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By M. Boss. Iowa State University.

Immersive environments are often named in this context and describe VR systems that are intended to block out the real world and help the user become part of the virtual scene discount super cialis 80 mg amex. VR has been described as being about the computer graphics in the theatre of the mind super cialis 80 mg discount. Virtual Reality is also a new medium for getting your hands on information purchase 80mg super cialis visa, getting inside infor- mation cheap super cialis 80 mg fast delivery, and representing ideas in ways not previously possible (1). In addition, building virtual environments (VEs) requires the understanding not only of the existing technical components but also of the pattern and behavior of human perception. In 1990, I started to set up a test bed for three- dimensional (3-D) input and output devices at the Technical University of Berlin. This led to the installation of a VR laboratory, which, was moved into the medical environment at the University Hospital Benjamin Franklin (UKBF), as part of the Free University of Berlin. A VR system is composed of di¨erent components, which are explained and described by example. The individual components must be carefully selected, depending on their functionality and their use within the medical environment. The devices need to be regarded from the point of view of their technical de- scription and their limitations. The advantages of the individual components, however, are not the only criteria for choosing them, because the interrelation 5. The costs are often an im- portant limiting factor for in¯uencing the choice of a particular device. The activity of the sense organs has to be organized so that perception, learning, and decision making can take place (2, 3). Human beings receive stimuli from their environment by means of the ®ve major senses, which are processed in parallel using di¨erent percentages of the available bandwidth (as noted in parentheses below) (4). In the development of a VR system, special attention should be given to focusing action (accommodation), the color vision of humans, and the foveal vision in combination with visual perception phenomena (e. If a human looks directly at an object, its image falls on the fovea, because the fovea is located directly in the line of sight. Audition (20%) is the perception channel for which the auditory system is responsible. With respect to VR systems, the physical speci®cation of sound waves and their behavior in space should be taken into account. Olfaction (5%), the sense of smell, is carried out by the olfactory system and allows humans to distinguish between various scents. Gustation (1%), which tells us how something tastes, is carried out by the gustatory system. The sense of balance, which gives information about the position and movement of the head and limbs, does not belong to the classical ®ve senses but should be taken into account when using 3-D output devices that su¨er from a response lag (discussed later). The ratings of each perception channel represent the available bandwidth for the perceived information but do not necessarily correspond to the importance of the stimulus. For example, a simulation of cutting tissue would require more tactile feedback than audible feedback. Currently, there are no de®nitive re- sults indicating any long-term health problems that could be attributed to the regular usage of VR systems. Thus, in the concept phase, the designer of medical VR systems should thor- oughly examine topics before starting to implement a medical application sys- tem within the scope of VR. User and task analyses help de®ne user groups and the tasks to be performed by the system. The analyses could follow the guide- lines of the user centered design Allison et al. Who are the medical users of the system and in what circumstances will they use it? Accordingly, information must be gathered on the participating user groups pertaining to the following factors: age, sex, education, job, job experience, computer experience, intelligence, handicaps, physical ability, motor skills, and language. To describe the task to be performed, the following factors must be analyzed: performance speed, frequency of use, duration of sitting, ability to change tasks, security factors, and problems.

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The first of these is to try to restore the lost functions order 80 mg super cialis, often through retraining order 80 mg super cialis with amex, with the use of repetitive techniques such as learning lists generic 80 mg super cialis mastercard, and helping people to re-acquire skills with progressively more complex tasks discount super cialis 80mg line. The second is based on the idea that, because it will be difficult to regain the lost functions, compensatory strategies are needed, in which other devices and procedures are used, such as trying to minimize distractions, or using other means of reminding you about activities that you need to do. Both of these approaches are designed to help people manage their everyday lives better despite any cognitive impairment. We need to repeat that cognitive rehabilitation, as a formal programme, is not available everywhere for people with MS. At present, following assessments, you will probably have most contact with an occupational therapist, whose skills focus substantially on the abilities needed to accomplish everyday activities, but we expect that many such therapists will increasingly be using at least some of the key techniques for managing problems that you may have in the area of memory or concentration. Self-help People with MS can be affected by a range of cognitive problems, and it is difficult to advise you precisely without knowing exactly what they are. Sometimes the problem is that we have many things going on at the same time – television, other people talking and a whole range of other activities going on. However, for someone with MS, concentrating on one of these activities – a conversation, for example – can be quite difficult, when so much else is happening. So the key thing is to try and have only one thing going on at a time – a conversation or the television, not both at the same time. Find out when and where problems for you are most difficult, and then work on reducing the distractions to the minimum. Obviously changing your pattern of normal activities to help you concentrate may not be easy, but may be preferable to having continuing concentration problems. Some of these are routine, and may appear overpedantic or fussy for someone who has only minor memory difficulties, but all help to deal with short-term memory problems. For example, just making sure that clocks and watches show the right time; ensuring that today’s date is prominently displayed somewhere; having a message board to note activities for today and tomorrow; having a list of activities that you are intending to do, with times and dates, perhaps in the form of a diary or similar record. Although this might seem almost too formal, note things down that you have agreed to do, or that you and others think important, so that it doesn’t appear that you have forgotten it. If you have difficulty with reading, check with your doctor whether you have any of the several potential eye problems associated with MS, that may interfere with your ability to read. Secondly, try and find a strategy to read in a particular way to maximize your ability to retain a story line. As a broad guideline, the more of your senses that you use, the more likely you are to remember and retain ideas. It may be worth repeating what you read out loud, or at least key parts of it; or relate some elements of the story to another person; or write key ideas down. In this way, using more than one of your senses – writing, seeing, hearing and saying – you stand a better chance of remembering the story, or indeed other material. Admittedly, this approach may require some tolerant support from those around you but, if you are making a big effort to improve your memory, they will probably feel that they are gaining too. FATIGUE, COGNITIVE PROBLEMS AND DEPRESSION 87 You may find that you do not need to go to these lengths to help your memory – you could work out the main lines of the story or newspaper article by ‘skim reading’ so that, although you may have lost the element of surprise (about the ending of a story, for example! Depression The incidence of depression amongst people with MS has been a matter of controversy for many years. In the early years of research it was thought that relatively few people with the condition had ‘clinical’ depression, but more recent research indicates that the level of depression is far higher than was previously thought. Recent research suggests that up to 50% of people with MS (compared to only 5–15% of people without) will experience serious depression at some point in their lives, and at any one time perhaps one in seven may be experiencing this kind of depression. An inspirational personal account on coping in MS is given in Multiple Sclerosis – a personal exploration by Dr Sandy Burnfield (see Appendix 2 for details). Although it is difficult to give precise figures, it does appear that the rate of suicide is higher for people with MS compared with the general population. There may be many reasons for this: • Depression is associated with a higher rate of suicide – and as we have indicated people with MS have a higher rate of depression. In all these circumstances, it is very important that all avenues are explored for help, for through the management of depression and feelings of hopelessness, often situations that seem hopeless at the time are then viewed differently. Of course there is a related major debate under way, which is about the extent to which people can, or should be able to end their life if they 88 MANAGING YOUR MULTIPLE SCLEROSIS wish – if necessary with assistance – if they are acting rationally knowing what they are doing and in full command of all their faculties. Such assistance is currently illegal in Great Britain and a number of recent high profile court cases have confirmed this position.

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Telling your colleagues Given the way that news gets around super cialis 80 mg amex, it is unlikely that you will be able to tell one colleague without others becoming aware of your situation quite quickly generic super cialis 80mg online. Despite your wishes order super cialis 80mg, sometimes it can even happen that information from outside your work situation alerts colleagues about your MS unintentionally buy super cialis 80 mg cheap, for example an inadvertent message from a family member to a colleague about an absence from work. So it is probably wise to work out ways in which to tell your colleagues in a planned process. Although most of your colleagues will have probably heard something about MS, their views will be based on a wide range of experiences and ideas, and thus may not be accurate. The best thing may be to give each of your colleagues some written information about MS – perhaps one or more of the pamphlets on MS available from the MS Society – at the time you are informing them about your situation. They can then have EMPLOYMENT 147 accurate information, and you can respond to any questions that they might want to ask you about your own MS. It may be worth reminding them, if they were not aware of your MS before you told them, that this shows how little your work, and your working relationships with them were affected – and indeed this may continue for a long time. The Disability Discrimination Act 1995 and employment The provisions of the Disability Discrimination Act 1995 are in principle very substantial, and apply to many aspects of employment. However, the exact implications of many of the provisions have not yet all been legally tested, so it will only become clear over the years how precisely the Act will apply. It is important to remember that the Act applies to organizations and companies with over 20 employees, although those with under this number are expected to abide by the spirit of the provisions. Broadly, the position under the Act is that unlawful discrimination in employment occurs in the following circumstances: • when a disabled person is treated less favourably than someone else; • this treatment is given for a reason relating to that person’s disability; • the reason does not apply to the other person, and • the treatment cannot be justified. Such discrimination must not occur in: • the recruitment and retention of employees; • promotion and transfers; training and development, and • the dismissal process. In addition employers must make reasonable changes to their premises or employment arrangements if these substantially dis- advantage a disabled employee, or prospective employee, compared to a non-disabled person. These provisions sound formidable and very supportive of the situation of many people with MS, and in many respects they may be; however, the detailed interpretation of the provisions of the Act awaits clarification. Many of the provisions of the Act hinge on what a ‘substantial’ disadvantage to a disabled person is, and what is ‘a 148 MANAGING YOUR MULTIPLE SCLEROSIS reasonable’ adjustment on the employer’s part is. Nevertheless, some examples may help to clarify certain provisions: • Employers probably cannot justify dismissing disabled employees if they were sometimes off work because of their disability, if the amount of time they take off is what the employers accept as sick leave for other employees. Examples of changes to physical features that may be required are: • widening doorways; • changing taps to make them easier to turn; • altering lighting for people with restricted vision, and • allocating a particular parking space for a disabled person’s car. Examples of changes to procedures or practices that may be required are: EMPLOYMENT 149 • altering working hours; • supplying additional training; • allocating some duties to another employee; • allowing absences during working hours for rehabilitation, assessment and treatment; • providing a reader or interpreter; • providing supervision; • acquiring or making changes to equipment; • modifying procedures for testing or assessment, or • transferring person to another place of work. Further information on the provisions of the Act can be obtained from the Disability Discrimination Act Information Line (see Appendix 1). There is also a booklet containing guidance and a code of practice on employment available from the Stationery Office (see Appendix 2). Exceptions to the Act Although all permanent, temporary and contract workers are covered, certain organizations or work settings are not covered. These include: • people in the armed services; • police officers; • fire brigade members if they are expected to take part in firefighting; • Ministry of Defence firefighters • prison officers and prison custody officers; • people working on board a ship, aircraft or a hovercraft; • people who work outside the UK; • individual franchise holders with less than 20 employees, even if the whole franchise network has more than 20. As a different kind of exception, there are charities and organizations providing supported employment who can discriminate in favour of disabled people. Having said that, most employers are understanding and many will go out of their way to support people in similar circumstances, and informing them of your complete circumstances will be beneficial. However, only you can judge how your employer might react to the news of your diagnosis. This is not only because people’s own circumstances are all different, but because the rules and regulations governing eligibility to benefits, pensions and so on are themselves complex and can change frequently. It is very important that, in addition to taking note of the points we make below, you consult other sources of information. Choices that you may make about continuing or leaving work, or about benefits or pensions, may have long-lasting consequences, so it is important to think them through carefully, after seeking impartial advice. Benefits Sources of help The most obvious written source is the Disability Rights Handbook.

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