t s . We c a n make s u re y o u r a c h y j o i n t s a re nothing m o re t h a n t h e bi t t e rsweet w e l c o m e o f Fa l l . This mo n t h ’s i s s u e o f A r i z o n a Pain Mo n t h l y i s d e d i c a t e d t o ex p ecta t i o n s . Wi t h t h e h o l idays ap p ro a c h i n g , w e e x p e c t many g re a t m e a l s , t i m e w i t h friends a n d f a m i l y a n d t i m e t o relax . Yo u ’l l fi n d g re a t a u t u mnal rec i p e s , a f e a t u re a r t i c l e

o n b r a c e s p re s c r i b e d t o h e l p with pain, and information a b o u t u l t r a s o u n d t ec h n o l o g y – o n e o f t h e m a n y w e p ro v i d e a t A r i z o n a Pa i n S p e c i a l i s t s . We h o p e y o u a re e x p e c t i n g t h e be s t t h i s m o n t h t o o ! F ro m o u r fa m i l i e s t o y ou r s , D r. Pa u l Ly n c h a n d D r. To ry M c J u n k i n A r i z o n a Pa i n S p e c i a l i s t Fo u n d e r s

For I know the plans I have for you, declares the Lord, plans for welfare and not for evil, to give you a future and a hope. Jeremiah 29:11  Paul Lynch, MD and Tor y McJunkin, MD


November 2011

CLINICAL EDITOR: Tory McJunkin, M.D. PUBLISHER: Nick Ryan EDITOR/WRITER: Kelli Donley,

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CONTENTS

Kristen Wesley LAYOUT: Addie Mirabella

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WELCOME LETTER CONTACT US BOOST MEDICAL

We welcome you to the November issue!

9977 N 90TH STREET, SUITE 320 SCOTTSDALE, AZ 85258 Phone: 888-627-6121 Email: info@boostmedical.com

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ASK THE EXPERT What is Electromyography (EMG)?

PRINT SUBSCRIPTION INFORMATION 888-627-6121

Volume #20 Published November, 2011

PAIN Q&A

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A Drug-Free Alternative to Pain Relief By Dr. Chance Moore, DC

Scottsdale, AZ 85258

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These autumnal recipes use seasonal produce to flavor your holiday table. They are easy to prepare and great to share. We wish you a lovely Thanksgiving!

TENS UNIT

9977 N 90th Street, Suite 320

Durable Medical Equipment Helps Chronic Pain Patients By Kelli M. Donley, MPH

Ultrasound Technology: Diagnostics Fine Tuned By Ryan Cooper

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Boost Medical

DME: BRACING FOR CHANGE

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NOVEMBER COOKING

Published monthly by

9

SUDOKU Sudoku has a unique solution that can be reached logically without guessing.


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November 2011

ASK THE EXPERT: ELECTROMYOGRAPHY(EMG) Glen Halvorson M.S., M.D. is well known in his field for his extensive research and practice of electromyo g r a p h y. B u t w h a t e x a c t l y is an EMG and what should patients know about t h i s d i a g n o s t i c t o o l ? D r. Halvorson explains. Q : W hat is an EMG?

An EMG is an electrical test of skeletal muscle.

A: The letters “EMG” stand for e l e c t r o m y o g r a p h y. A s o p p o s e d t o a n E K G, w h i c h i s a n e l e c t r i cal test of the heart, an EMG is an electrical test of skeletal muscle. There are two aspects of this test: the first is the muscle test, called the EMG. The second tests the nerves – specifically the peripheral motor nerves and

the sensory nerves. This test is called a Nerve Conduction S t u d y, o r N C S . W h e n s o m e o n e r e f e r s a p a t i e n t f o r a n E M G, common usage of the term incorporates both tests. As such, I don’t personally use “EMG.” When I write for such tests, I use the term, “EDX” which is an electrodiagnostic exam. This comprises both


November 2011

muscle and nerve testing. Q. W hat should patients know ab out EMG s? A : L e t’s start with what the t est do e s. And EMG is a test o f no rm al v s. abn or mal elect r i c a l activity in the muscles a n d nerves. If you have pain, n u m bness, burning, weakness o r t i ngling, symptoms of nerve i r r i t a tion – these may come f ro m either peripheral nerve or n e r v e root injury. When your nerves come out of the spinal cord, they are called nerve roots. From there they divide into nerve branches that become periphe r a l n e r v e s . We t r e a t m a n y people with radiating nervelike pain when structural lesions of the spine such as herniated discs, bone spurs, and/or degenerative arthritic narrowing cause pain by pressing on nerve roots. In simple terms: if a person has a pinched nerve in the spine o r e x t r e m i t y, I c a n d o a t e s t t o determine where it is pinched, how severely it is pinched and if there is evidence of permanent or temporary damage. I can also distinguish between injury to motor versus sensory nerves as well as

d i ff e r e n t i a t i n g n e r v e t r a u m a from nerve disease. The value of the testing is in trying to accurately determine location and severity of the injury and give the referring/treating physician this information. From there, the physician can best determine whether the patient needs a procedure and what kind of procedure. Q: Are t h e re s i d e e ff e c t s o r a n y issues p a t i e n t s s h o u l d l o o k f o r f ollowi n g a n EM G? A: No, an EMG is a safe procedure. There is some mild discomfort involved. The test should take between 30-90 minutes depending on the complexity of the test and number of abnormal findings. Patients can take all of their medications prior to testing. The only restriction we require is no lotion, cream or body oil used prior to the test because we are sticking electrodes on the skin to record the nerve responses. From a practical perspective, if you wear a short sleeve shirt and shorts, patients probably don’t have to get into a gown. Q: Is an E M G t y p i c a l l y c o v e re d b y insu ra n c e ?

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A: Some insurance do not require pre-authorization for in-clinic procedures. Others do. It is highly variable. Sometimes you can get immediate authorization over the phone, and for others it might be a few days to a couple of weeks. Evidencebased guidelines for who, what, and when to test are established by the AANEM. Medicare guidelines pretty much follow the AANEM guidelines verbatim, which have been established by medical experts in the fields of neur o l o g y, w h o s p e c i a l i z e i n e l e c trodiagnostic medicine. D r. G l e n H a l v o r s o n i s b o a r d c er t if ied in el ec t rodi a g nosis with the American A s s o c i a t i o n o f N e u ro m u s c u l a r a n d E l e c t ro d i a g n o s t i c M e d i c i n e ( A A N E M ) . H e i s a f o r m e r o ra l examiner for the national EMG board and former Arizona State p h y s i c i a n re p re s e n t a t i v e t o the AANEM for 10 years. He is a Qualified Medical Examiner for the State of California. As m e d i c a l d i re c t o r o f a M e d i c a re licensed independent testing f a c i l i t y h e h a s i n t e r p re t e d i n t h e p a s t t h re e y e a r s o v e r ten thousand nerve tests of pa t ien t s w it h pr ima r i ly d i a b et ic n eu ropa t h y.


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NOV E M B E R CO O K ING SWEET POTATO SOUP Ingredients: • 1 tablespoon flour, (or corn starch, to be gluten free) • 1 tablespoon unsalted butter • 1 1/2 cups broth • 1 tablespoon brown sugar • 2 cups cooked sweet potatoes • 1/4 teaspoon ground ginger • 1/2 teaspoon all spice • 1 cup milk • Dash of salt Directions In a Dutch oven, warm flour and

butter over medium heat, stirring constantly until a light caramel color. Add broth and brown sugar. Bring to a boil and then lower to simmer. Add potatoes and spices. With an immersion blender, puree soup until it is smooth. (This can also be done in batches in a blender.) Add milk and a dash of salt and pepper last.

CROCKPOT TURKEY CHILE Ingredients: • Dash of olive oil • 1 lb ground turkey • 1 cup onion, diced • 2 cloves garlic, pressed • 1 small can chopped chilies, drained • 1 small can black beans, rinsed • 1 small can kidney beans, rised • 1 small can corn kernels • 1 bag frozen squash or sweet potatoes • 1 large can diced tomatoes, with juice • 1 small can tomato paste • 1 tablespoon chili powder

• 1 tablespoon cumin • 1 teaspoon kosher salt Directions: In a cast iron skillet, warm a dash of olive oil until bubbling. Add garlic and onion. Lower heat to medium. Add turkey. Cook until no longer pink, then drain cooking liquid. Add to crockpot with remaining ingredients, minus squash and corn. Cook on high for 6 hours. Turn down to medium heat. Add frozen squash and corn. Cook one more hour. Top with sour cream, cheese or salsa.

These autumnal recipes use seasonal produce to flavor your holiday table. They are easy to prepare and great to share. We wish you a lovely Thanksgiving!


November 2011

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TEN S UN IT: A D R UG-F R EE A LT ER NAT IVE TO PAIN RELIEF % \  'U& KD QF H  0RRUH   '& TENS, or transcutaneous electrical muscle stimulation, is a drug-free alternative for m a n a g i n g p a i n . Fo r 3 0 y e a r s , patients found safe, comforting relief in TENS treatment. Plus, this FDA approved tool is reimbursable by most insurance providers. A TENS unit looks like a small cell phone and has one or two sets of wire leads attached. The wire leads have a set of self-adhering pads attached to them. The TENS unit generates a gentle electrical current that travels through the lead wires to the pads to the area on the body being treated. The TENS unit works to decrease pain levels by electrically

stimulating the local sensory fibers, overriding the brain’s ability to process the pain messages from that area. A good analogy is when you rub your knee when you hit it against something. The rubbing sensation somewhat overrides the pain sensation and provides mild pain relief. To a c h i e v e t h e b e s t r e s u l t s o f T E N S t h e r a p y, i t i s i m p o rtant to remember this technology merely activates the b o d y ’s o w n p a i n - f i g h t i n g mechanisms. The electrodes should be placed directly over or near the painful area. The electrodes will deliver a painblocking current to the nerves in this area. Also, it is good

to vary the placement of the electrodes each treatment to avoid skin irritation. Studies show it takes an average of 30 minutes for TENS treatment to begin to relieve pain. Some patients find hours of pain relief from short 30-to-60 minute sessions. Others use their TENS units for several hours a day o r a l l d a y, d e p e n d i n g o n t h e pain generated by daily activities. It is recommended TENS not be used while sleeping. This is simply because movement during sleep may c a u s e e l e c t r o d e s t o c o m e o ff or be pressed into the flesh, causing skin irritation. U n l i k e o v e r- t h e - c o u n t e r o r


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November 2011

TENS, or transcutaneous electrical mu scle stimulation, is a dr ug-free alter native for managing pain.

prescription medications, TENS is virtually risk-free from i n j u r y, s i d e e ff e c t s o r a d d i c tion. The low-volt electrical current delivered by the electrodes only penetrates the

skin to the level of the nerve fibers. This poses no danger t o m o s t i n d i v i d u a l s . H o w e v e r, those with cardiac conditions and/or pacemakers, and pregnant women, should

consult their doctors before using TENS. Use caution when you drive or operate heavy m a c h i n e r y. M o s t i m p o r t a n t l y, always use TENS according to y o u r p h y s i c i a n ’s d i r e c t i o n s .


November 2011

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Wrist Brace by BREG www.breg.com

D M E: BR ACING FO R C H ANG E D u ra bl e medical equ i p m e n t h el ps ch ro n i c pain pa ti ents. % \  .HOOL0 ' RQ OH \  03+

“Conservative care� is a term often heard at pain speciali s t s ’ o f f i c e s . I d e a l l y, p a i n physicians want to be able to treat their patients and

eliminate all pain in the most minimally invasive method. There should be no rush to procedures, unless the pain is acute.

Most patients, however, have chronic – or ongoing, nagging pain. Conservative care plans for such pain may include changing a patient’s diet, encouraging


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November 2011

lifestyle changes and chiropractic appointments. One of the many tools chiropractors have to help chronic pain patients is DME – or durable medical equipment. Think support braces for the back. “ D M E is designed to support a n a rea to reduce mechanical s t re s s, and promote healing,” say s C hanc e Mo o re, DC. “DME c a n help muscle spasm, m usc l e te ars, spinal disc inju r i e s , knee ligament tears or s p r a i ns and a variety of other c ond i ti o ns. ” M o o re regularly prescribes D M E to patients to help with c h ro nic pain. “TENS and lumbar spine bracing are the most commonly prescribed DME for pain,” says Moore. (See page X for more information on T E N S u n i t s . ) “ We t r e a t m a n y c o n d i t i o n s o n a n y g i v e n d a y, but the most frequent area we treat is the lumbar spine – or lower back. When the structures of the lumbar spine are injured the brain sends messages to the surrounding musculature to contract. This can result in muscle spasm. Bracing of the lumbar spine supports the area to reduce

DME can help muscle spasm, muscle tears, spinal disc injuries, knee ligament tears or sprains and a variety of other conditions.” Knee Brace by BREG – www.breg.com


November 2011

muscle spasm and speed healing. TENS is a great device that reduces the perception of pain. TENS can be used almost a n y w h e r e o n t h e b o d y. ” While Moore has seen great results from DME with patients, Kim Rowe, a DME representative with Desert Medical, says braces may provide temporarily relief but not a cure. “Many patients think that a spine or knee brace will completely heal them and eliminate their pain,” says Rowe. “This is far from the truth. The idea behind bracing a pain patient is to help increase their daily activity levels w h i l e m i n i m i z i n g p a i n . Fo r example, if wearing a spine brace can help a patient sit or stand longer without having to take a pain pill or lie down, then it is successful. By w e a r i n g a b r a c e , y o u r u n d e rlying problem is still there, the brace will help support the injured area while you are undergoing treatment.” Moore says while working with a patient on a treatment plan, D M E p ro v i d e s n e c e s s a r y l i t e r a l support. Many patients have a n i m p ro v e d q u a l i t y o f l i f e

thanks to these tools. “I have s e e n g re a t re s u l t s , ” says Mo o re . “ S o m e p a t i e n t s come in t o t h e o ff i c e u n a b l e t o stand d u e t o t h e s e v e r i t y o f a muscle s p a s m . T h e i m m e d i a t e suppor t t h a t a l u m b a r b r a c e can pro v i d e w i l l re d u c e t h e muscle s p a s m a n d c a n a l l o w the pat i e n t t o w a l k o u t o f t h e off ice a n d p e rfo rm t h e i r a c t i v ities of d a i l y l i v i n g .” Ro we s a ys a s a bra c i n g c o n s u ltant, s h e e n j o y s w o r k i n g w i t h patient s t o f i n d t h e r i g h t D M E to help w i t h t h e i r p a i n . “I spec i a l i z e i n a l l t y p e s o f b r acing : s p i n e , k n e e , s h o u lder, ne c k , a n k l e , h i p , e t c . , ” she says . “ D a i l y, I fi t o rt h o p edic and p a i n p a t i e n t s f o r m a n y differen t a i l m e n t s a n d i n j u r i e s . Spine a n d k n e e b r a c e s a re b y far mos t c o m m o n l y p re s c r i b e d by phy s i c i a n s a n d h e a l t h c a re p rovide rs . B u t , i f y o u s h o w m e where y o u r p a i n i s , I c a n f i n d a b r ace fo r i t ! ” During s u c h a m e e t i n g w i t h a bracing c o n s u l t a n t , p a t i e n t s will als o l e a r n h o w t o w e a r, remove a n d c a re f o r t h e b r a c e . Patient s s h o u l d a s k h o w l o n g they are t o w e a r t h e b r a c e a n d what to l o o k f o r i f t h e b r a c e

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i s n ’t w o r k i n g . Ty p i c a l l y, D M E i s c o v e re d b y i n s u r a n c e . “Before fitting our patients for a brace, we make sure to notify them of their remaining deductible amount and co-pay benefits,” says Rowe. The patient should know exactly what he/she will owe before being fit.” A s w i t h a n y t re a t m e n t , t h e re a re ri s k s . H o w e v e r, M o o re s a y s the risks for injury with DME a re m i n i m a l . “TENS is a great treatment as long as the patient does not have any electrical implanted devices,” says Moore. “Over-reliance of bracing causes weakness and dependence on the brace. It is important to not overuse the brace and when appropriate engage in a supervised stretching and strengthening program. I f a p a t i e n t i s s u ff e r i n g f r o m chronic back pain and is interested in first exhausting all conservative care treatment options before surgery – DME is a smart option to c o n s i d e r. Yo u r p a i n p h y s i cian should be able to discuss DME options and schedule a bracing consult.


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November 2011

ULTRASOUND TECHNOLOGY: DIAGNOSTICS FINE TUNED % \  5\ D Q& RRSHU U l t r a sound technology, or u l t r a sonography, refers to the u s e of high frequency sound w a v e s, above the threshold of h u m an hearing, to perform a t a s k. In medicin e, ultrasound h a s t wo broad uses; ultrasound c a n be used as a n imaging m o d a lity and dia gnostic aid to v i s u alize tissues and organs w i t h i n the body, and also as a t h e rapeutic modality with a v ar i ety o f appli c ations 1 . Each of t h ese i s di sc us sed in detail. A s a n imaging modality and d i a g nostic aid, ultrasound t e c h nology reflects short p u l s es of high-frequency s o u n d waves off of organs and t i s s u es to create an image u s e f ul in identifying a variety o f d i seases and pathologic co nd i ti o ns 1 , 2 . D i a gnostic ultr as o u n d offers several distinct a d v a ntages over other medical i m a g ing modalities such as

MRI, CT, o r X - R a y. T h e s e include 1 , 2 , 6 : • Ultrasound captures images in real-time, allowing internal organs and blood flow to be visualized “live” in motion • Ultr a s o u n d h a s a n e x c e l l e n t safe t y re c o r d ; p a t i e n t s a re not e x p o s e d t o p o t e n t i a l l y har mfu l i o n i z i n g ra d i a t i o n • Ultr a s o u n d c o s t s l e s s t h a n man y i m a g i n g a l t e r n a t i v e s , p ar t i c u l a rl y M RI • With f e w e x c e p t i o n s , ultr a s o u n d i s t y p i c a l l y non - i n v a s i v e • Ultr a s o u n d i s p o r t a b l e a n d can b e p e r f o r m e d a t t h e b ed s i d e Diagnostic ultrasound is commonly used to image blood flow and vessels (a Doppler ultrasound), soft tissue, the heart (an echocardiogram), and other organs 1 . Diagnostic ultrasound is also often used in obstetrics

to estimate fetal age, screen for potential complications of pregnancy such as ectopic pregnancies or uterine abnormalities and bleeding, and can be used to guide needles during procedures such as amniocentesis 4 . Diagnostic ultrasound is also often used in real-time for more accurate needle placement during biopsies and other procedures 1 . Ultrasound technology has


November 2011

l o n g been used f or therapeutic a p p l i cations, engaging long or c ont i n uo us pulses of high f req u e n cy sound waves to induce c ellular e ffe c ts and b iologi c a l c h ang e 3 . Although exact m e c h anisms to systematically e x plai n the the rap eutic b ene f i t s of ultrasound remain u n k n own, the primary effect o f t h erapeutic ul trasound is t h o u ght to be the generation o f h e at within ta rget tissues, w h i c h could have a number

13

Ultrasound can be used as an imaging modality and diagnostic aid to visualize tissues and organs within the body, and also as a therapeutic modality with a variety of applications.

of bene f i c i a l e ff e c t s s u c h a s increas i n g b l o o d f l o w. A n o t h e r p otentia l m e c h a n i s m o f t h e rapeutic u l t r a s o u n d a t h i g h e r intensit i e s i n v o l v e s c a vit atio n, or t h e c re a t i o n o f s m a l l b ub b les t h a t c a n re n d e r t a rgeted t i s s u e m o re p o ro u s , t h u s allowin g f o r t h e d e l i v e r y o f medica t i o n s a n d g e n e t h e r a p y through t h e s k i n 3 .

Therapeutic applications of ultrasound technology are dependent upon the intensity used. Low power ultrasonography can be used for treating soft tissue injuries, hastening wound and bone fracture healing, softening scar tissue, and managing swelling- particularly in joints 3 . Higher intensity ultrasonography can be used to destabilize


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from a few minutes to an hour to perform. In the case of diagnostic ultrasound, a radiologist interprets the image and will report back to the patient and/ or referring doctor 2 . T h e fu t u re o f u l t ra s o u n d t ech n o l o g y fo r p h ys i c i a n s is m on itoring needle positioning d u ri n g s u rg i c a l p a i n proced u re s . W i t h t h i s n o n i n v a s i v e imaging technique, physicians can facilitate his/her needle p l a c e m e n t . T h i s t e c h n iqu e pro v i d e s a s a f e a n d e ff e c t i v e w a y t o a s s i s t p h ys i c i a n s in d el iv eri n g p a i n re l i e f. Ultra sound technology has long been used for therapeutic applications, engaging long or continuous pulses of high frequency sound waves to induce cellular effects and biological cha nge.

cellular membranes, thus inducing the cavitation necessary to allow gene and drug delivery through the skin. High intensity ultrasound has also shown some promise in targeting tumor cells and other benign masses for cellular destruction, in dissolving blood clots, and in sealing blood vessels to prevent bleeding and block blood and nutrition flow to growing tumors 3 . When undergoing treatment or imaging with ultrasound technology, a device known as a transducer is placed such that it

can aim sound waves at targeted tissue 2 . Water or water-based gels are often used to buffer and help transmit the sound waves from the transducer to the target surface 3 . Ultrasound imaging and treatment are generally painless procedures done over the skin; however some procedures are more invasive in that the transducer is inserted within a natural opening in the body for improved access or effect 5 . Depending on the location and goal, an ultrasound procedure can take anywhere

References: 1 U.S. Food and Drug Administration. (2011) Ultrasound Imaging. Available at http:// www.fda.gov/Radiation-EmittingProducts RadiationEmittingProductsandProcedures/ MedicalImaging/ucm115357.htm. Accessed October 5th, 2011 2 Mayo Clinic Staff. (2009) Ultrasound. Available at http://www.mayoclinic.com/print/ultrasound/MY00308/METHOD=print&DSECTION=all. Accessed October 5th, 2011 3 Haar, G. (2007) Therapeutic applications of ultrasound. Progress in Biophysics and Molecular Biology. Vol. 93;1-3, 111-129. 4 Williams, D.; Pridjian, G. (2011). Diagnostic Ultrasound. Rakel: Textbook of Family Medicine, 8th Ed. MD Consult Web site, Core Collection. 5 Nidus Information Services. (2011Ultrasound. Patient Education. MD Consult Web site, Core Collection. 6 Hashimoto, B., et al. (1999). Applications of Musculoskeletal Sonography. J of Clinical Ultrasound. Jun;27(6):293-318.


November 2011

    

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Arizona Pain Monthly November  

This month's issue covers Durable Medical Equipment, Ten Unit, Electromyography, Ultrasound Technology and our famous recipe section.

Arizona Pain Monthly November  

This month's issue covers Durable Medical Equipment, Ten Unit, Electromyography, Ultrasound Technology and our famous recipe section.

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