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By X. Karlen. Antioch University Seattle. 2018.

Similar disagree- ments concerning pain mechanisms and intervention approaches are found when considering anthropological order alli 60mg with visa, nursing buy cheap alli 60mg online, pharmacological cheap alli 60mg amex, surgical buy generic alli 60 mg on-line, neurophysiological purchase alli 60 mg without prescription, genetic, or any other perspective on pain; however, the focus here is on psychological processes. Roots of dissension concerning models of pain and pain management are found in persistent and uncontrolled pain. Pain remains a very serious problem with highly debilitating and destructive consequences for large numbers of people. Almost everyone can anticipate episodes of poorly con- trolled acute pain in their future, and there are distressingly high numbers of patients with persistent or recurrent pain. Both signal the failures of cur- rent explanatory models and the inadequacies of current applications of treatment or palliative interventions, despite numerous advances in our un- derstanding of biological, psychological, and social mechanisms in pain and 303 304 CRAIG AND HADJISTAVROPOULOS improved pain control strategies (Wall & Melzack, 2001). There should be urgency and contention in the field until a better measure of pain control is accomplished. Indeed, it seems surprising that the inadequacies of our un- derstanding of pain and our limitations in controlling pain are not more widely understood or publicized, and that they are not greater sources of scientific, practitioner, and public unrest. Recent decades have seen concerted efforts to provide an evi- dence-based understanding of pain, and to improve utilization of these un- derstandings by practitioners. Many of the recent advances have resulted from the inspiration and leadership of John Bonica (1953; Loeser, Butler, Chapman & Turk, 2001), the integrative perspective and heuristic benefits of the gate control theory of pain (Melzack & Wall, 1965), and the organiza- tional structure and impetus generated by the founding of the International Association for the Study of Pain in 1974 (http://www. Many factors contribute to differences of opinion in our understanding of pain and pain management. Scholars from numerous disciplines, includ- ing the humanities and the biological, behavioral, and social sciences, as well as health care professionals with diverse education and commitments, all bring varied perspectives to the challenges of understanding a broad range of issues and untested concepts about the nature of pain and pain management. The tragedies of uncontrolled pain and suffering have en- gaged humans throughout evolutionary history in varied, and sometimes isolated, cultures around the globe; hence, varied views in different cul- tures and communities have emerged (Craig & Pillai, in press). Most of these views deserve respect, but no model has as yet proven wholly satis- factory. Nonetheless, the evidence-based perspective (McQuay, Moore, Moore, 1998) has great potential because methods of science are more ef- fective in identifying valid concepts and useful interventions than are trial and error solutions. In the developed world, there is a tendency to focus on technological un- derstandings and answers, in part because of the unfettered promise of bio- logical solutions. In addition, government agencies and the pharmaceutical industry provide generous resources to support this perspective. Although there have been celebrated successes in development of new analgesic pharmaceuticals, these often remain unavailable to the community at large, and sometimes the widespread potential of such discoveries appears exag- gerated. Dissatisfaction with biomedical approaches is reflected in the ma- jor resurgence of interest in alternative and complementary medicine and the substantial market share of health expenditures this sector has been able to capture in providing services to chronic pain patients who have not benefited from conventional western medical care. Essentially, failures of Western approaches to health care and urgent need for relief from pain have led to free-market competition. PSYCHOLOGICAL PERSPECTIVES: CONTROVERSIES 305 vantageous, as it encourages exploration of new ideas and diffusion of inno- vation on an essentially global basis. The psychological perspective on pain offers considerable promise, and there have been substantial advances since Sternbach (1968) published the first book representing a synthesis in the area. Most major health problems (cardiovascular disease, musculoskeletal disorders, diabetes, obesity, HIV- AIDS, cancer) are largely due to psychosocial and lifestyle factors. The fo- cus of medicine is on management of disease, with the medical profession not effectively addressing behavioral health issues or pain arising from many conditions. The well-being of patients would seem to dictate stronger alliances between primary care physicians, other health care professionals, and psychologists. Our task in this chapter is to identify contentious issues, both those al- ready recognized and others that became apparent as we surveyed the field. Having noted this, we recognize that this ac- count represents a subjective perspective. Not everyone would recognize the same controversies, and we would encourage those who do not agree with our concerns to describe the issues that are problematic for them. THE NATURE OF PAIN AND CONTROVERSIES ABOUT ITS DEFINITION As amply demonstrated in the earlier chapters of this volume, concepts of pain have evolved dramatically throughout the last century. Sensory-spe- cific models proved unable to explain many of the complexities of pain (see Melzack & Wall, 1996 for an overview) and yielded to multidimensional models that acknowledge pain as a complex synthesis of thoughts, feelings, and sensory input, as described in the chapter by Melzack and Katz in this volume as well as in the work of others. For example, Price (2000) showed that the cortico-limbic pathway in the brain integrates nociceptive input with contextual information and memory to provide cognitive mediation of pain affect. There is no need here to review the history or the basis for the advances in thinking, although the transformations in thinking have not fully pervaded the practice of working with pain patients. While there would be agreement that considerable pain is suffered need- lessly (Melzack, 1988), one might generate the argument that not all pain is undesirable. Advocates of corporal punishment and those who practice vio- lence appear to perceive merit in inflicting pain to punish or modify the be- havior of others.

In adolescents alli 60mg lowest price, on the other hand discount 60mg alli with mastercard, sporting accidents are the commonest cause buy 60mg alli fast delivery. In our own investiga- to the fact that the thorax is much more elastic in children tion cheap 60 mg alli overnight delivery, the sporting activity that resulted in (severe) and adolescents than in adults discount alli 60 mg on line. A second frequency peak spinal injuries was skiing in 33% of cases, swimming for the pediatric age group was observed for the thoraco- in 13%, horse riding and gymnastics both in 12% of cases, lumbar junction, where most of the adult fractures also mountaineering in 8%, paragliding in 4% and diving in occur. An increased frequency of accidents has Classification also been reported for trampolining. The risk of spinal A special feature of pediatric spinal trauma is traumatic injuries during skiing is higher in adolescence than either paraplegia without any detectable changes on the x-ray before or after this period. By contrast, the currently (known as SCIWORA syndrome, which stands for spinal popular youth-oriented sport of snowboarding does not cord injury without radiographic abnormality). Such appear to involve an increased risk of spinal injuries (in injuries are not included in the usual classifications since contrast with injuries to the upper extremities) as the they do not produce any radiographically visible lesion. The injuries with radiographically visible frac- Localization tures can be classified as for adult fractures. The principal sites of injury in adults are the lower cervi- cal spine and the thoracolumbar junction (T11–L3). In general, lesions of the lumbar spine are more common To this end we use the AO classification, in which the than cervical injuries. With the exception of vertebral fractures are subdivided according to the mechanism bodies T11 and T12, fractures of the thoracic section are of injury: extremely rare. By contrast, in our own study with A: Compression 51 children and adolescents with 113 fractures we found B: Distraction that the thoracic spine was actually the most frequently C: Torsion affected site of injury (⊡ Fig. AO classification of spinal trauma one week can prove helpful in uncertain cases. In particu- Type Features lar, the presence or absence of any instability can then be established with a (careful) functional x-ray in inclination A: Compression and reclination. A 1: Impaction Radiographs of the thoracic and lumbar spine are eas- 3 ier to evaluate than those of the cervical spine. Compres- A 2: Split fracture sion fractures can be differentiated from wedge vertebrae A 3: Burst fracture in Scheuermann disease since the endplate of compressed B: Distraction vertebral bodies tends to overlap the anterior edge slightly. Moreover, the intervertebral disk space is normal in con- B 1: Distraction with transosseous injury trast with the situation in Scheuermann’s disease. One B 2: Distraction with intra-articular injury should not overlook injuries of the vertebral arches and pedicles (type B and type C fractures). On an AP x-ray, B 3: Distraction and extension which must also be recorded in every case, we look for C: Rotational asymmetry of the endplates, i. The latter is evidence of a (usually C 2: Rotational + type B severe) torsion injury. Myelography or a CT scan (a CT-myelogram) can provide further information in uncertain cases. Fragments in the spinal In a group of over 1,400 fractures, type A dominated canal are best viewed by CT. The MRI scan has little place with 74% of cases, followed by types B and C in 10% and in acute diagnosis and is primarily suited to the imaging 16% of cases respectively. Over half of the type A injuries of soft tissue injuries in those patients with neurological were pure compression fractures (A 1). Clinical features, diagnosis Prognosis If a spinal injury is suspected, AP and lateral radiographs! In addition, meticulous neurologi- in adults, they are more commonly associated with cal examination is required. The chances of recovery are particularly those of the cervical spine, is not always easy. On the one hand, a distinction needs to be made between incomplete ossification, particularly in the upper cervical Of 174 children with spinal injuries 45% had a neu- spine, and fractures or even pseudarthroses. Os odontoideum is common and can be mistaken more recent study confirms the high rate of neurological for a dens fracture. On the other hand, the relatively improvement following severe traumatic pediatric spinal substantial mobility of the upper cervical spine also needs cord injury.

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The most reproducible results can be introduction of moiré photogrammetry by Takasaki 1970 obtained by bending the spinal area to be investigated in Japan discount alli 60 mg with mastercard, which was followed by other new photo- over a padded roll cheap alli 60mg visa. Risser sign: The stage of skeletal maturation (0–V) can: This template on transparent film can be used to determine the be evaluated according to the ossification of the iliac crest apophysis 60 mg alli visa. The template is placed The ossification starts on the lateral side at the peak of the pubertal over the vertebral body and aligned with the edges discount 60mg alli visa. The extent of the growth spurt (roughly contemporaneously with the menarche in girls) rotation is read off the scale via the line that passes through the center (Risser stage I) discount 60mg alli overnight delivery. The pubertal growth spurt is concluded with Risser of the pedicle on the convex side of the scoliosis (shown at the bottom stage IV, and ossification of the apophysis (stage V) takes a further 2 as an angle between 0° and 60°) years to complete a b c ⊡ Fig. Functional x-rays with maximal lateral inclination to the as reproducible results as possible. In a lumbar scoliosis, the left (b) and right (c) are needed to evaluate the correctability of a correction of the lumbar curve with the VDS instrumentation may scoliosis (a). For correction purposes, we bend the spinal section not go beyond the straightening of the thoracic countercurve in the to be investigated over a roll (visible in b left and c right), to obtain functional x-ray 79 3 3. On a three-dimensional object be- planes, making angle measurements almost impossible. This produces shadows on the three-dimensional surface like the contours of Natural history, prognosis a geographical map. The contours with corresponding The diagnosis of idiopathic adolescent scoliosis in pu- depressions and projections are visually displayed on berty then raises the question of the likelihood of the the surface of the back. Since the contours are so clearly subsequent progression of the condition. In an investigation of over 700 patients, the surface is symmetrical or asymmetrical. However, the following factors of relevance to prognosis were resulting image is greatly dependent on the positioning determined: of the patient. Since it is difficult to assess the extent of any asymmetry using moiré curves, other methods for the three-dimen- No other factors, including for example the extent of sional calculation of the back surface have been devel- rotation, lordosis, family history, sex, etc. We ourselves have designed a technique in which positive correlation with progression. The bar chart in dots of light are projected onto the surface of the back and ⊡ Fig. We used In a recent study the progression velocity of scolio- this method for 15 years. A grid pattern notable with a growth velocity of >or=2 cm/year, at ages is projected onto the surface of the back and a virtual between 9 and 13 years, bone ages between 9 and 14 »plaster cast« calculated. In boys, scolioses appear to progress at a later lordoses can be evaluated very reliably by computer and stage than in girls, even taking into account the skeletal any subsequent changes over time documented. If a scoliosis of >20° persists be- yond infancy, progression is inevitable. Additional imaging methods Computer tomography Progression in adulthood CT is suitable for checking rotation and has been used in In scolioses with a Cobb angle of over 50° on completion a number of clinical studies. Consequences of scoliosis Thanks to investigations involving substantial numbers Magnetic resonance imaging (MRI) of patients and observation periods of up to 50 years we MRI is a non-invasive, but expensive, method that can now know a great deal about the consequences of sco- be used for identifying intraspinal problems (anoma- lioses [3, 102, 103]. MRI is indicated if neurological symp- untreated scolioses is moderate after 50 years. It is not the incidence of back pain is increased, this is rarely seri- suitable for monitoring the progress of a condition as ous [103]. In the lumbar area, the outwardly visible cosmetic impairment only starts to appear from a lumbar prominence angle of 15° (corresponding to a Cobb angle of approx. Asymmetry of the waist, how- ever, can have a more detrimental effect on the cosmetic 3 appearance. Risk of progression in relation to age and the initial angle The probability of back pain is increased in: of the scoliosis. The probability of back pain is only slightly or moderately increased in patients with thoracic scolioses [3, 103]. Paralysis Spontaneously occurring paralysis does not occur in id- iopathic scoliosis (paralysis only occurs in cases of con- genital kyphosis and secondary scoliosis resulting from a tumor). Although commonly used for many years it only provides an incomplete description of the possible types.

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Temporal summation refers to the enhancement of pain sensation as- sociated with repeated stimulation generic alli 60 mg overnight delivery. It results from a transient sensitization of dorsal horn neurons in the spinal cord and is thought to play an impor- tant role in the development and expression of postinjury tenderness and hyperalgesia cheap 60 mg alli with mastercard. Zheng order alli 60 mg visa, Gibson buy cheap alli 60 mg online, Khalil discount alli 60 mg without prescription, McMeeken, and Helme (2000) extended these observations by comparing the intensity and time course of post- injury hyperalgesia in young (20–40) and older (73–88) adults. Although the intensity and area of hyperalgesia were similar in both groups, the state of mechanical tenderness persisted for a much longer duration in the older group. As mechanical tenderness is known to be mediated by sensitized spinal neurons, these findings may indicate a reduced capacity of the aged CNS to reverse the sensitization process once it has been initiated. The clin- ical implication is that postinjury pain and tenderness will resolve more slowly in older persons. However, in combination with the studies of tem- poral summation, these findings provide strong evidence for an age-related reduction in the functional plasticity of spinal nociceptive neurons follow- ing an acute noxious event. PAIN OVER THE LIFE SPAN 135 Variations in pain sensitivity depend not only on activity in the afferent nociceptive pathways but also endogenous pain inhibitory control mecha- nisms that descend from the cortex and midbrain onto spinal cord neu- rons. A recent study has shown that the analgesic efficacy of this endoge- nous inhibitory system may decline with advancing age (Washington, Gibson, & Helme, 2000). Following activation of the endogenous analgesic system, young adults showed an increase in pain threshold of up to 150% whereas the apparently healthy older adult group increased pain thresh- old by approximately 40%. Such age differences in the efficiency of endog- enous analgesic modulation are consistent with many earlier animal stud- ies (see Bodnar, Romero, & Kramer, 1988, for review) and would be expected to reduce the ability of older adults to cope with severe or per- sistent pain states. There are widespread morphological and neurochemical changes to the central nervous system with advancing age, although few studies have ex- amined those areas specifically related to the processing of nociceptive in- formation (see Gibson & Helme, 1995, for review). An investigation of the cortical response to painful stimulation has documented some changes in adults over 60 years. Using the pain-related encephalographic response in order to index the central nervous system processing of noxious input, older adults were found to display a significant reduction in peak amplitude and an increased latency of response (Gibson, Gorman, & Helme, 1990). These findings might suggest an age-related slowing in the cognitive proc- essing of noxious information and a reduced cortical activation. There has also been one report of a more diffuse topographic spread in the post- stimulus electroencephalogram (Gibson, Helme, & Gorman, 1993). Although this finding could indicate a wider recruitment of CNS neurons during the cortical processing of noxious input, more recent neuroimaging techniques, with better temporal and spatial resolution, would be needed to confirm this suggestion. Age Differences in Pain Assessment During the Adult Years Three main approaches have been used to assess clinical pain in the adult population: self-report psychometric measures, behavioral–observational methods, and third-party proxy ratings. The vast majority of research into pain measurement has been conducted on young and middle-aged adults and there is a huge literature on this topic (for review see Katz & Melzack, 1999; Lee, 2001; Williams, 2001). In order to consider pain measurement from a developmental perspective there need to be direct comparative studies between young and older adults. There is no literature on age differ- ences in pain assessment, although issues of measurement reliability and 136 GIBSON AND CHAMBERS validity have been investigated within specific age segments of the adult population. Evidence from a variety of sources would suggest that any measure- ment approach found to be useful in young adult populations, also has a potential for use with most older persons (Helme & Gibson, 1998; Parmelee, 1994). Single-item scales of self-reported pain intensity, such as verbal descriptor scales, numeric rating scales, colored analogue scales, and the pictorial pain faces scale, have all been shown to possess some at- tributes of validity and reliability when used with healthy older adults and even in those with mild cognitive impairment (Benesh, Szigeti, & Ferraro, 1997; Chibnall & Tait, 2001; Cook, Niven, & Downs, 1999; Corran, Helme, & Gibson, 1991; Ferrell, 1995; Gloth, 2000; Helme et al. Visual an- alogue scales (VAS) also have some evidence of validity (Scherder & Bouma, 2000), although several others have raised concerns about the suitability of this measure for use with older patients (Benesh et al. In particular, it has been suggested that older persons may have difficulties with the more abstract nature of the visual analogue scale scaling proper- ties (Herr et al. However, most data would support the use of such instruments in older adults with and without cognitive impairment (Corran et al. Some older persons will suffer from multiple comorbid medical illnesses, physical impairments in vision or hearing, severe cognitive impairment, or difficulties with verbal communication skills, all of which may complicate routine psychometric pain assessment. Behavioral–observational meas- ures of pain can bypass many of these difficulties and have been examined for use in frail older populations (e. Interrater reliability and concurrent va- lidity appear to be adequate in older nursing home residents, including those with mild to moderate cognitive impairment (Kovach, Griffie, Matson, & Muchka, 1999; Simons & Malabar, 1995; Weiner et al. However, the level of agreement between resident and staff perceptions of pain as indexed by behavioral markers has been shown to be relatively poor (kappa.

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Congenital and infantile scoliosis Scoliosis from birth to walking age is generally of two types: infantile idiopathic or congenital scoliosis alli 60mg line. Infantile idiopathic scoliosis is defined as a spinal curvature making its appearance during the first three years of life discount 60mg alli free shipping. Although it is relatively rare in the United States buy generic alli 60mg on line, it is not uncommon in the UK and Europe trusted alli 60mg. It is more commonly found in males order 60 mg alli otc, Common orthopedic conditions from birth to walking 32 and shows a preponderance of left-sided thoracic curves (Pearl 3. Most of the spinal curvatures are not recognized during the neonatal period but are commonly seen between two and six months of age. In most studies spontaneous improvement or resolution has been observed in well over 50 percent of the patients. The curvatures require close observation, as some of these curves are progressive and can lead to significant deformity. Not uncommonly plagiocephaly, mental retardation, and breech malposition have been associated with a number of the described cases. Because of the difficulty in establishing an appropriate prognosis for these curves, early orthopaedic referral is suggested. Bracing (orthotics) is usually ineffective and surgery is generally reserved for progressive curvatures. Congenital scoliosis is a result of anomalous vertebral formation (Figure 3. Most cases of congenital scoliosis are related either to defects in segmentation of a part, or all, of the vertebrae with resultant fusion of segments, or to failures in formation of a part or all of the vertebrae. The various types and subtypes of congenital scoliosis are associated with quite different prognostic courses, and the understanding of that evolution more likely should rest in the domain of the orthopedic surgeon. It is, however, important for the primary care physician to be constantly vigilant in the search for other systemic abnormalities in the presence of a congenital scoliosis. Congenital muscular torticollis with prominent most common associated abnormalities are sternocleido-mastoid muscle. The embryonic development of these systems occurs in close relationship of the development of the vertebral column. Infantile scoliosis Intraspinal abnormalities such as hydromyelia or diastematomyelia are not uncommonly Left thoracic encountered. Magnetic resonance imaging Males > females evaluation should probably be entertained in Spontaneous correction all cases of congenital scoliosis (vertebral Brace effectiveness anomalies). In spite of the impressive radiographic nature of many of the cases of 33 Birth palsies (brachial plexus injuries) congenital scoliosis, not all progress and many are simply observed until maturation. Bracing is rarely, if ever, effective in managing progressive curvatures and surgery is generally the only successful treatment. Early recognition and orthopedic referral are recommended for the primary care physician. Birth palsies (brachial plexus injuries) Injuries of the brachial plexus occurring during delivery result in varying degrees of paralysis of the upper extremity. The mechanism of injury is generally a forcible stretching of one or more components of the brachial plexus. Commonly the injuries are a by-product of a difficult delivery involving a large infant. Damage can occur in a cephalic presentation, as a consequence of forced head and neck traction in an effort to deliver broad shoulders through a tight canal. It can also occur in a breech extraction while attempting to deliver the head. Fortunately the nerve roots are rarely completely avulsed, and are usually disrupted with the nerve still in continuity. The degree of severity of the nerve lesion will dictate the rapidity and extent to which the lesion will recover. Resolution of these palsies is therefore directly related to the damage done at the time of injury. The types of palsies are generally divided into injuries to the upper plexus (C5–C6 roots), Erb’s palsy, or an injury to the lower plexus (C8 and T1 roots) Klumpke type, or a mixed pattern, in which all components of the plexus are involved, with generalized paralysis.

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