HLTAP501A/B/C Analyze Health Information
HLTCOM510B Provide Services to Clients with Chronic Disease or Conditions
Asthma is a chronic problem that influences lung function. Clinically asthma is identified by the variation in expiratory airflow and abnormal respiratory symptoms such as wheezing, chest congestion, cough, and shortness of breath. The aetiology of asthma is linked to a mixture of genetic and environmental factors, though; heredity or atopy also plays a role in asthma. Asthma is categorized into two types: extrinsic (allergic) and intrinsic (nonallergic). Allergic asthma is an outcome of the reaction of an antibody in the respiratory tract, while intrinsic asthma is a result of ANS neurological imbalances.
The most significant feature of Asthma includes inflammatory cell infiltration. The pathophysiology of asthma is multifaceted and involves inflammation, discontinuous airflow hindrance, and bronchial hypersensitiveness and remodelling.
The leading symptoms include narrowed airways and difficulty in breathing. Other signs and symptoms of Asthma are Wheezing, Coughing, Shortness of breath, Chest tightness.
The Medication of asthma mainly involved corticosteroids, which is not safe for long-term use. The option of remedial massage has provided a positive response on asthmatic conditions as well as overall health. As in this case patient has multi problems like cardiovascular, mild depression and arthritic knee due to post menopause condition. Massage has relieved the symptoms linked to the entire diagnosed problem giving a relaxed mental and physical health.
Description of Disease: 4
Clinical Manifestations 6
Complementary Treatments 11
Benefits of massage 13
Cautions and Contra-indications 13
Helen’s medical history was obtained from an interview with her. She is a 54 years old lady and worked as a case manager in a firm. She used to have a massage for Musculoskeletal Problem from a physiotherapist two years ago. She is a full-time mom now as she has taken temporary retirement from work due to her back injury. She goes on a walk for 30 minutes daily and does mild exercise 2-3 days a week. For relaxation, she likes to watch television at night for 1-2 hours. Her hobbies are internet surfing and reading that she does three days in a week. Her current stress level is 7; that is quite high. She is worried about her children’s welfare and other family problems. These are the main causes of stress and depression. Her sleeping patterns are normal; she takes a long uninterrupted nap of 8 hours and feels refreshed when awake.
Water intake is normal, and 2 cups of green tea and 1 cup of coffee is fine. No habit of alcohol, smoking and even no extra intake of sugar as juices/soft drinks.
Medication includes Symbicort 400 mg twice a day, Sevikar 40/10 mg daily, Olmetec 10 mg daily and Venlaflaxine 150 mg, Crestor 10 mg once daily and Deptran. No history of previous surgery or accidents. Diagnosed with non-allergic rhinitis in 2003, and influenced by physical environmental factors, rather than any allergic cause. The symptoms included intermittent sneezing, congestion in nasal turbinates and itchy throat. She was prescribed with Nasonex on a judicious basis, to control the symptoms. Has fever, but no food or skin allergies. She was diagnosed with arthritic knees due to ‘post-menopause’ condition and also suffering from cardiovascular hypertension from 5 years. In 2005, she was detected with Asthma, taking Symbicort 400 mg twice a day as the main drug for Asthma and was diagnosed with major Depression from last 24 years.
Description of Disease:
Asthma is a chronic lung disease that impacts pulmonary function. It can affect any age. Clinically asthma is recognised by the presence of both the variation in expiratory airflow that tends to increase and higher than normal, and secondly respiratory symptoms such as wheezing, cough, chest congestion and shortness of breath. These symptoms vary and sometimes may get absent (National Asthma Council Australia, Merckmanuals.com, 2014).
Asthma clinically manifests itself through following signs and symptoms such as chronic reoccurring episodes of infections, rapid change in sputum colour, occasional dyspnea due to breathlessness, and familiar history of allergies. Allergies may include hay fever specifically in spring season, sinusitis, nasal polyps, bronchitis, and asthma. Decreased pulmonary function also impact daily activities. A high pitch whistle noise similar to wheezing indicates the onset of bronchospasms, narrowing and secretion of mucus within the bronchioles, whether allergically or non-allergically induced (Emedicine.medscape.com, 2014). In brief, the possibility of the patient developing Chronic Obstructive Pulmonary Disorder or COPD that is characterised by the progressive obstruction of the airways together with hypertonicity within the bronchi causing difficulty in breathing. Although COPD can act partly reversible, it could lead to an immunosuppressed state in turn making the client prone to infections, therefore, exacerbating or flaring up their symptoms.
The turbinates and paranasal sinuses humidify and warmly inspire ambient air to body temperature and humidity. Due to inhalant allergies a transverse crease is developed that also induce itchiness and discomfort in nasal passages (Brown & Morgan, 1999).
In extrinsic or atopic asthma a genetic liability and tendency of the client to allergens and virus are factors that highlight pathogenesis of extrinsic asthma, but in many cases the cause is uncertain. The Pathogenesis of Atopic asthmatic conditions such as anaemia, musculoskeletal spasms or fasciculation, tachypnea, and tachycardia can lead to more serious result in the form of cardiovascular complications.
In intrinsic asthma, the pathogenesis directs two genetic influences associated with asthma. First is the ability of any person to develop asthma (atopy) and secondly, hyper-responsiveness of airways that is independent of atopy. A lochus on chromosome 11has been linked with atopy, and it has an abnormal gene encoding a part of immunoglobin IgE receptor (Barnes, 1996). Environmental factors mix with hereditary factors to develop such conditions of bronchospasms (McDowell, 2000; Williams, 2005).
Inflammation in the muscles of the airways that involves the contraction of the bronchioles on the exposure to certain triggers (e.g., cigarettes smoke,) make the breathing difficult and exhausting. In the cases of severe exasperation and imminent respiratory failure other symptoms are also noticed like changed mindfulness, skin staining due to reduced oxygen or cyanosis, pulsus paradoxus higher than 15 mm Hg, and hyperinflation. In Rare Occasions, pneumothorax or pneumomediastinum is observed in chest x-ray reports. (Asthma: Asthma and Related Disorders, Merckmanuals.com, 2014).
Helen’s family history shows her brother has been a patient of mild Asthma. Helen had no record of any long respiratory tract problem and travelling made her condition worse. It suggests that her symptoms were mostly affected by physical environmental factors rather than any allergic cause. This incidence proves the environmental factors’ involvement in budding asthma. Other examples of environmental factors include: exposure to particular allergens for instance, dust mites, mould spores, pollens, pets and animals. Environmental irritants such as, cold/dry air, smoke and air pollutants also play a significant role.
The aetiology of asthma is associated to a mixture of genetic and environmental factors, though; heredity also seems to have a role like allergens. According to the latest Report from several experts from National Asthma Education and Prevention Program of National Heart, Lung, and Blood Institute states that atopy could be a solid reason. It is a genetic disposition that is found to be responsible for the IgE-mediated responses against common type of aeroallergens. Asthma is categorized into two types: extrinsic (allergic) and intrinsic (non-allergic). Allergic asthma is an outcome of the reaction of an antibody on mast cells in the respiratory tract (Bradding, Walls & Holgate, 2006). This reaction in turn triggers the release of inflammatory mediators that bring out the clinical results linked with an asthma attack. Intrinsic asthma is a result of neurological imbalances in the ANS (autonomic nervous system). When alpha and beta adrenergic and cholinergic sites of the ANS are not synchronized, such situation arises (National Asthma Council Australia, 2014; Miller, 2001).
The most considerable and consistent immunohistopathologic feature of Asthma includes inflammatory cell infiltration. The pathophysiology of asthma is multifaceted and involves inflammation, discontinuous airflow hindrance, and bronchial hypersensitiveness and remodelling. Inﬂammation is typically characterised by four signs. These are calor and rubor because of vasodilatation, and tumour developed due to plasma exudation or oedema. Dolor is due to sensitivity and activity of sensory nerves (Barnes, 1996; Inflammatory, 2009).
Inflammation can result in cell damage and remodelling. Several eosinophil products, like MBP and ECP, may release cytotoxins that contribute to the damage of epithelial cell population. Moreover, collagenases released from active eosinophils damage the basement membrane and proteases derived from mast cell may loose the intercellular adhesion. Thus, these factors together can result in the epithelial fragility. This epithelial disturbance contributes to the bronchial hyper-responsiveness (Frigas & Gleich, 1986). Epithelial cytokines, growth factors linked to mast cell, eosinophil and macrophage activation can influence fibroblast proliferation, activation and smooth muscle mutagenesis. These occurrences tend to an augment in airway bulk as well as muscle hyperplasia and hypertrophy; both factors are found responsible bronchial hyperresponsiveness (Howarth, Redington & Montefort, 1993). The corticosteroid therapy can reduce the mucosal inflammation along with improvements in spirometry and bronchial responsiveness, which provides additional support to the inflammatory pathogenesis of the asthma (Emedicine.medscape.com, 2014).
Significant advancements have made to analyse the modifications occurred in Asthmatic patients, but it had not much helped in clinical manifestation. The considerable structural changes in the airways passages are believed to produce the changes in airway functioning. This change is considered as the primary clinical Asthma symptom (Barnes, 1996).
The leading symptoms include narrowed airways and difficulty in breathing (Cavallazzi, 2009).
As a patient of asthma from last 10-11 years, I recognized following signs and symptoms in Helen:
• Congested nasal turbinates
• Coughing & Wheezing
• Shortness of breath
• Chest tightness
• Inability to have a good sleep due to breathlessness
• Increased respiratory rate
The age of asthma onset can identify the causes of asthma whether it is intrinsic or treatable extrinsic, even in the old age. However, the precise prognosis factors are still not complete, but only emphasized on the basis of two points, age at the onset of infection and its type. Multiple allergic manifestations and sex ratio also have been found involved in determining the infection strength. Most of the asthmatic cases with adult-onset are diagnosed in their forties or fifties of life; however, age of diagnosis differs extensively. It is observed that several patients hide the symptoms for a long time until the onset of any severe symptoms. According to the literature, prior 10 years male to female ratio is 2/1 and reaches toy 1/1 by the age of 14-15. Moreover, males are found suffered from more severe cases (Howarth, Redington & Montefort, 1993; Cavallazzi et al., 2009).
Helen’s the prognosis is good. Helen’s Asthma is well managed & she is responding better to her Asthma medication in the summer because she has non-allergic Asthma influenced by cold weather. The warmer climate is suitable for her, so there are fewer chances of getting worsened Asthma symptoms.
The following tests could be prescribed to Helen as investigative methods for testing Asthma:
Spirometry- Spirometry is a breathing test which is carried out to assess the health of lung's physiology. The spirometry is useful in distinguishing asthma from other lung conditions, for instance, chronic obstructive pulmonary disease (COPD). Helen’s lung functioning was well, and lungs were clear.
Peak expiratory flow test- This test defines the peak expiratory flow (PEF) to diagnose the level and advancement of a previously diagnosed asthma. This test would show clear results in Helen’s case as she was facing mild Asthma, with no problem in lungs. Though, she was facing a bit difficulty in breathing that was due to swelling in nasal wall.
Airways responsiveness-This test takes diagnosis to the next level if it remains unclear from the other simple tests. This test measures the responsiveness of airways on exposure with a trigger.
Testing airway inflammation-This test is useful to check the inflammation in the airways. It is done in two main ways, either taking a sample of mucus or through exposing nitric oxide. Both tests are performed to test the signs of inflammation. Airways responsiveness and testing airway inflammation tests do not seem necessary for Helen.
Some allergy tests- Several skin tests or a blood test can be performed to confirm whether asthma is associated with specific allergies, like pollen grains, dust mites or any foods. (Galant, 1974; Nathan et al., 2004; Schatz et al., 2006). Helen’s skin test results were negative, thus proving her Asthma is not associated with specific allergies.
It can be seen in a letter from Doctor Gayed explaining his observation and findings from diagnostic History. I can also detail from Gayed’s diagnosis by saying that M.C was diagnosed with 20 years history of sneezing and rhinorrhoea, but no lower respiratory infection was detected. Doctor concluded that she was suffered from non-allergic rhinitis, so immunotherapy would not be helpful in her case. Her lung functions and skin tests were showed negative results. She may have symptoms for a long time, and she was suggested Nasonex to prevent further severeness of infection. Though her x-ray report of facial bones revealed some thickness in nasal turbinates and mild maxillary changes were obvious.
Medical Report Summary
As stated in the report and a letter from Gayed, Helen suffers from Asthma, Depression, cardiovascular problem and arthritic knee. It was diagnosed through specific signs and symptoms arising from lifestyle and medical questionnaires and confirmed through various tests. Based on what Helen reported and her conversations with me, I observed following side effects:
- weight gain
- skin bruising
- light-headed or dizzy
- mood changes
Asthma treatment includes a range of treatment methods, from anti-inflammatory bronchodilator asthma inhalers to oral medications. It is a better option to learn the ways to monitor breathing at home regularly.
Asthma control inhalers are used that contain substances that control inflammation, prevent flares, keep symptoms in control and protect them from getting worse. Bronchodilators act as airway openers they work to open the airways and relieve asthma, e.g., salbutamol and terbutaline (MyDr.com.au, 2001). Other options are asthma nebulizer (breathing machine); it is given to youngest and oldest asthma patients to deliver medication.
Early and aggressive asthma treatment to relieve the symptoms and prevent further attacks is capable of stopping coughing and wheezing quickly. Doctor Gayed suggested Helen to use Nasonex (Mometasone, a steroid) to avoid severity of the symptoms. Steroids & Other Anti-Inflammatory Drugs are used for thick mucus and swelling in the airways. The main types of preventive medications for asthma are inhaled corticosteroids such as beclomethasone, budesonide, ciclesonide and fluticasone.
The long-term use of these inhaled corticosteroids result in easy bruising, osteoporosis, and it may infrequently cause adrenal suppression. At advanced level of infection Bronchial thermoplasty is suggested where gentle heat given to shrink the smooth muscles in the lungs (Cavallazzi et al., 2009).
In this case Helen is prescribed following medications.
1-Symbicort (Brand name); Budesonide and formoterol (Generic names of the drug)
SYMBICORT is the primary medication for asthma due to which Helen’s Asthma is controlled and she is treated with it. SymbicortTurbuhaler is inhaled for the treating asthma or Chronic Obstructive Pulmonary Disease (COPD). It contains two active ingredients: budesonide and eformoterol. Budesonide is a corticosteroid and acts directly on airways to lessen inflammation. Eformoterol belongs to a group of beta-2-agonists, and it widens the airways to smoothen the breathing. It is a preventer as well as a reliever and needs to be regularly taken.
Patients with problems like thyroid problems, diabetes, heart problems, liver problems, tuberculosis (TB) and low levels of potassium in the blood should not take this drug. SymbicortTurbuhaler may interfere with several diuretics and antiarrhythmics (Quinidine) medicines and with those that are used to treat heart problems like beta-blockers.
Side effects of this drug include sore, yellow patches in the mouth (thrush), gruff voice, coughing, trembling or shakiness. Some other symptoms include nervousness, irregular heart rate, chest pain, anxiety, headache, feeling dizzy, thirsty, nausea, diarrhoea and difficulty sleeping.
The side effects experienced by Helen due to intake of Symbicort include; Bruising, dizziness/ lightheadedness, headache, weight gain, anxiety, tiredness/ fatigue & occasional Tachycardia.
After using SymbicortTurbuhaler, mouthpiece must be cleaned and kept in a cool, dry place below 30°C.
2-Sevikar-Sevikar is prescribed to treat high blood pressure or hypertension.
Sevikar contains olmesartanmedoxomil substance and belongs to the medicine group angiotensin-II receptor antagonists. Sevikar also contains a calcium channel blocker, amlodipine besilate. This drug may interact with medicines of high blood pressure, angina, such as diltiazem, non-steroid anti-inflammatory drugs (NSAIDs) or COX-2 inhibitors, antibiotics like erythromycin or rifampicin and antifungal and antidepressant medicines.
Side effect from this drug includes feeling dizzy, cough, nausea, diarrhoea, unusual tiredness, fatigue, sore throat, back pain, urinary tract infection, skin rash and weak muscles.
3-Olmetec-Olmetec plus is given when to treat hypertension.
It also belongs to a medicine group of angiotensin-II receptor antagonists. Side effects from this drug include dizziness or faintness, headache, cough, diarrhoea, runny or blocked nose, sore throat, bronchitis, pharyngitis, back pain and urinary tract infection.
4-Venlaflaxine-Venlafaxine Actavis XR contains active ingredient venlafaxine hydrochloride. It is given to treat and prevent a relapse of depression and anxiety, including escape or fear of social condition. Side effects associated with this drug are at various levels, such as Stomach, bowel or urinary tract problem. Behavioural changes such as difficulty sleeping or abnormal dreams, Paranoia, sexual problems, difficulty in thinking or working, changes in your sight, hearing, taste or touch also observed.
5-Crestor-Crestor is for lowering high cholesterol levels, and it lowers the threat of a stroke or heart attack in above 50 and 60 years people. Crestor belongs to HMG-CoA reductase inhibitors group. Side effects of this drug are constipation, headache, memory loss, dizziness, stomach pain, unusual tiredness, nausea, itchy skin, stiff or painful joints (arthralgia).
Helen responded very well to the medication. The medicines prescribed dosages of medicines worked for her and occasional used as a symptom reliever also. It has impacted her very much in a positive way.
Here is a table illustrating the side effects in Helen’s case due to the use of prescribed drugs.
HA = Headache
GI Comp = gastro intestinal complications
UTI = Urinary Tract Infection
Joint P = joint Pain
DZ = Dizziness
Frequently, mild exercise, massage and Hydrotherapy can be prescribed to Helen as she is a patient of depression and arthritis also. Helen is facing depression, mood swings, and stress is linked to menopause and hormonal alterations. Low oestrogen level is associated with low serotonin level that impacts mood, emotions and sleep.
Regular mild workout can help Helen in preventing and managing this stress. Regular physical activity results in the stimulated release of Serotonin and Endorphins that leads to a happy and healthy life. However, due to non-allergic rhinitis asthma, the weather conditions should be kept in mind. It is better to suggest avoiding cold and dry weather. Exercises that can improve posture are helpful as they maintain good exchange of air, and useful in maintaining elasticity and expansion of bronchial tissues and lungs. A regular training has impacted her mental and physical health. Apart from medication the patients is suggested to follow healthy eating habits and take a good amount of water (Parkman, 2002; Hondras, Linde & Jones, 2005).
Hydro therapy presented an excellent combination with my chosen modality, Swimming. Swimming covers an aerobic form of exercise that is good for depression and improves pulmonary function as well as muscular strengthening (resistive training in water) and escalating HDL levels. Helen reported that it improved the stiffness of the Knees appreciably & also reduced her stress levels. Though, she doesn’t like water, and very often she is not comfortable in going for swimming, she needs to look for alternative therapies.
A proper massage reduced the side effects of medicines. The main noticeable effects of massage seen in Helen are following, enhancement in asthma symptoms, quantity of reliever medication is reduced than before, and breathing capacity is enhanced. Overall an upgrade in quality of life is visible.
Massage and its benefits:
Massage provides an extensive range of techniques to treat the pain, firmness and lack of mobility of joints experienced by arthritic people. These therapies include thermotherapy, massage, joint mobilisation and evaluation of posture and the development of customised exercise and massage programmes for each ((MyDr.com.au, 2001). Through Remedial massage a pressure and movement are applied through hands to the skin, muscles and tendons. Massage helps in relieving muscle tension and spasm, in loosening firm joints through promoting relaxation. Efficient MRI data suggested that modest pressure massage was characterized in specific brain areas that are involved in stress and emotion regulation (Field, 2014). Massage therapy is being evaluated for its usefulness in pain relief. In a study on children with daily massages, numerous positive effects were noticed (Field, 1998).
In Helen’s case massage is highly beneficial, especially on the face and limbs. It relaxes the swelling on nasal and maxillary portions. Massage has been proven effective and helped to relieve the various pains such as muscle soreness, pain due to injuries, fibromyalgia, controlling asthma. Positive results of massage have also been noticed on other symptoms like anxiety, fatigue, and pain in Asthmatic patients and stress in female due to menopause (Taylor et al., 2000; Huntley, White & Ernst, 2002).
Reflexology may also help Helen. This enhanced massage therapy depends on manual pressure applied on the specific regions of the foot by hands. I will suggest Helen to follow Structural integration. It involves a deep tissue treatment, and correct alignment of bone and muscle is attained by manipulating and stretching muscles and fascia. (Merckmanuals.com, 2014).
The other recommended therapies to Helen include music therapy, relaxation therapy and hypnosis, and meditation techniques. Several other therapies are qigong, tai chi and buteyko also found involved in improving lung functions. They act as a reliever, not preventer. Session of these therapies for 3-4 times a week for 10 weeks will leave a good impact on the patient.
Following are benefits of massage:
• Reduces emotional as well as physical pain
• Stimulates the feel-good Endorphins and neurotransmitters such as Dopamine and Serotonin
• Creates a soothing effect by stimulating the parasympathetic nervous system
• Reduce the stress level and related chemicals such as adrenaline and cortisol
• Stabilizes blood sugar and Increases immunity
• Relieves breathing difficulties and improves health of lung
• Increases energy levels, Lower depression and anxiety, and hostility
• Lower the risk of heart attack, stroke, blood pressure or kidney failure (Field, 2014 & 2005).
Asthma and Massage for Helen:
Post-acute stage indicated tightness due to strenuous breathing, especially during expiration (exhalation), so the treatment focus on the ribs by springing, specifically the thoracic region. Cupping / Topotments is recommended for decongesting the lungs and increasing blood flow, Raeking to intercostals, deceasing tight hypertonic muscles such as, Scalenes, SCM, Pectoralis Minor & Major, Diaphragm, Rhomboids, Serratus Posterior Inferior, Quadratus Lumborum and Throlacolumbar fascia give optimal result in decreasing breathing difficulties. It also helps the thorax cavity feel lighter and function better.
Techniques such as MFR Indirect (thoracic hold, transverse hold) /Direct, Broadening, XFF, TP, STR, DCTM, Dips, Hook & drag and Striping are used to treat the muscles listed above.
Acute as the joint may be swollen and inflamed, only Manual Lymphatic Drainage will be suitable and helpful in order to decongest.
The treatment mainly aims to open up the joint space; increase fluid and nutrition supply and breakdown built up of scar tissue/stiffness. DTF, XFF & STR to, supra patella & infrapatella tendons and coronary ligaments, LCL & MCL ligaments as well as the pesanserine , PJA, TP and STR on Quads, hamstrings, Triceps surae, popliteus & plantaris. Also, frictions around the joint line to reduce adhesion and break down any scar tissue that may be causing stiffness around the joint capsule.
General massage & Lymphatic drainage and PROM techniques are useful in reducing adhesion that cause immobility and joint stiffness, as well as pain and help, remove debris aiding ROM.
PJA help breakdown scar tissue as nourish the joint surfaces via spreading the synovial fluid and stimulating the synovial membrane combined with stretching is helpful to maintain full ROM.
Cautions and Contra-indications
1. Need to be mindful of hygiene as any dust may lead to her allergic rhinositis flaring up and in turn worsening Asthma as it is the primary trigger for Helen’s asthmatic cough. Her last bad asthma attack episode was approximately last winter & she reported that at that time she was really rundown and was emotionally affected as her father in law passed away. During the massage, was aware of the subject of conversation because Helen was being very sensitive.
2. Client may experience thirst /dry mouth a glass of water is very beneficial.
3. Caution and watching for dizziness when client is getting off the massage table due to the possibility of falling off so must be sure the client is alarmed and fully conscious/aware.
4. Not giving a very vigorous massage and being aware of effleurage as it can have a systemic effect pertaining to an increase in B.P that may lead to vasodilatation. Client suffering from hypertension, as well as hypercholesterolemia, therefore not too many systemic stocks are suitable.
5. Client tends to get fatigued easily; treatment duration needs to be deceased.
6. Client is prone to bruising; therefore, deep/high pressure techniques are contraindicated
7. Pain perception can be altered and effected as a consequent side effect of medications there M.T must work closely with the client.
8. No deep and vigorous massage to shoulder and upper traps as it can cause overstimulation of the Vagus Nerve leading to vasodilation.
9. No deep abdominal massage as it may cause stimulation of the vagus nerve, also cause pain if the client is experiencing diarrhea.
10. Massage is contraindicated if infection is involved.
Here are the main cautions, complications and contraindications from the medication during the two massage treatments:
1. Dizziness/light-headedness, asking if they're ready to stand up and assisting them on/off table.
2. Drowsiness, get them involved and engaged in the treatment by using topotments, PNF, STR active and CRAC stretching.
3. Dry mouth, offering glass of water after treatment and recommending high fluid intake.
As a coping mechanism for her Depression, Anxiety & nervousness Helen was more than usual talkative that was time-consuming and made it difficult to give her instructions as well as focusing.
During the second treatment there was less anxiety and nervousness, Helen felt much at ease but never the less the nervousness as a side effect of the medication.
As a result, I didn’t see many complications in the second treatment compared to the first. The second session consisted of mild dizziness, shortness of breath and drowsiness.
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