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Home Remedies for Whiplash
Neck Pain UnPlugged
The Complete, Step-by-step Self-assessment/self-treatment System For Neck Pain Sufferers. Neck Pain UnPlugged is a simple-to-use, step-by-step system that is full of life changing benefits. Finally understand the underlying cause of your neck pain. Learn simple to follow steps for improving your neck pain. Save Time and $: Drastically reduce or eliminate your need for dangerous medications and endless trips for treatment. Changes that give you the long term neck pain relief that you deserve. Customized to You: No More generic stretches and exercises. Everyone is different. Only do what Your body needs to feel great. Wake up feeling great. Do the thing You want to do. Get your life back!
Neck Pain UnPlugged Summary
Contents: Ebooks
Author: Dr. Jerry Kennedy
Price: $47.00
My Neck Pain UnPlugged Review
The author presents a well detailed summery of the major headings. As a professional in this field, I must say that the points shared in this book are precise.
When compared to other e-books and paper publications I have read, I consider this to be the bible for this topic. Get this and you will never regret the decision.
Pathophysiology of nonspecific neck pain
Many patients with nonspecific neck pain show degenerative changes in the cervical disks with osteophyte formation and involvement of adjacent soft tissue structures. However, similar degenerative changes in the cervical spine are common in asymptomatic people over the age of 30 years, with changes being evident both on plain X-rays 3 and MRI scanning 4 . As there is such a poor correlation between symptoms and radiological findings, the boundary between normal aging and disease is difficult to define, and diagnosis is usually made on clinical grounds alone. Whiplash Patients develop symptoms soon after a sudden acceleration-deceleration of the neck, as occurs in road traffic or sporting accidents. While symptoms are often severe, the source of the pain is uncertain, and no specific pathology can be identified on detailed clinical or radiological investigation. While soft tissue injury is considered likely, this is difficult to confirm even using MRI scanning. In some patients with...
Natural history of nonspecific neck pain and whiplash with factors associated with chronic disability
Nonspecific neck pain usually resolves within days or weeks, but can recur or become chronic. Once pain becomes persistent, outcome is more unpredictable, and there is little consistency in the literature regarding the duration of symptoms and factors that influence outcome. A systematic review of the clinical course and prognostic factors in nonspecific neck pain found little consensus as to outcome or relevant prognostic factors, although this was based on poor-quality studies 19 . The systematic review found evidence that in patients with chronic pain treated in secondary care or an occupational setting, 20-78 (median 54 ) of patients remained symptomatic, irrespective of the therapy given. Six of the included studies documented prognostic factors, and the severity of pain at presentation was the best predictor of a poor outcome, although previous episodes of neck pain were also important. Three subsequent studies also considered the factors at presentation which might influence...
Box 83 Therapeutic options for acute and chronic whiplash
Acute whiplash Chronic whiplash Most neck pain appears to respond to conservative measures, although the effect size is often quite small, and the optimal therapeutic approach for uncomplicated neck pain has yet to be established. Even where an initial benefit is shown, this advantage is not sustained. Few modalities of treatment have been assessed in high-quality randomized studies, but I will try to present the best available evidence for the most commonly used modalities. The evidence is often contradictory because of the poor quality of many of the studies, use of interventions in combination, and diverse patient groups. The lack of consistency in study design makes it difficult to identify which intervention may be of use in which type of patients.
Neck pain with radiculopathy see
Neck pain with radiculopathy usually has a favorable prognosis without the need for surgical intervention, but there are very few studies looking at conservative approaches to therapy, like epidural injection or a comparison between conservative and surgical treatments. Systematic reviews 2, 73-75 identified two small poor-quality RCTs which provided insufficient evidence on the effects of cervical epidural interlaminar steroid injections for radiculopathy complicating nonspecific neck pain. One RCT (40 patients with radiculopathy confirmed by MRI and diagnostic transforaminal block) had one transforaminal injection of either steroid or saline plus local anesthetic with weekly assessments for 3 weeks. Six of 20 patients in each group reported improvement at 3 weeks, with no difference between the groups for any parameter at any time 76 . Epidural injections are more invasive in the cervical than lumbar region, and need to be used with caution. Complications, such as infection or...
Acute Neck Pain continued
Physical examination does not provide a patho-anatomic diagnosis of acute idiopathic or whiplash-associated neck pain as clinical tests have poor reliability and lack validity. Tenderness and restricted cervical range of movement correlate well with the presence of neck pain, confirming a local cause for the pain. Plain radiography is not indicated for the investigation of acute neck pain in the absence of a history of trauma, or in the absence of clinical features of a possible serious disorder. Acute neck pain in conjunction with features alerting to the possibility of a serious underlying condition is an indication for MRI. Except for serious conditions, precise identification of the cause of neck pain is unnecessary. Once serious causes have been recognised or excluded, terms to describe acute neck pain can be either 'acute idiopathic neck pain' or 'acute whiplash-associated neck pain'.
Imaging Studies in Neck Pain
With a history of trauma, cervical spine x-ray in an AP, lateral, odontoid view may be helpful. History suggestive of infection or tumor also warrants urgent x-ray of the cervical spine. Cervical spine x-ray is not generally indicated if the patient is alert, does not have neurological deficits, and does not have midline tenderness posteriorly. CT is best for bone changes and MRI is best for soft tissue evaluation. Both CT and MRI are not required initially in neck pain that appears uncomplicated.
Treatment of Neck Pain Acute Neck Pain
The natural history for acute neck pain is recovery within 3 months. Reassure patient that serious causes, which are rare, are ruled out. Patient should be encouraged to maintain normal activities. The most effective treatment may be simple neck exercises to keep the neck mobile and increase range of motion. If there is no improvement, patient should be further evaluated with imaging (e.g., MRI). There is no evidence that analgesics, non-steroidal anti-inflammatory agents, or muscle relaxants are effective in acute neck pain, although they are often prescribed. In general opioids are not indicated in acute neck pain. Studies have reported long-term relief in up to 60 of patients with cervical epidural steroid injections using the interlaminar or transforaminal approach. Rare but serious complications can occur with these injections, (particularly with the transforaminal approach), including spinal cord or brainstem infarction and death.
Epidemiology of nonspecific neck pain
Epidemiological studies of neck pain are based on questionnaires and surveys, which may overestimate the frequency of the condition. Nevertheless, it is clear that nonspecific neck pain including whiplash places a heavy burden on individuals, employers, and healthcare services. About two-thirds of the population will experience neck pain at some time in their lives 7, 8 , with the condition being most common in middle age, and in women 9 . The reported prevalence of neck pain varies widely between studies, but has a mean point prevalence of 7.6 (range 5.9-38.7 ) and a mean lifetime prevalence of 48.5 (range 14.2-71 ) 9 . A UK survey found that 18 of 7669 adults had neck pain at the time of the survey, but when symptomatic people were re-questioned 1 year later (58 responded), half were still symptomatic 10 . A Norwegian survey of 10,000 adults also reported that 34 of responders had experienced neck pain in the previous year 11 . Neck pain is second only to back pain in frequency of...
Acute neck pain
For the treatment of acute neck pain, the Australian Acute Musculoskeletal Pain Guidelines Group found evidence that collars were ineffective, and found evidence to be lacking or insufficient on the effectiveness of acupuncture, analgesics, manipulation, passive mobilization, electrotherapy, gymnastics, multidisciplinary biopsychosocial rehabilitation, muscle relaxants, neck school, nonsteroidal anti-inflammatory drugs, patient education, spray and stretch, traction, or transcutaneous electrical nerve stimulation (TENS).100 I The literature pertaining to this evidence is reviewed in detail elsewhere.100,101 The Australian Guidelines Group recommended that the treatment of acute neck pain be based on explanation and reassurance, activation, and exercises.100 I These recommendations were consonant with the results of an earlier systematic review of conservative therapy for neck pain.102,103 I In support of these recommendations, the literature is positive but limited. Contentious is how...
Neck Pain
Just as with back pain, the cause of common neck pain is often not apparent. Neck pain of less than 3 months duration is considered acute neck pain, while neck pain that has been present for more than 3 months is generally considered chronic neck pain. Neck pain can arise from the cervical spine and surrounding anatomical structures. These structures include the facet or zygapophysial joints, the intervertebral disks, the vertebral bodies, the anterior and posterior ligaments, the prevertebral muscles, and the posterior neck muscles. Serious but rare causes of neck pain include tumors (vertebral body, spinal cord) and infection (e.g., epidural abscess, meningitis, discitis, and osteomyelitis). Abnormal neurological findings associated with neck pain can be found in patients with cervical radiculopathy, cervical myelopathy, spinal cord tumor, and thoracic outlet syndrome (Carette 2005). Risk factors for neck pain differ from those for back pain. There appears to be no consistent...
This is a term for an event that occurs in a rear end collision in a motor vehicle accident, sometimes leading to in neck pain. Studies have shown that whiplash is not a flexion-extension or acceleration-deceleration injury as popular belief would have it. It appears that the cervical spine is subjected to a compression injury in which the trunk is forced upward into the cervical spine, resulting in possible strain and injury to the disk and facet joints. According to epidemiological data not all patients sustain injury, and most injuries are minor from which the majority of patients recover (Bogduk and McGuirk 2006c).
Chronic Neck Pain
In chronic neck pain, there is no solid evidence that the use of the following is effective traction, use of cervical collar, TENS, acupuncture, botulinum toxin injections, conventional physical therapy, and manipulation therapy. Exercises appear to be as effective as manual therapy or physical therapy in reducing pain. There is evidence that percutaneous radiofre-quency neurotomy for cervical facet pain provides pain relief for chronic neck pain. Pain from the facet joints can be diagnosed by diagnostic blocks of the medial branches that innervate the joints.
Efficiency and equity
These studies are useful as reference points for subsequent economic analyses,32 but rely heavily on estimates and underlying assumptions and should be treated with caution.33 In addition, there are theoretical debates about the most appropriate method for estimating productivity and indirect costs.33 The human capital approach considers the value of potentially lost production resulting from a disease in terms of absenteeism, reduced productivity, and disability or premature death at a specific age until the age of retirement. The alternative, friction cost method, assumes that production losses are confined to the period needed to replace the sick worker.34 The differences in results can be highly significant. For example, the indirect nonmedical costs of neck pain in the Netherlands in 1996 were estimated at US 530 million, using the human capital approach and US 96 million using the friction cost method.35 Similarly, the indirect cost of back pain in the UK in 1998 was estimated...
Disorders of unknown pathology
The remaining rubrics listed in Table 12.7 concern the differential diagnosis of spinal pain. Some require and invite no investigations. Acceleration-deceleration injury of the neck is the formal rubric for whiplash - a diagnosis made on the basis of history alone. Similarly, spinal pain of unknown origin pertains to pain whose cause cannot be or has not been pursued. The gluteal and piriformis syndromes are diagnosed clinically, and do not require special investigations.
Herpes simplex virus type
The most common central nervous system (CNS) complication of HSV-2 infection is aseptic meningitis (headache, fever, and stiff neck). Aseptic meningitis may follow recurrent genital infection. HSV-2 aseptic meningitis occurs any time of year and can recur.9 The CSF contains a mononuclear pleocytosis. Unlike HSV-1 in encephalitis, HSV-2 can readily be isolated from CSF during aseptic meningitis.10 Infection is
Clinical Aspects Of Bacterial Meningitis
Bacterial meningitis is clinically characterized by stiff neck, headache, fever, photophobia, malaise, vomiting, alteration of consciousness, seizures, confusion, irritability, and, rarely, acute psychosis. Cerebrospinal fluid (CSF) usually reveals an elevated white blood cell count of more than 1000 white blood cells l, consisting of more than 60 polymorphonuclear leukocytes, an elevated total protein content and a decreased CSF serum glucose ratio. A CSF white blood cell count of less than 1000 cells l may be found early in the disease, in partially treated bacterial meningitis, in overwhelming bacterial meningeal infection ('apurulent bacterial meningitis') and in immunosuppressed and leukopenic patients.
Regional Anesthesia and Other Interventions
Traumatic brain injury (TBI) is another common cause of chronic pain and disability, affecting nearly 1.5 million Americans per year. The prevalence of pain following TBI varies dramatically, ranging from 18 to over 90 depending on the surveillance method, severity, and associated trauma (Cohen et al. 2004). The most common pain complaints in patients with mild TBI (Glasgow Coma Scale 13-15, loss of consciousness
Magnetic resonance imaging
In patients with acute neck pain, but with no clinical indicators of any serious cause, magnetic resonance imaging (MRI) offers little prospect of a positive diagnosis. The only indication for MRI is as a screening test for rare and clinically occult disorders in patients with persistent or chronic neck pain. Yet even in that context, the use of MRI is questionable. By definition, rare conditions are unlikely to be evident, and in the absence of clinical indicators they are even more unlikely. The cardinal indicators are a past history of cancer, risk factors for infection, or signs of systemic illness. In patients with risk factors for aneurysm (see Chapter 12, Diagnostic procedures in chronic pain), magnetic resonance angiography is indicated. and with increasing frequency with age.74,75 Finding such abnormalities does not provide a diagnosis. In patients with neck pain after whiplash, multiple studies have shown that MRI reveals nothing but normal age changes, with the same...
Radiofrequency neurotomy
Percutaneous radiofrequency (RF) neurotomy is the one surgical procedure that has withstood scientific scrutiny. In this procedure, the nerves that innervate the cervical zygapophysial joints are coagulated in an effort to relieve pain stemming from these joints.140 Under double-blind, controlled conditions, the procedure has proven not to be a placebo.141 II Moreover, it is the only treatment for neck pain that has been shown to achieve complete relief of pain, and restoration of activities of daily living.141,142 II , III Furthermore, relief of pain is attended by complete resolution of psychological distress.143 III A limitation of the procedure is that pain recurs as the treated nerves regenerate, but in that event, the procedure can be repeated and the pain once again completely relieved. Long-term studies have shown that continued, repeated relief can be sustained for up to 2000 days.142 III In the context of whiplash, it has repeatedly been shown that the outcomes following RF...
Pain from Cervical Spine
Pain from cervical structures referred to the head is called cervicogenic headache. It can be experienced in the occipital, parietal, frontal, or orbital regions. The sensory axons from C1, 2, and 3 converge on dorsal horn neurons that also receive afferent supply from the trigeminal nerve. Hence pain mediated by the C1, 2, and 3 nerves is perceived in areas supplied by the trigeminal nerve. A common cause of cervicogenic headache, particularly in patients after whiplash injury, is pain from the C2-3 facet joint mediated by the third occipital nerve. The source of pain can be diagnosed using controlled diagnostic blocks. Facet intra-articular injection with steroid and more so radiofrequency neurotomy is effective in relieving pain.
Somatic Chest Pain Referred
Chronic thoracic pain.113 It has been estimated that 15 percent of spinal pains originate in the thoracic spine.114 Of those, it has been suggested that nearly half originated in the zygoapophyseal joints.115,116 Painful cervical facets were the cause of the pain in 55 percent of patients with neck pain and 42 percent patients with thoracic pain.116 Manchikanti et al.116 found this to be more prevalent in people with sedentary jobs. The diagnosis is made by exclusion of other pathologies and a high index of suspicion since there are no defined clinical or radiological features.117 There have been descriptions of patterns of distribution of this pain in healthy volunteers, and these are mainly centered on the back.118,119
Measurement of costs and benefits
There is also debate as to whether the human capital approach (where a year of working time lost is measured by average salary) or the friction method (where production losses are dealt with by transferring work lost to other workers) should be used in measuring indirect costs. The differences in results may be highly significant. For example, the indirect non-medical cost of neck pain in the Netherlands in 1996 was
Generalized anxiety disorder
Improvement in anxiety was more important than changes in physical capacity in predicting outcome.36 Similar benefits when reducing anxiety in patients with back pain were shown in a Finnish study.37 In a recent World Health Organization (WHO) survey, people with back and neck pain were over 2.5 times more likely to have GAD than controls without this condition.38 This survey was not able to show the temporal relationship between pain and anxiety, but other studies have strongly suggested that anxiety sensitivity is a feature in this population.27'36
Physiological Influences
Investigated, but the findings to date in the elderly suggest genetic factors are not important. A study looking at the development of neck pain in the elderly failed to demonstrate a significant influence of genetic factors.11 IV Similar work on back pain in the over 70 age group suggests a small genetic effect in men but not women. Significant predictors for back pain found in this latter study included previous or current diagnosis of osteoporosis, arthritic or lumbar disk disease, as well as environmental effects.12 IV
Case 2 Gareth Suneil Ramessur Mbbs Bsc Hons FRCA DipHEP
Gareth, 40-year-old man, is referred to you with persistent pain and tingling around his neck and upper limbs. The pain started following a road traffic accident during which he sustained whiplash injury several months ago. He has tried various pain killers and physiotherapy without much benefit. The attending neurologist has requested you to see Gareth. A recent MRI of cervical spine is showing arthritic changes in the cervical facet joints. Though the presentation and investigations indicate pain secondary to the whiplash injury and cervical facet joint arthropathy, it essential that a detailed first-hand history and clinical assessment are performed. In whiplash injury, pain course can be difficult to predict. Pain can persist for many years. There could be periods of remission and exacerbation. Regular medications and interventions such as physiotherapy, trigger point injections, and acupuncture have all been tried with variable success. Another interesting aspect of pain in such...
Lymphomatous Meninigitis
CNS lymphoma may present as lymphomatous meningitis, a condition characterized by headache, fever, stiff neck and mental status changes with cranial or spinal nerve palsies. CSF white blood cell count, protein and glucose can be normal or elevated. CSF cytological analysis may reveal malignant cells. Brain imaging reveals atrophy with or without meningeal enhancement. The mean survival from the time of diagnosis of lymphomatous meningitis is only 5 weeks. At this stage, treatment is not usually helpful.171
Which of the following is true about the use of antidepressants and their analgesic effects
Mary is a 35-year-old female who has been suffering from a headache following whiplash injury. She says that her pain starts from the back of her head and radiates to the forehead and into both of her eyes. On examination, she has tenderness over the posterior occiput. The following statement is not correct
Sreekumar Kunnumpurath Mbbs Md Fcarcsi Frca Ffpmrca
Andrew is 75-year-old man who has been very active until about a year ago. He used to play golf twice a week. One year ago, he slowly started to get persistent lower back pain which gradually began to worsen. A few months later he noted that he was getting pain in his thigh and to his dismay his neck was becoming painful too. Finally, he had to stop playing golf altogether. He was seen by his PCP who after a careful examination made a diagnosis of non-specific back pain. Andrew was started on acetaminophen and ibuprofen, which reduced his back pain to such an extent that he could play some golf again. However, a few months later during a routine checkup his PCP noticed edema of his ankles. On further investigation, he was found to have elevated blood urea and crea-tinine. Ibuprofen was promptly stopped with resulting recurrence of back and neck pain. Andrew was then prescribed regular codeine phosphate and diazepam before bedtime for Can you correlate neck pain and back pain
Physical Examination
The cause of common neck pain is not usually determined on physical examination. Range of motion of the neck and areas of tenderness in the neck and shoulder girdle muscles are noted. In patients with neurologic symptoms, a neurological examination including motor, sensory, and reflex testing in upper and lower extremities may help narrow findings to specific nerve roots (Table 26.7). The presence of hyperreflexia, clonus, Babinski's sign, and abnormal gait may indicate myelopathy.
Severity and Characteristics of the Pain
Somatic pain is generally described as a dull, aching pain. Pain that is shooting or lancinating is usually indicative of a neurogenic origin. The level of pain reported by the patient is useful information. Severe acute neck pain requires urgent evaluation. In patients with chronic neck pain, assessment of the level of pain may be useful in guiding effectiveness of various treatment modalities. Factors that relieve or exacerbate pain may include specific patient or activities, although none are specific for any source of pain.
Skeletal Muscle Relaxants
There was fair evidence that cyclobenzaprine, carisoprodol, orphenadrine, and tizanidine were effective compared to placebo in patients with musculoskeletal conditions (primarily acute back or neck pain). Cyclobenzaprine has been evaluated in most clinical trials and has consistently been found to be effective. There are very limited or inconsistent data regarding the effectiveness of metaxalone, methocarbamol, chlorzoxazone, baclofen, or dantrolene compared to placebo in patients with musculoskeletal conditions. There was insufficient evidence to determine the relative efficacy or safety of cyclobenzaprine, carisoprodol, orphenadrine, tizanidine, metaxalone, methocarbamol, and chlorzoxazone. Dantrolene and, to a lesser degree chlorzoxazone, have been associated with rare serious hepatotoxicity (Chou et al. 2004).
Diagnostic blocks
Among the possible sources of low back pain are the lumbar zygapophysial joints and the sacroiliac joints. Among the sources of neck pain and headache are the cervical zygapophysial joints, the lateral atlantoaxial joints, and the atlantooccipital joints. For these joints, a variety of diagnostic blocks has been devised and implemented in some circles. Yet their use has met with acrimonious dissidence. Even though the validity of these blocks has been established in double-blind, controlled studies, they have been decried as amounting to no more than placebos.81 The irony is that the same critics extol the virtues of sympathetic blocks, which lack doubleblind, controlled studies.81 In the pursuit of neck pain, the atlantooccipital and lateral atlantoaxial joints can be anesthetized using intraarticular injections of local anesthetic agents.82,83,84, 85, 86, 87 The cervical zygapophysial joints can be anesthetized using intraarticular blocks or blocks of the medial branches of the...
List of Tables
6.1 Acute Neck Pain as the Principal Presenting Feature Possible Causes 90 6.2 Medical, Social and Occupational Risk Factors Shown Not To Be Aetiological Risk Factors for Neck Pain 93 with Neck Pain 93 6.4 Psychosocial Risk Factors Shown Not To Be Related to Neck Pain 93 with Acute Neck Pain 96 6.6 Factors Associated with Chronic Neck Pain After Whiplash with Chronic Neck Pain After Whiplash 103
Literature searches on therapeutic options for treating mechanical neck pain were carried out using the following databases Chirolars (now called Mantis), Bioethicsline, CINAHL, Current Contents, and Medline, with data being used to prepare and update an article in Clinical Evidence 2 . I will summarize the evidence on treatment modalities currently in use, with an indication of questions which still need to be answered. Studies relating to specific conditions like fibromyalgia and disk prolapse will not be discussed. Data on therapy will be considered for patients with (uncomplicated) nonspecific neck pain, neck pain plus radiculopathy, and whiplash. Therapies will then be categorized as likely to be effective, where there is at least one high-quality RCT suggesting benefit and reasonable consensus from other studies likely to be ineffective, where there is at least one high-quality study suggesting a lack of benefit from the treatment and unknown effectiveness, where there is...
Future research
The benefit of most therapeutic interventions for nonspecific neck pain is small, and many patients improve with limited or even no treatment 97 . It is therefore important that future studies set predetermined minimum differences, which are considered to be clinically relevant. This approach should avoid the current difficulty that many studies, while showing statistically significant differences in outcome, may have little clinical importance.
Nonspecific neck pain including whiplash is a very common cause of disability, and places a heavy burden on individuals, employers and society. However, there are many aspects regarding etio-pathogenesis and treatment which remain poorly understood. Furthermore, if the factors that influence the progression from acute to chronic pain were better understood, it might be possible to reduce the frequency and severity of chronic disability for both whiplash and other causes of nonspecific neck pain. Most studies of acute neck pain are in patients following whiplash injury, and it is not clear if the findings from those studies can be generalized to neck pain from nontraumatic causes. There have been some higher quality randomized controlled trials of therapy in patients with nonspecific neck pain, which suggest that exercise 32, 33 and manual therapy (mobilization physiotherapy or manipulation) 45, 46, 48 are the treatments of choice, and are more effective than less active therapies, but...
There are three forms of encephalitis produced by measles virus. The most common form is a post-infectious encephalomyelitis characterized by the acute onset of headache, fever, stiff neck, seizures and focal deficit, usually within 14 days of rash. Mortality is about 10-20 ,222 and survivors are often left with seizure disorders, impairment of cognitive function and deafness. Pathological changes are found mainly in white matter and are indistinguishable from the inflammatory demyelination seen in fatal cases of post-vaccinial encephalomyelitis due to rabies immunization or smallpox vaccination. Measles virus is not found in the brains of patients who die of measles post-infectious encephalo-myelitis.223
An additional tract that may be lesioned is the quintothala-mic tract. It is located superomedial to the spinothalamic tract. This decreases transmission of extralemniscal emotional suffering. The best results have been using stereotactic approaches for the treatment of nociceptive head and neck pain secondary to malignancy and neuropathy. The main untoward side effects are dysesthesias and oculomotor dysfunction (Fig. 13.41).
Value and efficacy
In 2003, Assendelft et al.69 I performed a meta-analysis of 39 randomized controlled trials evaluating spinal manipulation in low back pain. They concluded that spinal manipulation was superior to sham therapy and to therapies that have been judged to be ineffective or harmful, but it had no advantage when compared with general practitioner care, analgesics, physical therapy, exercises, or back school. Results were similar for acute and chronic low back pain. A Cochrane review by Gross et al.70 I concluded that manipulation and or gentle mobilization were not beneficial when performed alone, but they were beneficial when used with exercise. The review also concluded that neither was superior to the other and that there was insufficient evidence about their effects with radicular findings. The review acknowledged the methodological limitations of many of the underlying trials. Fernandez et al.71 I published a meta-analysis evaluating whether manual therapies have proven efficacy in...
Tensiontype headache
Peripheral factors have traditionally been considered of major importance in TTH. Numerous studies have reported increased tenderness of pericranial myofascial tissues in these patients.43,44 Moreover, TTH patients are more liable to develop shoulder and neck pain in response to static exercise than healthy controls.45 The increased myofascial pain sensitivity in TTH could be due to release of inflammatory mediators resulting in excitation and sensitization of peripheral sensory afferents.43,44 A recent study demonstrated normal in vivo interstitial concentrations of inflammatory mediators and metabolites in a tender point of patients with CTTH.46 Concomitant psychophysical measures indicated that a peripheral sen-sitization of myofascial sensory afferents was responsible for the muscular hypersensitivity in these patients,47 but firm evidence is still lacking.
Neck pain is pain perceived in a region bounded laterally by the margins of the neck, superiorly by the superior nuchal line, and inferiorly by an imaginary transverse line According to this definition, neck pain is perceived in the back of the neck, and this is typically where patients indicate neck pain. It is unusual for a patient to indicate neck pain anteriorly. In such cases, neck pain needs to be distinguished from pain in the throat or elsewhere in the visceral column of the neck. If a patient complains of visceral pain it should be so described and recorded, and not confused with neck pain. Conceptually, anterior neck pain would be pain perceived behind the visceral structures of the neck. Accordingly, the term anterior neck pain'' should be reserved strictly for those patients who can identify pain at the front of their neck, but not in the pharynx, larynx, trachea, or esophagus, or their adnexae. Little has been published about this type of pain. The evidence base for neck...
Risk factors
Many factors have been studied as risk factors for the development of neck pain. Some have been refuted others have only a weak or moderate association, with odds ratios less than 3.0 (Table 36.1 ).17 The most pervasive risk factors for neck pain relate to the work environment. They include high job demands,18, 19 low decision authority,19,20 little influence over the work situation21 or low job control,22 low coworker social support,19,22,23 high psychological demand,23 and low decision latitude.23 Although psychosocial in nature, these factors stem from the patient's work circumstances, and do not constitute personal psychological factors. Specific and classical psychological variables have failed to emerge as determinants of neck pain. Distinctly unrelated to neck pain are variables such as social support, depression, anxiety, coping ability, self-confidence, ability to solve problems, sense of humor, irritability, impatience, psychosis, extroversion, and lying, on the Eysenck...
Natural history
Some 14 percent of the population experience a new episode of neck pain in a given year, with 0.6 percent experiencing disabling pain.27 Approximately 37 percent of those affected progress to complete resolution, with the passage of time and a further 33 percent experience improvement but neck pain persists in the remainder.27 Some 23 percent of individuals suffer a recurrence within the year. In effect, neck pain persists in about half of those initially afflicted.28 Some 25 percent of patients have moderate symptoms after ten years, and some 7 percent remain or become severely disabled.29,30 Table 36.1 Refuted and weak to moderate risk factors for the development of neck pain.17 Table 36.1 Refuted and weak to moderate risk factors for the development of neck pain.17 Systematic reviews have found few studies that reported on prognostic factors for neck pain.31,32 None provided a statistical analysis that yielded either the relative risk or odds ratio for any association....
Prognostic factors
Persistence of neck pain after whiplash is not related to factors such as age, gender, psychological response, or compensation.54 It is weakly related to sleep disturbance, cognitive impairments, poor concentration, neuroticism, past history of headache, and being unprepared for the collision.54 The cardinal determinant of poor outcome is the initial intensity of pain and other symptoms.54, 55, 56, 57 Patients least likely to recover exhibit hyperalgesia, both in the cervical region and in regions remote from the neck, as well as psychological distress in the face of their symptoms.58,59,60,61,62 Evidence has also emerged that, independent of the initial intensity of pain, engaging a lawyer is a predictor of poor outcome.56,57
The favorable natural history of neck pain after whiplash indicates that most patients suffer no substantive injury. Perhaps they suffer a minor muscle strain, or a minor injury to a joint in the neck, which spontaneously resolves. A pathology is required only to explain the minority of cases in which pain becomes chronic. Rare injuries include disruption of the alar ligaments, prevertebral hematoma, perforation of the esophagus, tears of the sympathetic trunk, damage to the recurrent laryngeal nerve, spinal cord injury, periplymph fistula, thrombosis or traumatic aneurysms of the vertebral or internal carotid arteries, retinal angiopathy, and anterior spinal artery syndrome.51,58 Fractures after whiplash are so uncommon as to be rare. Such fractures as have been attributed to whiplash have been reported only in case studies or small, descriptive series. These fractures may be difficult to detect on conventional investigations, and special attention needs to be paid to their...
Clinical assessment
A comprehensive history of neck pain can be recorded by noting the standard features of any type of pain, as listed in Table 36.3. Asking the duration of illness establishes if the condition is acute or chronic. The circumstances of onset identify if the cause was spontaneous or traumatic, or associated with an illness or intervention. The mode of onset is usually unremarkable, but a sudden, spontaneous onset of severe neck pain should warn of a red flag condition. The site of pain and its radiation may be helpful in indicating, prima facie, the likely segmental origin of pain, but widespread neck pain offers no localizing clue. Neck pain should be dull and aching in quality lancinating or sharp pain suggests a possible neurogenic cause. Asking about frequency and duration establishes if the pain is episodic or constant, but lends little to establishing the cause, nor does the timing of the pain. Pain precipitated and aggravated by neck movement suggests an articular or muscular...
Plain radiography
The only valid indication for plain radiography in a patient with neck pain is a history of trauma. In that context, radiography is used as a screening test for fractures. However, the pretest likelihood of fracture is low, even in patients with a history of trauma.70 The Canadian C-spine rules define the responsible use of radiography in such patients71 (see Chapter 12, Diagnostic procedures in chronic pain). Radiography is indicated if the patient is older than 65 has suffered a dangerous injury, such as a fall or high speed collision or expresses neurological symptoms. A simple rear-end motor vehicle collision does not qualify as a dangerous injury, and is not an indication for radiography. Otherwise, if the patient has been ambulatory and is able to rotate their neck by 45 to the left and right, radiography is not indicated. Under these rules, the chances of missing a significant fracture by failing to undertake radiography are essentially nil. In patients with neck pain but no...
Emerging prospects
It is possible that lesions responsible for neck pain can escape detection because of the limited resolution of conventional imaging techniques. Advanced technology has been explored for its ability to provide greater resolution. A case report illustrated that functional MRI could reveal lesions of the atlanto-axial joints and ligaments that had escaped detection by conventional means.83 A pair of studies reported that MRI could demonstrate various grades of lesions in the alar and transverse ligaments, and that such lesions were significantly more common in patients with a history of whiplash than in control subjects.84,85 Others have not yet reproduced these observations. Nor have the lesions detected been shown to correlate with pain. A study in progress issued a preliminary report to the effect that lesions affecting the zygapophysial joints, disks, and other structures could be revealed in patients after whiplash, using MRI spectroscopy.86
Surgical therapy
There is no compelling evidence of the efficacy of cervical fusion for neck pain. Such studies as have reported on this therapy claim success,135,136 IV but outcome measures are few and lacking in rigor. Some studies report disheartening results,137 IV particularly for surgical therapy of neck pain after whiplash.138 IV Some 57 percent of patients report their pain as much better after surgery, but only 10 percent are rendered free of pain.139 IV Table 36.5 The pain scores reported in various studies of exercises for chronic neck pain. All studies provide level II evidence. Table 36.5 The pain scores reported in various studies of exercises for chronic neck pain. All studies provide level II evidence.
Litigation and Pain
Concerns naturally arise about the potential role of ongoing litigation and its effect on the experience of pain, the rehabilitation process, and allegations of disability. It is conceivable that the pursuit of litigation could have an impact on the treatment and rehabilitation of a patient's pain (Gatchel et al. 1995). It has been reported that people with whiplash injuries who were in the midst of litigation reported more pain than those who were no longer involved in litigation (i.e., whose cases were settled or resolved) (Swartzman et al. 1996). However, there was no statistically significant difference between those who were in the midst of litigation and those who were not with regard to employment status, return to work, and functional adaptation. The clinician is cautioned against making causal assumptions about the role of the litigation in influencing the patient's agenda (Swartzman et al. 1996). It is possible that for some patients, pain is exaggerated so as to increase...
Medial Branch Blocks
Cervical medial branch blocks can be used to test if a zygapophysial joint is the source of a patient's neck pain. They involve anesthetizing, under fluoroscopic control, the small nerves that innervate the target joint, each with no more than 0.3 mL of local anesthetic89 (Figure 36.5). Epidemiologic studies, using double-blind, controlled, diagnostic blocks, have shown that zygapophysial joint pain is the single most common basis of chronic neck pain, both after whiplash and in heterogeneous samples. In patients with a history of whiplash, prevalence figures (with 95 percent confidence intervals) of 54 percent (40-68 percent)94 and 60 percent (46-73 percent)95 have been reported. In patients with headache after whiplash, the prevalence of C2-3 zygapophysial joint pain was 53 percent (37-68 percent).96 Amongst drivers involved in high-speed collisions, the prevalence was as high as 74 percent (65-83 percent).97 In patients with neck pain not restricted to those with whiplash, the...
Neuronal Plasticity
Repetitive activation of muscle nociceptors leads to peripheral sensitization, therefore decreasing the excitation threshold and increasing the response to low level noxious stimuli (hyperalgesia). Wind-up occurs in the spinal dorsal horn, when repetitive input from the C-fiber nociceptors increases the response of the neurones. This causes increased release of substance P and glutamate activating the N-methyl-D-aspartic acid (NMDA) receptors by removing the magnesium block. Temporal summation studies have been carried out in FMS patients with intramuscular electrical stimulation. The results showed that temporal summation was more pronounced in FMS patients compared to controls, indicating central sensitization.54 Similar results were reported for FMS and whiplash patients,55 again supporting the hypothesis that localized pain (or trauma) can develop into FMS.
Tions or gummas) disease develops within 1-30 years after primary infection.129 Meningovascular infarcts,130 CNS gummas, and myelopathy131 may occur. Meningovascular syphilis is characterized by headache, fever, stiff neck, and focal neurological deficit. Seizures and cranial nerve deficits, particularly optic neuritis, facial weakness and hearing loss, may also develop. In fact, 20 of syphilis meningitis patients become deaf. Dementia and psychosis characterize general paresis, a late complication of neurosyphilis. The onset of memory loss, delusions of grandeur and dysarthria is insidious. Tabes dorsalis, another late complication, consists of lightning pains in the lower extremities and abdomen, diminished reflexes, severe loss of vibratory and proprioceptive sensation and bilateral Argyll-Robertson pupils (small, irregular pupils that do not react to light, but do accommodate).
Medical History
A careful medical history including questions regarding systemic illness, unexplained weight loss, history of neoplasm, fever, infection, neurological changes including numbness and weakness in the extremities, and history of substance abuse is important to exclude serious causes of neck pain. Just as there are red flags with the assessment of low back pain, the same red flags should be emphasized in patients with neck pain. Infection, tumor, trauma (spinal cord, epidural hematoma, fractures) are serious causes that require urgent evaluation


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It is important that, along with your confirmation and the information we provide in our brochure and on our website, you read the following carefully as they make up your contractual agreement with us. If you've booked a special offer, its terms will also apply. The terms and conditions apply to bookings made directly with Park Leisure in person on one of our Parks, online or by phone and not to any private letting contracts made directly with a caravan holiday home owner on our Parks.
From time-to-time, we may need to update these terms and conditions and so the latest version can always be found at www.parkleisure.co.uk/terms-and-conditions. If we make a significant change to our terms and conditions that fundamentally changes your reservation after you've booked, we commit to giving you the opportunity to cancel and receive a full refund. If you're not happy with our terms or have any questions about them, please call your Park prior to your arrival during normal business hours, otherwise we'll assume that you've accepted and agree to abide by them.
For the sake of clarity, here are the definitions of some of the things we say in our terms and conditions:
Since only the people named on the booking confirmation can use our caravan holiday homes, pitches and Park facilities, it is essential that you check it as soon as you receive it to ensure it is correct and subsequently tell us of any changes after you've booked. The total number of people coming with you (including children and babies) must not be more than the actual berths in your caravan holiday home, typically this will be between four and up to a maximum of eight people. Any additional guests over the maximum will unfortunately be turned away at check-in. Also, we want our holidays to be enjoyable for all of our guests meaning that if any member of your party acts in an antisocial way, the party may be asked to leave the Park immediately with no refund for any portion of your stay. If the behaviour is capable of being put right, we will give you one warning before we ask you to leave.
We do not offer holiday insurance products however, for your peace of mind, we strongly advise that you take out suitable holiday insurance covering cancellation, medical and personal possessions as a minimum for the duration of your stay with us
So that you and your fellow guests have the best time, here are some commitments we make when we accept your booking and because it's a two-way street, you will be making commitments to us when you book.
We will make every effort to provide you the holiday as described in our agreement. We will make every effort to provide you with precisely what you booked but if you booked a two-bedroom holiday home and one is not available for the entire duration of your holiday we may upgrade you in to a three-bedroom holiday home of the same grade instead.
We will make every effort to ensure you and those holidaying with you have a fantastic holiday full of happy and lasting memories. We will make every effort to prevent things from going wrong and, in the event that something does go wrong, tell us (see section 6 a) and we will make every effort to put things right in the quickest possible time.
You commit to telling us who is coming with you in your party and that you will only allow these people onto the park. You commit to looking after our accommodation and facilities so that other people can enjoy them with and after you. In the unlikely event that you cause any damage, you will tell a member of our Team straight away so we can sort it out. You commit to not acting in any way that can be reasonably considered as being antisocial and adversely affecting the holiday experience of other guests on Park. Any behaviour that in our opinion is likely to upset other guests will be considered to be antisocial. You and your party commit to not breaking any of these terms and conditions since, if you do, for the sake of your fellow guests, we will be obliged to tell you and your party to leave the park immediately with no refunds. If the behaviour is capable of being put right, we will give you one warning before we ask you to leave.
Our current prices, inclusive of VAT at the prevailing rate on the date on which payment is made, are on our website however the exact price you pay can only be confirmed at the time of booking. We will not change your holiday price once you have booked and paid your deposit unless the VAT rate changes, or unless we both agree. Please note that deposits are non-refundable and are £50 at the time of booking, where due.
Unfortunately, mistakes do happen since we are all human so if we should happen to undercharge you because of a mistake on our part, we reserve the right to contact you to offer you the options of either paying the full price or cancelling your holiday and receiving a full refund. Conversely, if we've overcharged you by mistake, we'll refund the difference in price. Don't forget that you may have to pay for optional extras like Spa treatments in advance – if this is the case, we'll always let you know.
All bookings made less than 4 weeks before the holiday start date have to be paid in full at the time of booking. If however you book more than 4 weeks before the start of your holiday, you can either pay the full amount or a deposit with your balance due date being clearly indicated on your holiday confirmation. It is your responsibility to ensure that you clear the balance by the date stipulated since failure to do so will lead to your holiday being cancelled and you will not get any monies already paid refunded.
Circumstances change so it may be that you need to alter your booking in which case we will try our best to meet your new requirements. If it is possible to make the requested change(s) it may result in your holiday costing more and you will be liable for this increase. Please bear in mind that there is a £20 admin fee for all changes and a change of park or dates within 28 days before your initial scheduled arrival date on Park may constitute a cancellation if we cannot meet your new Park and/or date requirements. Please check the details on your confirmation and advise us immediately of any concerns you may have.
We sincerely hope that you don't need to cancel your booking however, if you do, please call our Holidays team on your chosen Park as soon as you know so that we can try to offer you alternative options, for example we may be able to change the date of your holiday. Depending on how close you cancel to your planned holiday start date, you will otherwise receive a refund according to the amounts detailed in the following table, paying your refund to the card you used to make your booking or send you a cheque.
|Days before your holiday starts
|Refund entitlement
|29 or more
|Full refund minus your deposit or minimum loss of £50 per holiday home and £25 loss per touring or camping pitch
|70% refund, minus your deposit
|20% refund, minus your deposit
|10% refund, minus your deposit
|7 or fewer
|No refund
As previously mentioned, we commit to delivering the holiday experience advertised in our brochure and on our website. On the very rare occasions when we find we can no longer offer the holiday booked, we will contact you to offer one of three options: i An alternative holiday that is similar or even better than the one you originally booked ii An alternative holiday that is less expensive than the one you booked along with a refund for the price difference iii Cancellation and a full refund
Check-in times vary, depending on where you're staying.
On your arrival day, if you arrive before your check-in time, from 10am you are welcome to relax and enjoy the Park until your accommodation is ready for you. Alternatively, if you are planning to arrive after 6pm when our Reception closes or are running late, please let the park know in advance so we can make alternative arrangements for your arrival. If you do not arrive on the date on your booking confirmation and you have not informed us otherwise, we will assume that you have chosen to cancel your holiday with us. So, from noon on the day after the booked arrival date we reserve the right to re-let the accommodation.
We may ask you to leave a cash deposit with us when you check in. We'll return this once your holiday is finished provided your accommodation is clean, tidy and not damaged.
Check-out time is 10am and we kindly ask that you return the keys and always leave your pitch or caravan holiday home looking good. Having checked out, if you fancy using the Park facilities, you are invited to do so up until 3pm.
Where present, you have free use of our swimming pools and most other leisure facilities at the park during your stay. Some activities or Spa treatments cost extra or need a deposit, and some may not be suitable for everyone. Outside peak season, we won't have quite as much going on at most of our parks. This is why those holidays cost less.
There's no smoking of tobacco, e-cigarettes and vaporisers in any of our accommodations or public buildings and we require all guests not partake in these areas. We do have clearly signposted outdoor smoking areas outside the public buildings and politely ask you to smoke outside of the accommodation and away from any fire hazard. However, if it is apparent that smoking has taken place in your accommodation, additional cleaning costs will be charged.
Fitting a standard sized travel cot in the bedroom of a holiday home is not always possible meaning that it may be necessary to position the cot in the living room. If you need a cot or highchair, you can add this to your booking.
Whilst on Park, we do everything we can to keep you and all children in your party safe however they remain your responsibility at all times, and you must make sure they do what our team say for their own safety. We expect all children under 16 years to be accompanied by a parent or guardian after dark.
We welcome up to 2 well-trained dogs in designated accommodation and on our Touring facilities however we do not allow any dogs listed under the Dangerous Dogs Act which include Pit Bull Terriers, Dogo Argentinos, Fila Brasileiros and Japanese Tosas. If you wish to bring pets other than dogs you will need to contact your chosen Park before you book to see if this is possible. Your dog is your responsibility so if your dog is noisy or misbehaves we may be forced to ask you to remove them to kennels at your own expense. Therefore, we ask that your dog is kept on a lead and that a responsible adult is looking after him/her at all times. To this end, we require that pets are not left alone in any accommodation at any time. Please bear in mind that you won't be able to take your pet into our restaurants and public areas unless he/she is a Registered Assistance Dog.
If you have special needs or are travelling with someone who does, we do have some specially adapted caravan holiday homes and our Park Teams can give you advice and information as to their suitability. Since Registered Assistance Dogs are permitted in all of our holiday homes and in all areas of our parks, we cannot guarantee that we've never had any dogs in our accommodation.
We want to give you and everyone else at the park a great holiday and so our holidays are designed with families and couples in mind. We don't allow hen or stag parties. We may also turn down your booking or turn you away on arrival if you are travelling alone, or in a group which does not consist only of family members or couples, and we believe the reason for visiting is not in-keeping with our family focused values.
** Due to the Coronavirus outbreak and government guidelines regards social distancing, please note that our facilities may not be available during your stay. The possible closure of our facilities has been reflected in our discounted holiday booking prices. **
Our Food & Beverage Team Members are trained in food allergen awareness. If you have a food allergy or special dietary requirement, please talk to one of our team members before ordering your food. We will give you as much information as we can about the ingredients and how the food is prepared so you can make an informed decision about whether to or what to order in our bars and restaurants.
Due to the strict terms of our food safety policy, we apologise for not being able to reheat baby and infant food for you. However, we will happily provide hot water and a microwave, so that you can prepare your children's food according to your child's exact preferences.
Your hot tub will have been completely emptied, cleaned and refilled on the day of your arrival in order for us to maintain the required hygiene standards. Given the quantity of water involved, it may not be at the regular running temperature of between 37°C and 38°C until the evening of your arrival.
For your health and safety reasons, we test your hot tub's chemical and water quality twice a day and have to insist when using your Hot Tub you:
Supervise all children between the ages of 5 and 16 years. No child under 5 years should use the Tub.
To safeguard the holiday environment and the safety of all guests, the speed limit on Park is strictly 10mph unless your chosen Park rules stipulate otherwise and no driving is permitted around the site between midnight and 6am.
We'll do our best to give you a parking space next to your caravan holiday home or pitch and although the vast majority have adjacent parking, we can't guarantee this. Also, if you are planning to bring a large commercial vehicle, trailer, boat or jet ski for example, you will require consent from the Park so please check with your chosen park before you book. Unfortunately, some parks quite simply don't have the space.
We are planning to introduce electric vehicle charging points, but currently our Parks are not designed to supply the electricity required to support vehicle charging. In addition to the additional load on the accommodation's supply, there is an increased risk of electric shock and a trip hazard from any charging cables that would be in use. Although we are fully committed to doing our bit for the environment and welcome hybrid cars, we therefore have to insist that guests do not use the accommodation's electricity supply to charge up their vehicle.
You can only bring one tourer, motorhome, tent or trailer tent onto each pitch. If yours is on the large side please let us know when you book so we can to help fit you in. Additionally, the price you pay for your pitch is for up to 2 guests and there is a charge for additional guests and for larger units payable at the time of booking. Most of our pitches accept awnings however we ask that neither you nor a member of your party sleeps under the awning.
We all enjoy a celebration so please do advise us when you book if you'll be celebrating something special while on holiday with Park Leisure. In fairness to all guests on Park, if you are planning to hold a party of any description, we just need to approve your plans before taking your booking.
We hope you'll have such a great time and that you won't want to leave but if you do, we don't typically offer a refund.
With the wellbeing of all guests on Park in mind, please let us know if you come down with something that you think may affect anyone else. We may choose to contact a doctor depending on what you have contracted and ask you to stay in your accommodation or in extreme cases even ask you to curtail your holiday.
We have all done it so contact us as soon as you realise that you have misplaced something and we will do our best to relocate it although we are not liable if this isn't possible or if the item is damaged. If we find it, we'll return it to you, but depending on the size or nature of the item, you may have to cover the postage costs.
Whilst on Park, you and those in your party are responsible for looking after your own belongings so we strongly advise that any valuable items you bring on holiday are adequately covered by your insurance. We cannot accept any liability for loss or damage to your belongings unless we have been at fault.
Special facilities update in relation to the Coronavirus Government Guidelines:
We are following the Government guidelines closely with regards to the Coronavirus outbreak. At the time that we are able to welcome holidaymakers to our parks, our facilities will only be available subject to, and in line with, the government guidelines at that time. If we are still advised to observe social distancing measure at your time of arrival, our facilities will not be available to holidaymakers. Our discounted holiday prices reflect the fact that facilities may be unavailable during your stay.
Including the use of Park Leisure operated CCTV on Park, we do everything we can to keep you and your party safe and, of course, we have to comply with the law, Health and Safety Executive and local authorities. If there is an issue at your chosen park that we know about, we will advise you before you book. When on holiday, in the worst-case scenario it could mean us having to close facilities at short notice however we commit to alerting you as soon as we know. Regardless, it is vital that you follow our safety advice during your holiday with us.
With your health and safety in mind, we do have a few important rules designed to keep you safe including:
Swimming Pool safety: We operate several pools across our parks and depending on size, some are lifeguarded and others are not. The following age restrictions are in place:
For our lifeguarded pools:
In all instances, non-swimmers must be accompanied by an adult swimmer.
*An adult is defined a person aged 16+ years.
For our non-lifeguarded pools:
*An adult is defined a person aged 16+ years.
In all instances, non-swimmers must be accompanied by an adult swimmer.
For all non-swimmers, irrespective of age, the ratio of 1:1 applies and the accompanying person must be in the water providing direct supervision with the non-swimmer.
Regardless of the presence of lifeguards, you remain responsible for the behaviour and safety of all the children in your party at all times.
In the unlikely event that your accommodation is damaged by you or another member of your party during your stay, we reserve the right to recover the cost of any required repairs from you, including any extra cleaning costs. On rare occasions, we may choose to go into your holiday accommodation at a reasonable time and notice during your holiday to check that everything is ok.
We're totally committed to making sure everything is as you'd expect when you're on holiday with us. In the unfortunate event that you have a concern, we promise to resolve it as quickly as we can. If you have an emergency issue such as loss of electricity, gas or water, or a major water leak we'll work with our service providers to make sure your services are restored as soon as possible.
Our mission at Park Leisure is to exceed your expectations from start to finish and we genuinely value your feedback as to how we can improve your experience with us.
Unfortunately, there are times when things do not go according to plan and we do not meet your expectations, but rest assured, we will do our very best to put things right and get your holiday back on track on every occasion. So….
If you have yet to travel you can…
If you are on your holiday…
Please let our Park Team know immediately of any concerns so that we can resolve any issues immediately and enable you to continue to enjoy your holiday as planned. If the Customer Care Team on Park cannot resolve the issue, they will put you in touch with the Park's General Manager. As a last resort, please contact our Guest Services Team:
If you have now returned home…
… and still feel that the issue has not been resolved to your satisfaction, please put your complaint in writing to us giving us as much information about your complaint as possible. Depending on your preference, you can:
Guest Services Park Leisure Holidays Unit 1, Tudor Court York Business Park Nether Poppleton York YO26 6RS
You should do this within 28 days of returning from your stay, as we may not be able to consider a complaint if the evidence no longer exists.
We do listen and learn…
All comments, good and not-so-good are valued by members of the Leadership team. For the latter, they will ensure that the right Team member will address your issue and will do so promptly. For compliments, we operate a Team recognition scheme and will always communicate positive feedback to the individual or team concerned.
Finally, we politely request that, to make sure that all feedback is dealt with in a timely fashion, you include your booking reference in all correspondence or have this to hand if you choose to contact us by phone.
If we ask you to call them, rest assured that calls to 03 numbers are only charged at standard UK rates from a landline but may vary from mobiles. These calls are usually included in any talk inclusive phone packages.
Chances are that if you have a question, we have been asked it before and so we have compiled answers to many frequently asked questions online at www.parkleisureholidays.co.uk/faqs. If you cannot find an answer to your query there then please give us a call on 01904 786100 during office hours.
When you make a booking request, you're offering to buy one of our holidays and you are agreeing to follow our terms and conditions. We do have the right to turn down your booking request.
The holiday agreement between you and Park Leisure starts when either we accept your booking and deposit and subsequently issue you a booking confirmation or we confirm your booking online or over the phone. Our contract is with you as the lead booker and we remind you that you are making an agreement with us on behalf of everyone coming with you and it is your responsibility to make sure that they all know about these terms and that they accept them. This agreement does not allow either us or you to transfer or subcontract any of the things in it without getting permission in writing.
When you make your booking, we will ask you for details of your permanent home address and may check this against publicly available records both to prevent fraud and to make sure we can contact you by post before or after your holidayshould we need to. All guests may be required to produce proof of their residential address such as a bank or credit card statement no more than 3 months old and photographic identification such as a passport or driving licence.
We want to maintain a safe and secure environment for you and your family and may ask for your identification on arrival. We don't knowingly allow anyone to use or visit our parks who is a convicted child sex offender, subject to the notification requirements of the Sexual Offences Act 2003, or subject to a Risk of Sexual Harm Order or Child Abduction Notice.
If a court or a similar organisation questioned any of these terms, the rest of the agreement would still be valid. It would also still be valid if we allowed you to do something that we wouldn't normally allow under the agreement.
We accept responsibility for things that go wrong if, and only if, we should have foreseen them when you booked or they arose later and were our fault. Since our mission is to ensure you and your party have a fantastic holiday at Park Leisure and we want to see you return in the future, we never try to avoid our legal responsibility and we commit to always dealing reasonably with any claims for loss or damage that are our fault.
There are however situations beyond our control and under such circumstances we can't take responsibility or pay compensation for things like fire, flood, explosion, weather conditions or damage, criminal damage, civil strife, industrial action, natural or nuclear disaster, war or threat of war, terrorist activity and epidemics, that damage or even destroy our accommodation or facilities. We commit to doing our utmost to assist you in the unlikely event of any of the above actually occurring.
We are based in the wonderful city of York, so are subject to English law and therefore we both agree that English law applies and that English Courts would make any decisions relating to any cases relating to this agreement.
So that you can make an informed choice, our Marketing Team do their utmost to ensure any literature you receive along with the website and brochure are accurate when published. Please note however that due to the range of makes and models within each accommodation grade, photos, layout plans etc are there to give an impression of what it's like rather than present an exact likeness of what you will be allocated on arrival at your chosen Park.
Please note that nothing from our brochure or website can be copied or used without our written permission and nothing in our agreement gives you or members of your party any rights over our intellectual property.
By booking with us, you give us some personal information about you and your party. We may use it to:
We'll only talk to you or your travel intermediary if you booked through a 3rd Party about your information. When you book with us, you and your party agree that we can use the information as described. If you're using a travel provider, make sure you refer to their data protection policy.
Our privacy notice gives more detail about how we handle your information and is available on our website
We want you to capture many happy memories whilst you are on holiday with us however we do not allow any guests to film or photograph in our swimming pools and changing rooms.
On occasions, you may encounter a professional photography or video crew shooting for us or a TV show. Under this agreement, you and your party give us the rights to anything containing your image free of charge however if you or someone in your party does stray into shot without meaning to, we'll do our best to remove the image from our library. Therefore, if you don't want to be in shot, please try to keep clear of the area in which the photography and filming is taking place. We will always put up prominent signs.
On occasions, Park Leisure arranges bookings of some holiday homes as an agent of the Holiday Home Owner; a list of owners of the holiday homes that are available is available from the Park Reception. If you book one of these holiday homes then your contract will be with the Owner of that holiday home and not with us.
*Price Promise: if having booked and prior to your holiday start date, you see your identical holiday available on our website at a lower price, please contact your chosen Park and we will apply any adjustment to your booking, applicable from January 2020. All offers are for new bookings only and are subject to availability. Cannot be combined with any other offer. For additional information and conditions relating to your holiday, please visit: www.parkleisureholidays.co.uk/terms-and-conditions.
Maximum savings based on 14 night holidays taken outside of school and Bank Holiday periods. Discounts vary by holiday duration and date of travel. All discounts are subject to promotional availability and may change or be withdrawn at any time and without notice.
1. This promotion starts on Monday 9th March 2020 and runs till midnight on Thursday 9th April 2020.
2. There is one prize of a three night weekend (Friday-Monday) stay for up to six people in one of our Safari Tents on Pentire Coastal Holiday Park https://www.parkleisureholidays.co.uk/pentire Travel to and from the park is not included in the prize. The weekend will need to be taken before Friday 25th September and excludes August Bank Holiday. A dog-friendly tent is available on request, but most be notified in advance.
3. This promotion is being run by Park Leisure 2000 Limited and is in no way sponsored, endorsed, administered by, or associated with Facebook.
4. No purchase is necessary – to enter please like and share the post to be entered into our prize draw
5. Prize value is up to £449
6. Winner will be selected at random and notified on Facebook on 10th April 2020
7. Entrants must be over 18 and UK residents
8. Holiday terms and conditions must be adhered to they can be found here
We are offering FREE amendments to holiday bookings due to arrive on park before the end of June 2020. And so, if your holiday plans are directly affected by this decision to close our parks, we will be on hand to help you to reschedule your holiday until later in the year. As a gesture of our goodwill, we will also be offering you 'up to £100 credit*' in addition to the value of your existing holiday. The 'up to £100 credit' will be offered to customers that reschedule their holiday with Park Leisure to a holiday of equivalent or greater value as the original holiday booking. The 'up to £100 credit' offer does not apply to holidaymakers that choose to cancel their holiday booking, or to holiday bookings due to arrive after 27th April 2020.
For guests who have booked a holiday through a promotional partner, we will find you a holiday of equivalent or greater value later in 2020.
Due to the ongoing uncertainty caused by the coronavirus (COVID-19) outbreak, we're offering you FREE amendments on all 2020 holiday bookings, giving you the ability to beat the holiday rush and book your Summer or Autumn holiday now. Be holiday ready for when the restrictions are lifted, and we are able to go on holiday again. You can book any 2020 holiday with the confidence that, if you need to change your booking, we will give you the chance to amend your holiday booking free of charge up to 4 weeks before your holiday start date when the holiday balance is due.
We know how much you were looking forward to a well-deserved holiday, and so to help you secure your holiday booking and enable you to start daydreaming about your future holiday plans, we've also lowered our holiday booking deposit to £50 per booking.
To amend your holiday booking, all you'll need to do is email firstname.lastname@example.com with your booking reference, lead name and telephone contact details and a member of our team will contact you to make the desired changes. Please note that all amendments are subject to availability.
So beat the holiday rush and be safe in the knowledge that your future holiday is ready to enjoy!
N.B. All holiday home images are for visual purposes only. All holiday homes will be provided according to the grade booked, however the holiday home model may vary upon arrival.

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Continuing on our home tour of the soon to be (hopefully) historic home build in 1924 of the design duo Eric Guenther and Daviell Maldonado. This talented duo not only own one of the most memorable properties in Orange County, they also own one of the most memorable upscale furniture, home furnishings, jewelry and floral shop. Well, that's a whole lot of talent under one roof. And, their home truly shows what type of talent they possess.
An interesting lamp, grand unique mirror, books and collections of exotic items from all over the world.
The art of displaying a bookcase with layers of old books on top of books. They sure know how to do it. The old iron would lead to an interesting conversation I am sure. Maybe they found it in the home?
Well, this study makes me want to get a cup of coffee, grab one of their cashmere blankets and get comfy for a while. There are so many interesting items in this cozy study, I would love to ask the owners about many of them. But, for now... I enjoy just looking upon the beauty. A study of a study.
Does this study bring up any thoughts for you? Such as the love for the color, style or collections? Do you use old books as well? I think they bring a soul to a room. What do you think?
Thanks for stopping by. Have yourself one fabulous day!!!


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Gerhaert von Leiden: Medieval Standing Virgin and Child Sculpture
Art History
The Virgin, dressed in a long gown with a simple rounded collar, is enveloped by an even longer mantle that hangs in multiple looping and breaking folds. These pile up in irregular accumulations about her feet. The mantle is secured below the neck by a twisted double rope. The Virgin also wears a long veil that is pulled tightly over the high dome of her head and is secured by a thin crown. The crenate veil, divided at the back, is suspended in a wide curve over the Virgin's shoulders. The surfaces of the veil are enriched by fine, parallel hatchings. Waves of hair frame the polished, rounded planes of the Virgin's face; these waves continue in long thick strands at the back of the figure. A portion of one strand observed from the front below the Virgin's right elbow announces the rich cascade at the back of the figure. The nude Christ Child sits cross-legged in the palm of the Virgin's left hand while being steadied by her right. The Child faces outward in the same direction as the Virgin. The Virgin's fingers lightly press into the Child's flesh which has the same smooth finish as the Virgin's face and hands. The Child's hair, in contrast to the Virgin's, is carved in a series of tight ringlets. The base is constructed in three parts. The uppermost, a thin plinth, is carved in one piece with the figure. The Virgin's mantle tumbles over the fronts and sides of the edge of this plinth. The second and largest part of the base, executed separately and in a different wood from the figure, is decorated at the front and sides with multiple horizontal moldings. The back of this portion is crudely inscribed with an inlaid inscription providing the date "1517," perhaps in reference to Dürer's graphics of the Virgin and Child of 1508, 1510-11, 1514, and 1518. This section of the base, which was much taller when the sculpture was in the Rothschild collection in Vienna, must date from the nineteenth century, as suggested in recent publications. The lowest and third portion of the base horizontally extends the molded profile of the support still further.
Nikolaus Gerhaert von Leiden (North Netherlandish, active in Strasbourg, 1460–73) was the finest and most influential sculptor in the third quarter of the fifteenth century, a pivotal period in the development of late Gothic sculpture in northern Europe. This Standing Virgin and Child (ca. 1470) in the Museum's collection is especially notable for its sense of drama, monumentality, and elegance. The rhythm and balance of the drapery folds are counterpoised by the linear details and textural contrasts; naturalistic elements include the delicate manner in which the Virgin holds the child's chubby flesh. The statuette, which continues a long tradition of devotional works in boxwood, may have been commissioned by a member of the Viennese court. Our sculpture in hand-patinated bonded bronze is based on this splendid fifteenth-century original.Bonded bronze. Hand patinated. 15 3/4″H x 3 1/2″W x 6″D.
- Bonded bronze
- Hand patinated
- 15 3/4″H x 3 1/2″W x 6″D
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After being reassured by all the pundits, the early poll numbers, and her own staff, Hillary looked forward to trouncing Trump in a political landslide. Here is how it played out:
- Sitting back in her lounge chair, a vodka martini in her hand, Hillary smiles and chats with those gathered around her.
- Everything was fine until Trump won Ohio. Hillary downs another two drinks.
- Less than 20 minutes later, Trump wins Florida and Hillary explodes in rage. "How the fuck can this be happening?!" she screamed at the top of her lungs.
- 2+ hours later, and many martinis, Hillary is feeling no pain except in her head. She loses Pennsylvania and throws her glass at the wall. "Fuck all this fucking shit!!"
- An hour later and it's all over. Hillary is drinking vodka straight from the bottle at this point and screaming her head off. Of course, to her, it's everyone's fault but hers.
- She did not call President-Elect Trump to congratulate him. She was too drunk and too pissed off to make that call to her husband, Bill, made the cordial but short courtesy call.
For Hillary to not address her supporters at the end of election night was unforgivable and unprecedented. What a stupid bitch.


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Cranberry Blossom Festival
About Us
Early settlers thought the cranberry blossom resembled the head of a crane, and was given the name "crane berry," which was later shortened to cranberry. Cranberry blossoms, pretty and delicate pink flowers, come out in late June and early July. Small, green fruit develops behind the flower, growing and changing from green, to white, to dark red throughout the months of August and September. The Wisconsin Rapids area is the largest cranberry-producing region in the world. We produce nearly 30% of the world's cranberries and are home to several processing, juicing and value-added manufacturing facilities. Our unique agricultural heritage makes the blossom and harvest seasons special to our area.
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The sewing machine came out this week! I saw the most gorgeous knitting bag on instagram. It was made by Truly Myrtle (I don't usually like podcasts but she's very interesting to listen to). Here's the link to her bag.
It's a shape I haven't tried before. The pattern for the tote is a free one from Very Shannon. - the Reversible Box Tote.
I bought some gorgeous fabric from The Little Fabric Store. It's a sweet, little shop and worth a visit, if you're near. Helen is very lovely and helpful. I got some new Cloud9 fabric and linen to line the bag.
I bought another Clover tape measure too. They are really nice quality. I've found with the cheaper retractable tape measures that the tape will stretch and warp with use. I've had one for over a year (with daily use) and it is still as straight as the day I bought it. So I bought another because well…you can never have enough tape measures!
You can see the tape measure in the picture below.
The fabric that I chose happened to be what I'd used as inspiration for a stitch pattern that I'd created.
I used some cheap fusible fleece that I had in my stash – so it's not got as much form as I'd like. Next time, I'll use better quality.
I love my new bag anyway and have been carrying it around with me!
I haven't finished any knitting projects this week. The two I've been working on are an Artemisia jumper from the latest Rowan Magazine 57. I'm using the yarn from the pattern which is Rowan Softknit Cotton and amazingly I have spot-on gauge with the same size needles for the pattern, which makes a nice change. Though I have altered the pattern and the shaping to make it a few inches longer.
I bought Designer Knitting Magazine 2014/15 and there was an interesting article by Meg Swansen about different increases – including a few that I hadn't done before. I've tried out one that she names kibosirb (knit into the back of stitch in row below) for this jumper and it's quite a neat increase. Can you see it on the left hand side?
I started a selfish knitting project which is an Epistropheid by Kate Davies but this didn't go particularly well the first time. I went up 2 needle sizes and hoped for the best, as I didn't do a swatch (swatches are nearly as big as the hat so it's sometimes easier to gamble). I did a couple of inches and it wasn't looking hopeful – so I steamed blocked what I had and instead of 24 sts in 4 inches, I had 27. It was going to be way too small.
So I frogged it. The gauge was as loose as I wanted to go with this yarn, so instead of trying to meet gauge. I've added a repeat of the pattern instead. It's looking ok so far. (I'm electing to forget about the fiasco of forgetting to change to the larger needle for the body of the hat). I fear that this is going to be one of the ill-fated projects, where nothing goes right!


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MEDfor - Winter School
25 January 2019
MEDfOR - MEDITERRANEAN FORESTRY AND NATURAL RESOURCES MANAGEMENT
MEDfOR is a two-year world-class International Master Programme focuses on the integrating theme of sustainability in Mediterranean forests and woodlands, which cover over 9 % of the Mediterranean region's land area, to address topics that are specific to the Mediterranean forestry and that require special attention such as: forest as a unique world heritage, forest management and conservation and forestry role in the welfare of the Mediterranean communities.
Photo by Pilar Valbuena/iuFOR
More information on iuFOR, please visit sostenible.palencia.uva.es
More information on MEDfor, please visit www.medfor.eu
If you use one of our photos, please credit it accordingly and let us know.
You can reach us through our Flickr account or at: email@example.com.
Photo taken on 25 January 2019 (© iuFOR / Flickr)


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- Services
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The VHT program offers veterans and active military personnel the opportunity to learn the art of horsemanship. Horsemanship training also provides veterans with the opportunity to further develop the leadership and communication skills learned through the military.
The Veteran Service Program was established to provide opportunities for veterans who are seeking to give back to the community. Veterans are a valuable part of our community and we are thankful for their continued service. All service projects aid Refuge Services in maintaining and improving the facilities that aid in serving clients with a wide range of disabilities. Service projects are scheduled on a weekly basis.
If you are a veteran interested in participating in the Veteran Horsemanship Program or are interested in volunteering in Veteran Service Projects, please contact our Veteran Services Coordinator.
Operation Refuge
Operation Refuge is a unique horse therapy wellness program available free of charge to veterans of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) and also available to active military personnel. Therapy is provided in individual, family, and group formats depending on the needs of the soldier.
How does Operation Refuge Help?
Through the sessions the soldier, and family, will gain new perspectives on their current situation, and will be able to better adjust to life after war.
Who does Operation Refuge Benefit?
Types of conditions and needs served by Operation Refuge:
Additional Information about Operation Refuge
Check these out for more information: Couples, Men's Group, Groups
Operation Refuge is sponsored by Refuge Service's Boots and Buckles Benefit
"The best thing about this program is the comfort. This place is very relaxed and fun. The debriefings were fun and no matter what you have been through, it is easy."
"For someone in the military like me, it is hard to swallow my pride and say I need help. This was a safe environment to open up and talk. Sometimes the horses talked for me and helped show me the path to help my marriage."


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"Exactly what you want - value for money, professional, prompt and friendly service."
Paul Metcalfe – Knight Frank
The first place for floor plans
We have been providing our clients with a professional floor plans service for over 5 years from our London office.
Now with the launch of our new office in Bristol we can we feel we can offer you the same first class service in your area. Whether you need a Lease Plan, Measured Survey or Commercial EPC we can now provide it using local people in the Bristol and surrounding areas.
Call or email us now for a quote.


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Florida Gov. Rick Scott on Monday set the dates for a special primary and general election to replace Palm Beach County Democrat Jeff Clemens in the Florida Senate.
Democrats hold a 46.6-to-24.1 percent registration advantage in Clemens' old District 31, so his replacement will most likely be another Democrat. So Florida Democratic Party Chairman Stephen Bittelurged Scott to schedule a special election "immediately" to seat a new senator in time for the 2018 legislative session, which runs Jan. 9 to March 9.
Scott, however ordered a Jan. 30 primary and April 10 general election. If Republicans make good on Palm Beach County GOP Chairman Michael Barnett's prediction that his party will field a candidate, that means the District 31 seat won't be filled until after the regular session and Republicans will maintain a 24-15 advantage in the chamber until then.
The dates Scott chose were suggested by Palm Beach County Elections Supervisor Susan Bucher — a liberal Democratic state House member before she won the nonpartisan elections post.
Two Democrats — state Rep. Lori Berman and former state Rep. Irving Slosberg — have opened campaigns in District 31 and Democratic state Rep. David Silvers is another possible candidate. County GOP Vice Chairwoman Tami Donnally is also considering the race.


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Aarhus University welcomes applications from students holding Cambridge International AS & A Levels.
Students generally require at least nine subjects (IGCSE, AS and A Level) in six different subjects, three of which must be at A Level.
Alternatively, the three A Levels can consist of two A Levels + two AS Levels or one A Level + four AS Levels.
If the prior learning is not based on the IGCSE system but for instance on the Danish lower secondary examination (folkeskolens afgangsprøve), admission is based on two subjects at AS Level and three subjects at A Level (in total, five different subjects). Subjects at A Level can be replaced by two subjects at AS Level; however, at least one subject must be at A Level.
Meeting the minimum entry requirements does not automatically guarantee a place on a chosen Bachelor degree programme. It is important to check any subject-specific or language requirements before submitting an application. You can find a list of offered Bachelor degree programmes here: http://bachelor.au.dk/en/
Full details of minimum grade requirements, prerequisite subjects and specific language requirements can be found by checking our University website: http://bachelor.au.dk/en/admission/admission-requirements/
Alternatively, please contact our Admissions office directly: email@example.com


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Film: Bolshoi Ballet: Coppélia
Bolshoi Ballet presents
Music: Léo Delibes
Choreography: Sergei Vikharev after Marius Petipa and Enrico Cecchetti Cast The Bolshoi Principals, Soloists and Corps de Ballet
Swanhilda notices her fianceé Franz is infatuated with the beautiful Coppélia who sits reading on her balcony each day. Nearly breaking up the two sweethearts, Coppélia is not what she seems and Swanhilda decides to teach Franz a lesson…
The Bolshoi's unique version of Coppélia exhibits a fascinating reconstruction of the original 19th century choreography of this ebullient comedy involving a feisty heroine, a boyish fianceé with a wandering eye, and an old dollmaker. The company's stunning corps de ballet shines in the divertissements and famous "dance of the hours," and its principals abound in youthful energy and irresistible humor in this effervescent production. Expected running time approximately 165 minutes.
Personal Responsibility Statement: Proctors prides itself on offering a diverse selection of arts entertainment. Not all productions may appeal to or be appropriate for every person or for all ages. Patrons are encouraged to familiarize themselves with the shows we offer in order to make informed decisions prior to purchasing tickets.
FREE PARKING in the Broadway parking garage is provided by Upstate Ford Dealers. WE ARE IN YOUR AREA.


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Too many unnecessary CT and MRI scans
The number of CT scans per patient has doubled over the last 10 years, while the number of MRI scans has tripled, according to a recent study in the journal Health Affairs.
No wonder a growing chorus of critics wonder if all of these expensive medical tests are necessary.
There's reason to be concerned, said Dr. John Anastos, chair of radiology at Advocate Lutheran Hospital. He spoke to me today after attending the annual meeting of the Radiology Society of America in Chicago.
Too many scans repeat tests that doctors don't know about because of breakdowns in communication, Anastos says.
A small new survey sponsored by the radiology group confirms the doctor's assessment. Of 101 radiologists who responded, 69 percent said they had encountered "unnecessary or duplicative scans" in the last six months.
It's a vivid example waste in the health care system.
Anastos gives a fictional example to illustrate the problem. Take a college student who has abdominal pain and whose doctor orders an ultrasound of the gallbladder, he says.
Assume the ultrasound comes back showing the gallbladder is normal but there's a mass in the liver. The young woman's doctor then orders a high-powered CT scan to see if the tumor is malignant. When results are inconclusive, he orders follow-up scans at six months and a year.
Then, assume that the patient had a MRI a year earlier when she had a kidney infection--and that she doesn't mention this to the doctor who's currently treating her abdominal ailment. (Patients often forget to mention tests.) Because the specialist who treated her is in a different location and there's no shared medical record, her current doctor doesn't know.
There's the rub. If the physician had access to the MRI, he wouldn't need to order three CT scans that expose the young woman to radiation and potential complications associated with the chemicals used to produce color contrast in the scans, Anastos said. The MRI would have been enough to determine whether the tumor was benign.
"None of these (CT) scans needed to be done, but the doctor had no way of knowing that," Anastos says.
The solution is to create linkages between health care facilities, even those not joined by common ownership, so physicians in different locations can have joint access to archived scans, Anastos suggests.
He's helped bring the concept to Chicago's northwest suburbs, where nine medical organizations--including Advanced Radiology Professionals of Buffalo Grove, Advanced Radiology Consultants of Park Ridge, Oak Mill Imaging in Niles, and others--have been doing just that since last year. Anastos said he hopes to bring Advocate Lutheran General Hospital into the network by the end of the year.
This is how the system works: Before a patient comes in for an appointment, a doctor can enter her identifying information in a database and discover whether any of the participating groups have already performed scans on the patient. If so, he can review those images.
I asked the doctor what people should do to make sure they don't get unnecessary scans.
"Ask your doctor: 'Is this test medically necessary and are there other imaging options that don't use ionizing radiation?" he suggests. (The radiation is used in X-rays and CT scans.)
Also, keep a record of each scan you receive, where it was taken and when.
Treat that component of your medical history like you would medications, Anastos says. Just as it's important to let every doctor know what drugs you're taking, it's important to tell every doctor what scans you've had so tests aren't duplicated. If a patient is older and perhaps forgetful, a family member should have this information on hand, especially when a new doctor is consulted.