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By G. Hengley. Eastern Washington University.

These proc- esses ready the organism for extraordinary behaviors that will maximize its chances to cope with the threat at hand (Selye buy avanafil 50mg line, 1978) generic avanafil 200mg fast delivery. Although laboratory studies often involve highly controlled and specific noxious stimulation buy avanafil 100mg online, real-life tissue trauma usually involves a spectrum of afferent activity cheap avanafil 50 mg free shipping, and the pattern of activity may be a greater determinant of the stress response than the specific receptor system involved (Lilly & Gann purchase avanafil 50 mg fast delivery, 1992). Traumatic injury, for example, might involve complex signaling from the site of injury including inflammatory mediators, baroreceptor signals from blood volume changes, and hypercapnea. Diminished nociceptive transmission during stress or injury helps peo- ple and animals to cope with threat without the distraction of pain. Labo- ratory studies with rodents indicate that animals placed in restraint or subjected to cold water develop analgesia (Amir & Amit, 1979; Bodnar, Glusman, Brutus, Spiaggia, & Kelly, 1979; Kelly, Silverman, Glusman, & Bodner, 1993). Lesioning the PVN attenuates such stress-induced analge- sia (Truesdell & Bodnar, 1987). The medullary mechanisms involved in this are complex and include the response of the solitary nucleus to baroreceptor stimulation (Ghione, 1996). Stressor-induced, increased blood pressure stimulates carotid barorecep- tors, and these in turn activate the solitary nucleus, which then initiates ac- tivity in descending pathways that gate incoming nociceptive traffic at the dorsal horn of the spinal cord. This mechanism links psychophysiological response to a stressor with endogenous pain modulation. Some investigators emphasize that neuroendocrine arousal mechanisms are not limited to emergency situations, even though most research empha- sizes that such situations elicit them (Grant, Aston-Jones, & Redmond, 1988; Henry, 1986). In complex social contexts, submission, dominance, and other transactions can elicit neuroendocrine and autonomic responses, modified perhaps by learning and memory. This suggests that neuroendocrine proc- esses accompany all sorts of emotion-eliciting situations. The hypothalamic PVN supports stress-related autonomic arousal through neural as well as hormonal pathways. It sends direct projections to the sympathetic intermediolateral cell column in the thoracolumbar spinal 3. PAIN PERCEPTION AND EXPERIENCE 75 cord and the parasympathetic vagal complex, both sources of preganglionic autonomic outflow (Krukoff, 1990). In addition, it signals release of epineph- rine and norepinephrine from the adrenal medulla. ACTH (adrenocortico- trophic hormone) release, although not instantaneous, is quite rapid: It occurs within about 15 seconds (Sapolsky, 1992). These considerations impli- cate the HPA axis in the neuroendocrinologic and autonomic manifestations of emotion associated with tissue trauma. In addition to controlling neuroendocrine and autonomic nervous sys- tem reactivity, the HPA axis coordinates emotional arousal with behavior (Panksepp, 1986). As noted earlier, stimulation of the hypothalamus can elicit well-organized action patterns, including defensive threat behaviors and autonomic arousal (Jänig, 1985). The existence of demonstrable behav- ioral subroutines in animals suggests that the hypothalamus plays a key role in matching behavioral reactions and bodily adjustments to challeng- ing circumstances or biologically relevant stimuli. Moreover, stress hor- mones at high levels, especially glucocorticoids, may affect central emo- tional arousal, lowering startle thresholds and influencing cognition (Sapolsky, 1992). Saphier (1987) observed that cortisol altered the firing rate of neurons in limbic forebrain. Clearly, stress regulation is a complex, feedback-dependent, and coordinated process. The hypothalamus appears to take executive responsibility for coordinating behavioral readiness with physiological capability, awareness, and cognitive function. Chapman and Gavrin (1999) suggested that prolonged nociception may cause a sustained, maladaptive stress response in patients. Signs of this in- clude fatigue, dysphoria, myalgia, nonrestorative sleep, somatic hyper- vigilance, reduced appetite and libido, impaired physical functioning, and impaired concentration. In this way, the emotional dimension of persisting pain may, through its physiological manifestation, contribute heavily to the disability associated with chronic or unrelieved cancer pain. Central Serotonergic Pathways The serotonergic system is the most extensive monoaminergic system in the brain. It originates in the raphé nuclei of the medulla, the pons, and the mesencephalon (Grove, Coplan, & Hollander, 1997; Watson, Khachaturian, Lewis, & Akil, 1986). Descending projections from the raphé nuclei modu- late nociceptive traffic at laminae I and II in the spinal cord and also motor neurons. The raphé nuclei of the midbrain and upper pons project via the medial forebrain bundle to multiple limbic sites such as hypothalamus, sep- tum and hippocampus, cingulate cortex, and cerebral cortex, including frontal cortex. The potential role of serotonergic mechanisms in affective disorders, particularly depression and panic disorder, continues to receive a great 76 CHAPMAN deal of attention (Grove et al.

Rib fractures due to NAI are often multiple (commonly 6th–11th ribs7) discount avanafil 100 mg overnight delivery, bilateral and posterior8 order avanafil 200 mg line. They are thought to be present in up to 25% of cases although the majority are clinically occult5 50 mg avanafil sale. Rib fractures may be difficult to diagnose radiographically when acute and therefore buy generic avanafil 200 mg on-line, if suspected proven avanafil 100mg, a repeat x-ray 7–12 days later (when fracture heal- ing by callus formation can be identified) may be indicated. Vertebral fractures Vertebral fractures due to NAI are rare but, should they occur, are usually located in the region of the thoracolumbar spine (Fig. The mechanism of injury is commonly vigorous shaking of a young child resulting in hyperflexion of the spine. Radiographic evidence is typically height reduction at the anterior portion of the vertebral body with possible anterior endplate fractures and superior endplate extension. Avulsion of the spinous processes may also occur but as the tips of infant spinous processes are cartilaginous, this type of injury will not be apparent until calcification of the avulsed cartilage occurs16. Digital fractures Digital fractures (hands and feet) are uncommon in young children unless direct trauma has been experienced. Non-accidental injury to the hands and feet is usually the result of trampling, squeezing or hyperextension and, in the pres- ence of a vague clinical history, digital fractures are suggestive of physical abuse. Rosenthal Cleveland, Ohio Pain and Depression An Interdisciplinary Patient-Centered Approach Volume Editors M. This publication is listed in bibliographic services, including Current Contents® and Index Medicus. All opinions, conclusions, or regimens are those of the authors, and do not necessarily reflect the views of the publisher and the series editor. The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means electronic or mechanical, including photocopying, recording, microcopy- ing, or by any information storage and retrieval system, without permission in writing from the publisher. Population-Based Healthcare for Chronic Idiopathic Pain and Fatigue after War Engel, C. Much of the confusion about treatment of pain comes from inad- equate evaluation and understanding of pain and a lack of knowledge about the psychiatric conditions that accompany many pain disorders. The distinction between chronic and acute pain syndromes, as well as the distinction between those in whom the goal of treatment is rehabilitation and those who need to be made comfortable has been poorly appreciated in clinical efforts. The idea that pain must be assessed daily in all patients at every clinical interaction and treated with an opiate-based protocol has caused as many problems as it has solved. Acute pain with a known etiology that is expected in the course of treatment should be vigorously suppressed in most cases. Acute pain of unclear etiology should be evaluated for cause and appropriate treatment. Chronic pain in most patients deserves a comprehensive workup and thoughtful treatment plan which balances comfort with function and rehabilitation. It occurs at high rates in many chronic medical conditions and has been shown to affect recovery, cost, morbidity, and mortality. Depression is often missed in medical settings and is underdiagnosed and undertreated in most studied patient populations. It adds to the costs of treatment, magnifies the subjective experience of noxious stimuli, and retards rehabilitation. Depression is a barrier to patients’ engagement in treatment, and sometimes a barrier to physician engagement in VII patient care. The co-occurrence of these two conditions is well known but the details of phenomenology, interrelationships, and rational therapies remain spec- ulative. This volume focuses on the need for a coherent approach to the formu- lation of patients with chronic pain who suffer from depression. Depression is a personal experience that takes on many forms and emerges from many causes.

A similar study also suggested no specific benefit (in terms of pain ratings) for a distraction intervention compared to a “standard care” condition discount avanafil 100mg with visa, which frequently included EMLA cream (Kleiber discount 50mg avanafil mastercard, Craft-Rosenberg trusted 100mg avanafil, & Harper buy avanafil 100 mg free shipping, 2001) order avanafil 50mg without a prescription. For children all of whom were provided with a distraction inter- vention, no differences in pain ratings were reported between those receiv- 9. PSYCHOLOGICAL INTERVENTIONS FOR ACUTE PAIN 259 ing EMLA versus those receiving placebo cream, suggesting no additive benefit of EMLA beyond distraction (Lal, McClelland, Phillips, Taub, & Beat- tie, 2001). Lack of statistical power does not account for the differences be- tween these studies, as the study with the largest sample size (n = 180) re- ported the most negative results (Arts et al. These studies do not indicate whether other psychological strategies, such as brief relaxation or imagery, may have been more effective than distraction relative to the pharmacological approach. However, these studies suggest that for brief, low-intensity procedures in which simple pharmacological interventions with minimal side effects (e. Several of the most methodologically sound controlled trials, all con- ducted in children, comparing psychological interventions with a pharma- cological intervention have been reported by Jay and colleagues (1987, 1991, 1995). Results indicated that the psychological intervention re- sulted in lower pain, distress, and physiological arousal than either the Val- ium or control conditions (Jay et al. A similar follow-up RCT by these researchers revealed identical effects on pain and arousal whether patients received a psychological intervention alone or in combination with Valium (Jay et al. Results indicated that general anesthesia was associated with less procedural distress, but no dif- ferences between interventions were observed regarding self-ratings of pain provided postprocedure. Subjects, all of whom received both types of pain intervention in the within-subject design, did not indicate a significant preference for one versus the other type of intervention, and it was noted that the psychological intervention required less time (Jay et al. As a whole, results of these well-controlled studies indicate that psychological interventions are of at least comparable efficacy to standard pharmacologi- cal approaches for management of the pain associated with bone-marrow aspiration in children. It is important to note that such findings are not likely to generalize to all types of clinical acute pain. Clearly, procedures associated with more in- tense acute pain, such as even “minor” surgery, require pharmacological analgesia. However, the results reported earlier indicate that combining psychological and pharmacological approaches may have significant bene- 260 BRUEHL AND CHUNG fits to patients. MODERATORS OF RESPONSES TO PSYCHOLOGICAL INTERVENTIONS Spontaneous Coping Strategies Many individuals implement their own spontaneous pain coping strategies when faced with acute pain (Spanos et al. The possibility that externally imposed interventions may interfere with pa- tients’ implementation of effective pain control strategies already in their behavioral repertoire cannot be ruled out. Although some studies suggest that these spontaneous coping strategies may be effective for pain reduc- tion (Spanos et al. Coping Style Patients’ preferred style of coping with stress, whether Monitoring or Blunting in character, may be relevant to understanding the efficacy of spe- cific psychological acute pain interventions. Monitors, also referred to as Sensitizers or Vigilants, prefer to cope with stressful situations by seeking out information about the stimulus, and by monitoring and trying to miti- gate their responses to the stimulus (Schultheis, Peterson, & Selby, 1987). Blunters, also termed Repressors, Avoiders, Distractors, or Deniers, prefer to cope with stressful situations through avoidance and by denial of the stressor (Schultheis et al. A number of studies have hypothesized that psychological acute pain in- terventions work best if they match an individual’s naturally preferred cop- ing style. For example, providing a sensory focus intervention to a Blunter would be considered a mismatched intervention, whereas a relaxing imag- ery strategy would be considered a matched intervention for such an indi- vidual (Fanurick et al. Laboratory acute pain studies have provided some evidence indicating that interventions matched to preferred coping style result in more effective reductions in acute pain responsiveness (e. PSYCHOLOGICAL INTERVENTIONS FOR ACUTE PAIN 261 Clinical studies regarding this issue are mixed, but generally negative. Although there were no interaction ef- fects regarding pain experienced during the procedures, Monitors were found to experience less distress in the information provision condition whereas Blunters experienced greater distress (Shipley et al. Studies performed in the context of more severe acute clinical pain, on the other hand, are more negative. In a study of general surgery patients, efficacy of information pro- vision, relaxation, and no intervention was compared as a function of Moni- toring and Blunting coping styles (Scott & Clum, 1984). Blunters reported less pain and used less analgesics when provided with no intervention, which appear at least not inconsistent with the matching hypothesis. How- ever, contrary to the matching hypothesis, Monitors appeared to do best with breathing relaxation as opposed to information provision (Scott & Clum, 1984). Work by Wilson (1981) also in general surgery patients found that Blunters did not experience exacerbated pain following an information provision intervention, again failing to support the matching hypothesis. More recent work in surgical patients also indicated that efficacy of a relax- ation intervention did not differ depending on the degree to which patients preferred a Monitoring coping style (Miro & Raich, 1999). Differences in the measures used to assess coping style, types of interventions employed, and other procedural details make comparisons across studies more difficult.

Knee extension splint as follow-up treatment after length- it is much more common in patients with primarily dys- ening of the knee flexors generic avanafil 100 mg free shipping. The knee flexion position can quickly and tonic and slightly atactic disorders than in severely spas- simply be adjusted via the strap on the extension rod tic patients purchase avanafil 100 mg without a prescription. They may extensive lateral release (according to Green) best avanafil 100 mg, particularly help generic avanafil 50mg on-line, however avanafil 200mg lowest price, in bridging the period till the surgical in the cranial direction. Transfer of the tibial tuberos- deformities must be accepted or surgically treated. Functional fixation with the AO low contact plate (LCP) with screws follow-up treatment is difficult in patients with coordina- which provide angular stability, since the patients can tion problems since they tend to lose their footing and can start weight-bearing immediately and muscle power and thus tear apart the sutured medial muscles. An abduction flat- foot cannot be left untreated in order to compensate for Rotational deformities any internal rotation but must also be corrected. Both exter- Functional disorders nal and internal rotational deformities can occur. The swing movement at the knee foot), this defect often requires correction. Even a deficit which is the lever arm for the triceps surae muscle, goes of the knee extensors is compatible with minimally re- out of alignment with the direction of movement, this stricted walking. By way of compensation, the knee has essential muscle for posture control becomes insufficient. Twister cables, elastic strands fitted between a pelvic contracture of this muscle (equinus foot) will fulfill the ring and ankle foot orthoses, can provide functional same purpose. If the twister cables are pretensioned before slight equinus foot position (backward lean) with a stiff the ankle footorthoses are fitted (outward rotation for lower leg brace. Functional deformities in primarily flaccid locomotor disorders Deformity Functional Functional drawbacks Treatment benefit Knee extensor insufficiency – Standing with flexed knees not possible Full knee extension Knee flexor insufficiency – Deficient momentum (knee extension Passive swinging of the leg during contracture) walking 327 3 3. This maneuver transfers at least part of the postural work to the hip extensors. If In flaccid paralyses, full extension (or even slight hyperex- the upper body has to lean far forward the patients push tension) of the knee is required to compensate for insuffi- their arm against the knee to support themselves while ciency of the extensor mechanism ( Chapter 3. Any knee flexion contracture will prevent this with hyperextension of the knee«). A 5° hyperextension is compensatory mechanism from coming into play and harmless. If the hyperextension is more pronounced, how- thus restrict walking ability. If extension Structural changes is lost, the patients have to support themselves by placing a hand above the knee to extend the knee indirectly. Since > Definition this maneuver is only possible with a bent upper body, the Structural deformity of the knee caused by reduced or patients can no longer walk upright or look straight ahead absent muscle activity. Higher neurological levels are more likely to predispose to knee flexion contractures. Conservative treatment is possible with a support- ing and stabilizing thigh orthosis with a foot section and designed to lock the knee during the walking. A more attractive and promising alternative for patients is surgical lengthening at knee level. Various techniques are available: As any further muscle weakening in these conditions should be avoided the procedure of choice is the supracondylar extension osteotomy. We fix it with an AO LCP-plate with screws with angular stability which enables immediate weight bearing. Muscle or tendon lengthening procedures are also possible but bear the risk of additional weakening. Full extension can be achieved gradually by using an external fixator attached above the knee ( Chap- a b ter 3. Schematic view of flexion and extension moments to match the individual patient’s symptoms. One possible involved in knee extension: a in forward inclination, b in backward complication of such soft tissue lengthening procedures inclination is a temporary painful loosening of the ligamentous ap- ⊡ Table 3. Structural deformities in primarily flaccid locomotor disorders Deformity Functional benefit Functional drawbacks Treatment Knee flexion contractures, – Increased energy required Soft tissue lengthening procedures, non-osseous to walk and stand supracondylar extension osteotomy, Ilizarov apparatus in special cases Knee flexion contractures, – Increased energy required Correction osteotomy osseous to walk and stand Knee extension contractures – Sitting aggravated VY-plasty of the quadriceps tendon External rotational deformity Compensation of increased Feet not in direction of leg Correction osteotomy of the lower leg femoral anteversion axis Internal rotational deformity (Compensation of abducted Feet not in direction of leg Correction osteotomy of the lower leg pes planovalgus) axis 328 3.

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