Nonsystems And Safety

Question 1

Wheelchair prescription: Seat height, width, depth, back height, armrest height, and averages

Answer 1

Seat Height: Heel to popliteal fold + 2 inches (Avg: 19.5 in - 20.5 in)

Depth: posterior buttock along lateral thigh to popliteal fold - 2 in (Avg: 16 inches)

Width: widest part of buttocks, hips, thighs +2 inches (Avg: 18 inches)

Back height: seat of chair to floor of axilla - 4 inches (add width of cushion or measure person with cushion if one is to be used) Avg: 16 - 16.5 in

Armrest height: seat of chair to olecranon process with elbow flexed to 90 deg +1 in (Cushion same as back height) Avg: 9 in from chair

Armrest height:

Question 2

Gait patterns: two point, three point, four point, swing to, swing through

Answer 2

Two point: left crutch moves forward at same time as right LE (one point) followed by right crutch with left LE (second point)

Three point: Assistive device, followed by injured LE, followed by uninjured LE

Four point: left crutch, right leg, right crutch, left leg (or visa versa)

Swing to: advance the LEs to the point of the AD

Swing through: advance the LEs passed the AD

Question 3

Monitoring devices: arterial line, central venous pressure catheter, Hickman catheter, Swan-Ganz catheter

Answer 3

Arterial line: measures BP or obtains blood sample

Central venous pressure catheter: measures pressure in the right atrium or in the superior vena cava to evaluate right ventricular function, right atrial filling pressure, and circulating blood volume

Hickman Catheter (Indwelling right atrial catheter): put through cephalic or internal jugular vein to SVC and right atrium. Used for long term administration of substances into venous system (chemo, antibiotics, nutrition, etc)

Swan-Ganz catheter (pulmonary artery catheter): inserted into the pulmonary artery through a vein to provide continuous measure of pulmonary artery pressure

Question 4

Urinary catheters: external, foley, and suprapubic

Answer 4

External catheter: applied over shaft of penis

Foley catheter: indwelling catheter that has balloon attachment (goes in urinary tract)

Suprapubic catheter: indwelling catheter surgically inserted directly into bladder under general anesthesia

Question 5

Diagnostic tests: arteriography, arthrography, bone scan, computed tomography, Doppler ultrasound, electrocardiography, electroencephalography, electromyography, fluoroscopy, magnetic resonance imaging, myelography, venography, x-ray

Answer 5

Arteriography: Radiograph that visualizes injected dye in an artery. Identifies arteriosclerosis, tumors, blockages

Arthrography: invasive test, contrast medium to visualize joint structure in radiographs. Soft tissue damage ID through leak from joint

Bone scan: Invasive, uses isotopes to ID stress fractures, infection, tumors (4-7% bone loss can be IDed)

Computed tomography: cross sectional x-rays used to ID spinal lesions, diagnostic brain studies

Doppler US: evaluates blood flow in major vessels

ECG: records electrical activity of heart. Aids in identifying conduction issues, arrhythmias, and myocardial ischemia

EEG: records electrical activity of brain by measuring difference between electrode electrical potentials. Assesses seizure activity, metabolic disorders, cerebellar lesions

EMG: measures electrical activity in muscles at rest and during activity. Used to assess peripheral nerve injuries and to differentiate between various neuromuscular conditions

Fluoroscopy: shows motion in joints through X-ray imaging but not generally used due to high radiation exposure

Magnetic resonance imaging: uses magnetic field to produce image of bone and soft tissues. Great for muscles, menisci, ligaments, tumors, internal organs, but patient must be still for long time periods and MRI is extremely expensive

Myelography: invasive test combining fluoroscopy with radiology to examine spinal subarachnoid space through puncture of epidural space (IDs bone displacement, disk herniation, spinal cord compression tumors)

Venography: visualizes injected dye through radiograph to ID tumors or blockages in veins

X-ray: fractures, dislocations, bone loss. Planar so often require multiple views

Question 6

Principles of heat transfer: conduction, convection, conversion, evaporation, radiation. Examples of each

Answer 6

Conduction: gain or loss of heat through DIRECT CONTACT. Heat goes from an object of higher temp to an object of lower temp (ex: cold/hot pack, cryo cuff, ice massage, paraffin)

Convection: gain or loss of heat resulting from AIR OR WATER moving in a constant motion ACROSS the body (ex: cold/hot whirlpool, fluidotherapy)

Conversion: Occurs when non-thermal energy (mechanical, electrical, etc) is absorbed into tissues and transformed into heat (ex: diathermy, ultrasound)

Evaporation: liquid absorbs energy and transforms into a vapor (Vapocoolant spray)

Radiation: direct transfer from higher radiating temp to lower temp object (infrared lamp, laser, ultraviolet light)

Question 7

Contraindications to cryotherapy

Answer 7

• cold intolerance
• cold urticaria
• Cryoglobulinemia
• infection
• over an area of compromised circulation
• over regenerating peripheral nerves
• paroxysmal cold hemoglobinuria
• peripheral vascular disease
• Raynaud’s phenomenon
• skin anesthesia

Question 8

Ice massage area and treatment time

Answer 8

10cm - 15cm area treated in 5-10 mins

Question 9

Store cold packs at what temperature?

How long on patient and how?

Answer 9

• 25 deg Fahrenheit

- 20 mins over a moist cold towel to increase initial magnitude of cooling

Question 10

Cold bath: treatment time, temperature range, special considerations

Answer 10

• 15 - 20 min
• 55 - 64 deg F
• Be mindful of dependent positioning in cases of edema

Question 11

Controlled cold compression unit temperature range

Answer 11

50 - 77 deg F

Question 12

Vapocoolant spray: 1) layer of skin cooled, 2) used for, 3) application, 4) mechanism. 5) Risk

Answer 12

1) epidermis
2) treat trigger points
3) make 3-4 sweeps with spray in direction of muscle fibers in one direction only and NOT IN A BACK AND FORTH MOTION. Apply at 30 deg angle 12-18 inches from the skin
4) production of a counterirritant
5) Risk of frostbite if skin not rewarded between repeated treatments

Question 13

Superficial thermotherapy 1) tissue depth and 2) contraindications

Answer 13

1) up to 2 cm
2) acute trauma, arterial disease, bleeding or hemorrhage, over an area of compromised circulation, over malignant area, peripheral vascular disease, thrombophlebitis

Question 14

Hot pack 1) temperature for storage, 2) towel layer requirement, 3) treatment time, and 4) check skin after how long for irritation?

Answer 14

1) 158 - 167 deg F
2) 6 - 8 layers
3) 15 - 20 min
4) after first 5 minutes

Question 15

Temperature setting for Fluidotherapy? Maximum temp rise occurs when during treatment? Treatment time?

Answer 15

1) 100 - 118 deg F
2) after approximately 15 min
2) 15 - 20 mins

Question 16

Infrared lamp: 1) special consideration, 2) pt distance from heat source, 3) optimal absorption position, 4) treatment duration and special consideration

Answer 16

1) PT and pt must wear goggles
2) 20 inches
3) source perpendicular to skin
4) 15 - 20 mins, influenced by distance from heating source

Question 17

Paraffin: 1) contraindications, 2) temperature maintained between ___

Answer 17

1) heating contradictions and open wounds or infected skin lesions
2) 113 - 122 deg F

Question 18

Deep heating agents (US, electromagnetic): tissue depth

Answer 18

3 - 5 cm

Question 19

Ultrasound: 1) Depth, 2) typical frequency range, 3) Contraindications

Answer 19

1) up to 5 cm
2) 0.75 - 3 MHz
3) acute and post acute conditions for heating effect, areas of active bleeding or decreased sensation or circulation, DVT, infection or malignancy, over breast implants or pacemakers, over carotid sinus or cervical ganglia, over epiphysial areas in young children, over eyes, hearts genitals, over methyl methacrylate cement or plastic, over pelvic, lumbar or abdominal areas in pregnant women, thrombophlebitis, vascular insufficiency

Question 20

Nonthermal effects of ultrasound and mechanism

Answer 20

• increased cell and skin membrane permeability
• increased intracellular calcium
• facilitation of tissue repair
• promotion of normal cell functioning
• cavitation and acoustic micro streaming

Question 21

Ultrasound frequency: Tissue depth for 1 and 3 MHz

Answer 21

1) 1 MHz used for DEEPER tissues (up to 5 cm)
2) 3 MHz used for SUPERFICIAL tissues ( 1-2 cm)

• frequency is primary determinant of depth -

Question 22

Ultrasound duty cycle: 1) equation, 2) continuous vs pulsed, 3) duration

Answer 22

1) Duty cycle = [on time / (on time + off time)] x 100
2) - continuous = 100% duty cycle and thermal effects at higher intensity, nonthermal at lower intensity. - Pulsed = reduced average heating of tissue used mostly for nonthermal effects (ex: 20% duty cycle)
3) areas 2-3x the size of the transducer head require 5 minutes

Question 23

Contraindications for hydrotherapy

Answer 23

• advanced cardiovascular or pulmonary disease
• active bleeding
• diminished sensation
• gangrene
• impaired circulation
• incontinence
• maceration
• peripheral vascular disease
• renal infection
• severe infection
• severe mental disorder

Question 24

Contraindications to traction (Whole lot of them)

Answer 24

• acute inflammation, sprain, or strain
• bone diseases, dislocation, fracture, infection, subluxation, osteoporosis
• aortic aneurysm
• cardiac or pulmonary problems
• condition in which movement increases, is contraindicated, or peripheralizes pain
• hiatal hernia
• Meningitis
• positive instability testing, vertebral instability, positive vertebral artery test
• pregnancy for lumbar (not cervical)
• tumor
• trauma
• RA
• TMJ pain or dysfunction only for cervical (use of halter)

Question 25

Mechanical lumbar traction: 1) extended (prone) vs flexed (supine) pt positioning, 2) hold and relax period percentage in intermittent traction, 3) force percent needed for soft tissue, muscle spasm, and herniation, 4) % needed for disc separation, 5) treatment time

Answer 25

1) extended (prone) = greater anterior structure separation, flexed (supine) = greater posterior structure separation 2) relax period is 50% force of the hold period 3) 25% 4) 50% 5) 5 - 30 min (disk treatment usually 10 min or less but can be up to 30 if other spinal conditions exist)

Question 26

Mechanical cervical traction: 1) static vs intermittent traction, 2) percent needed for soft tissue, muscle, disk protrusion treatment, 3) % needed for joint distraction, 4) should not exceed how many pounds? 5) treatment duration

Answer 26

1) intermittent may be better for cervical ROM and pain reduction 2) 7-10% body weight (11-15 lbs) 3) 13-20% body weight (20-30 lbs) 4) 30 lbs 5) 5 - 30 mins (usually 10 or less for disk issues but varies with other conditions)

Question 27

Special note for cervical and lumbar mechanical traction:

Answer 27

Check pt. Response within initial 5 minutes and D/C temporarily if symptoms worsen or peripheralize

Question 28

Contraindications for electrotherapy

Answer 28

- cardiac arrhythmia - cardiac pacemaker - malignancy - osteomyelitis - over pregnant uterus - over carotid sinus - pt with bladder stimulator - phlebitis - seizure disorder

Question 29

Direct current stimulation is characterized as constant flow of electrons from the anode (_1_) to the cathode (_2_)

Answer 29

1) positive electrode | 2) negative electrode (think black cat)

Question 30

Biphasic, symmetrical, and asymmetrical describe ________ current types

Answer 30

Alternating

Question 31

Monophasic and biphasic describe _1_ current types, in monophasic the current is _2_ and in biphasic current is _3_.

Answer 31

1) Pulsatile 2) only positive or negative 3) one positive and one negative

Question 32

Electrode size and placement: 1) small electrode characteristics, 2) large electrode characteristics, 3) Monopolar placement, 4) bipolar placement

Answer 32

1) increased current density and impedance, decreased current flow 2) decreased current density and impedance, increased current flow 3) stimulating electrode placed over target area (active electrode is usually smaller than the dispersive electrode). Used for wounds, iontophosesis, or edema 4) two active electrodes over target area, usually equal sized electrodes. Used for muscle weakness and NM facilitation, spasms, ROM

Question 33

NMES: 1) electrode placement, 2) Frequency, 3) Duty cycle on vs off time, 4) reason for ramp time, 5) treatment time

Answer 33

1) electrodes should be aligned in parallel with one electrode over muscle's motor point and a minimum of 2 in separation between electrodes 2) 35 - 50 pulses/sec 3) on time:off time = 1:5 (6-10 sec usually for on time, 10 x 5 = 50) 4) makes onset of stimulus more comfortable 5) complete at least 10 contractions and a max of 20, at least 3x/week

Question 34

TENS: values for 1) conventional, 2) acupuncture-like, 3) brief intense, and 4) noxious

Answer 34

1) - Amplitude: sensory response provoking; pulse frequency: high (30-150 pps); pulse duration: short (50 - 100 usec), treatment time: variable 2) - Amplitude: to muscle twitching; pulse frequency: low (2-4 pps); pulse duration: long (100-300 pps); treatment time: 20-45 min 3) - Amplitude: to strong paresthesia or motor response; pulse frequency: high (60 - 200 pps); pulse duration: long (150-500 usec); treatment time: 15 min 4) - Amplitude: highest tolerated; pulse frequency: high or low; pulse duration: long (250 usec to 1 second); treatment time: 30-60 sec for each point

Question 35

Iontophoresis: 1) mechanism, 2) contraindications, 3) Dosage range, 4) current amplitude range, 5) monitoring

Answer 35

1) like charges repel so ions of similar charge will move away from electrical source and into the body 2) drug allergies, skin sensitivity to specific ions 3) 40 - 80 mA-min 4) 1.0-4.0 mA 5) PT to check every 3-5 min to ensure no signs of drug reaction or burns

Question 36

Iontophoresis: 1) acidic reaction, 2) alkaline reaction

Answer 36

1) hydrochloric acid forms under positive electrode (anode) | 2) sodium hydroxide forms under the negative electrode (cathode)

Question 37

Contraindications to massage

Answer 37

- acute injury - arteriosclerosis - cancer - cellulitis - embolus - infection - thrombus

Question 38

Massage techniques: 1) Effleurage, 2) friction, 3) petrissage, 4) tapotement, 5) vibration

Answer 38

1) light stroke directed towards the heart done in the beginning and end of massage to promote relaxation 2) small circular motions over a trigger point or muscle spasm. Deep, used with chronic inflammation or overuse injuries frequently 3) kneading to loosen adhesions, improve lymphatic return, and facilitate metabolic waste removal. Perform distal to proximal 4) rapid alternating movement for stimulation to enhance circulation and stimulate peripheral nerve endings 5) rapid shaking to treatment area and initiated from therapist's forearm. Mostly for relaxation

Question 39

Body mechanics: avoid any _____ movement when lifting

Answer 39

Rotary

Question 40

Airborne precautions:

Answer 40

- private room, monitored air pressure - 6-12 air changes within room per hour - door should remain closed - respiratory protection worn when entering room - limit pt transport outside room and have pt wear mask during necessary transport

Question 41

Droplet precautions and distance of possible transmission through air:

Answer 41

- up to 3 feet Precautions: - private room, or shared room with pts with same infection (door can be open) - keep 3 ft between pt and contact and wear mask when working closer to pt than 3 ft - limit trips out of room and wear mask (on patient) for trips outside room that are needed -

Question 42

Contact precautions:

Answer 42

- private room or pts sharing room with same organism - use gloves and change after direct pt contact - take gloves off before leaving room and proper hand washing - use gown for substantial contact and remove before leaving the room - limit trips out of room - dedicate non-critical equipment to that patient (no sharing) or if needed, disinfect properly

Question 43

Sterile field guidelines:

Answer 43

- sterile gowns are sterile only in the front from waist level upward including sleeves - only top surface of table or drape is sterile, with the outer 1/3 inch considered nonsterile - no talking, sneezing, coughing - do not turn your back to sterile field (back of gown is not sterile) - monitor sterile field constantly - if an object on the field becomes sterile, the whole field is sterile (discard field) - prepare the field as close to the treatment time as possible - any item falling below waist level is no longer sterile

Question 44

How long should hands be washed with soapy water?

Answer 44

30 seconds (sing ABCs 2x)

Question 45

Medical asepsis

Answer 45

Attempts to contain pathogens to a specific area, object or person to reduce the spread of pathogens

Question 46

Surgical asepsis

Answer 46

A state in which an area or object is without any micro organisms (i.e. A sterile field)

Question 47

Accessibility requirements: 1) Doorway, 2) threshold, 3) carpet, 4) hallway clearance, 5) wheelchair turning radius, 6) forward reach in chair, 7) side reach in wheelchair, 8) bathroom sink, 9) bathroom toilet

Answer 47

1) min 32 in width, max 24 in depth 2) less than 3/4 in for sliding door, and 1/2 in for other doors 3) 1/2 in pile or less 4) 36 in width 5) 60 in width, 78 in length 6) low reach 15 in, high reach 48 in 7) 24 in 8) min 29 in height, no more than 40 in floor to mirror or paper dispenser, 17 in min from sink to back wall 9) 17-19 in from floor to toilet top, min 36 in grab bar (1.25-1.50 in diameter), 1.5 in spacing from grab bar to wall (grab bar 33-36 in up from floor level)

Question 48

Ramp requirements

Answer 48

- 12 in horizontal run for each inch of vertical rise (8.3% grade) - 36 in wide minimum - must have handrails if rise greater than 6 in or run of greater than 72 in - landing area must be 5' by 5' (60 in) if ramp changes direction - must have level landing at top of the step

Question 49

Four primary concepts of the Nagi Model and core theme

Answer 49

- Pathology (cellular) - Impairment (tissue, organ, body system level) - functional limitation (at level of whole person) - disability - relationship between health and function

Question 50

ICF (international classification of functioning, disability and health): main points

Answer 50

- body functions - body structures - impairments - activity limitations - participation restrictions - environmental factors

Question 51

Direction and supervision of PTA: Sole responsibilities of the PT

Answer 51

- Exam, eval, interpreting referrals, diagnosis, prognosis, D/C planning - developing and modifying POC - determining when use of a PTA is appropriate - re-examination and revision of POC - oversight of all documentation

Question 52

Managed care

Answer 52

Uses contracted HCPs at lower costs (HMOs and PPOs). Concept is highest quality care for least cost

Question 53

Medicare patient population

Answer 53

People over 65, disabled, renal dialysis, and transplant patients

Question 54

Medicare part A coverage

Answer 54

Inpatient services and outpatient diagnostic (depending) services. Also hospice and short term care provided at home required by illness for which patient is hospitalized. Enrollment is automatic and paid for through payroll taxes

Question 55

Medicare part B coverage

Answer 55

Outpatient care and physician services or tests/procedures or equipment that are physician ordered. Diagnostic outpatient testing Voluntary enrollment with tax contribution and paid premiums from beneficiaries

Question 56

Medicare patient cost sharing

Answer 56

- 20% hospital stay paid by patient - deductibles and co insurance - set limit on total days in hospital on a lifetime pool (100 days)

Question 57

Medicaid coverage

Answer 57

Low income population

Question 58

Employers with _1_ employees or _2_ must pay a percentage of each employee's pay to the _3_.

Answer 58

1) 10 + 2) high risk jobs 3) workers comp board

Question 59

CPT codes vs ICD codes

Answer 59

- CPT codes are for billing and are in the 97000 series mostly for PT - ICD codes are for diagnostic purposes (---.--, first 3 are general diagnostic, last one or two differentiate the diagnosis by anatomical site or other characteristic)

Question 60

Maslow's hierarchy of needs from basic to highest

Answer 60

Physiological --> affiliative needs (security, stability, safety) --> esteem needs --> self-actualization needs

Question 61

Classical conditioning

Answer 61

An unconditioned stimulus (food) is preceded by a neutral stimulus (bell) => neutral stimulus becomes conditioned stimulus, with learner reaction termed the "conditioned response"

Question 62

Operant conditioning

Answer 62

Learner engages in behavior to receive specific consequences. - positive reinforcement = administer desirable consequence for a behavior - negative reinforcement = take away a negative consequence when specific behavior performed - extinction = removing variables that reinforce a behavior - punishment = administer negative consequence for undesirable behavior

Question 63

Health Belief model main factors

Answer 63

- perceived susceptibility - perceived severity - perceived benefit - perceived barriers - cues to action - self-efficacy

Question 64

Concepts of social cognitive theory (social learning theory)

Answer 64

- behavior capability - emotional coping responses - environment - expectancies - expectations - observational learning - reciprocal determinism (relationship bw person and environment ) - reinforcement - self-control - self-efficacy - situation (perception of environment)

Question 65

Trans-theoretical model (stages of change) stages

Answer 65

- precontemplation - contemplation - preparation - action - maintenance

Question 66

Difference between multidisciplinary, interdisciplinary, and transdisciplinary

Answer 66

Multi = disciplines function independently and communication is mainly through documentation Inter = disciplines routinely report to and may coordinate care Trans = function as collective units and use team rather than individual discipline goals

Question 67

An article's closeness to the truth is _1_, its impact is its _2_, and its usefulness in clinical practice is its _3_.

Answer 67

1) validity 2) effect size 3) applicability

Question 68

Levels of evidence from most to least strength

Answer 68

Systematic reviews and meta-analyses -> randomized controlled trials -> cohort studies -> case control studies -> cross sectional studies -> case series -> case reports -> ideas and opinions

Question 69

Cohort Study

Answer 69

Longitudinal, observational study that follows individuals with a risk factor for disease to compare occurrence of disease with that of the unexposed population (relative risk)

Question 70

Case control study

Answer 70

Retrospectional observational study taking people with a disease and matching them to a group without the disease to identify characteristics or exposure before onset of the disease

Question 71

Cross sectional study

Answer 71

Observational study where data/observations are only taken at one point in time and tests all subjects at about the same time. Tries to describe relationships between diseases and factors of interest in specific populations at a given time

Question 72

Scales of measurement: 1) nominal, 2) ordinal, 3) interval, 4) ratio

Answer 72

1) qualitative categories for which only one category can be used to describe the subject (blood type, breath sound) 2) ranking scale based on the property of a value of a variable (MMT grades, pain, joint laxity grades, assistance levels) 3) measurement scale with equal intervals and no true zero (temperature, weight) 4) intervals are equal and there is a zero point (ROM, distance walked, nerve conduction velocity)

Question 73

Internal validity

Answer 73

Confidence that the intervention caused the outcome

Question 74

Control group

Answer 74

A group to which the treatment (experimental) group is compared

Question 75

Experimental group

Answer 75

The treatment group

Question 76

Independent variable

Answer 76

Variable thought to. Have caused or influenced the dependent variable (what is controlled or manipulated by the researcher)

Question 77

Dependent variable

Answer 77

Response or outcome expected due to the influence of the independent variable

Question 78

P value and alpha level

Answer 78

- p value is the probability that something happened by chance - alpha level is the significance level or probability of rejecting the null hypothesis when it is actually true (type I error) - Reject the null when p value is smaller than alpha, do not reject when p is greater than alpha

Question 79

Type I or alpha error

Answer 79

Rejecting the null hypothesis when it is actually true. FALSE POSITIVE. Alpha set to 0.01 = 1% chance of a false positive or type I error

Question 80

Type II or beta error

Answer 80

Not rejecting the null hypothesis when it is actually not true. FALSE NEGATIVE

Question 81

Normal distribution

Answer 81

Majority of data clustered around the mean with the mean, median, and mode equal. 68% data is 1 SD above or below the mean, 95% is 2 SDs, and 99% is 3 SDs

Question 82

Left skewness and right skewness

Answer 82

Left = negatively distributed, mean and median are to the left of the mode and the left tail is elongated. Right = reverse of above and termed positive skew

Question 83

Sensitivity

Answer 83

Percentage of people in a population testing positive for a condition that actually have it - SnNout = high sensitivity means you can rule a condition out. This is because a negative test would rule OUT a disease

Question 84

Specificity

Answer 84

Percentage of people testing negative for a condition that actually do not have the condition - SpPin = high specificity means we are confident we can rule in a condition because a positive diagnosis would rule in the condition (true positive)

Question 85

Incidence

Answer 85

Only considers new cases.

Question 86

Prevalence

Answer 86

Existing cases including new and previously existing cases

Question 87

Relative risk and interpretation

Answer 87

Incidence of disease occurring in people exposed to a disease to the incidence pf those that were not exposed to the disease. Also known as risk ratio 1 = equally probable > 1 = exposure increases risk < 1 = exposure does not increase risk

Question 88

Odds ratio

Answer 88

Measurement of the odds of an event happening in one group to the odds of it happening in another group (also known as relative odds) 1 = exposure probably does not increase risk > 1 = exposure may increase risk < 1 = exposure may reduce risk of the disease

Question 89

Number needed to treat

Answer 89

Number of patients that need to be treated to prevent one bad outcome or result or to result in another good outcome Ideally NNT = 1, where everyone improves with treatment. The higher the NNT, the less effective the treatment