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By K. Potros. Tennessee Technological University.

When patients have catastrophic beliefs about their situation or ex- press hopelessness about their future cheap levitra soft 20mg online, they should be referred for a com- prehensive evaluation proven levitra soft 20 mg. Clinicians can also ask patients questions about their beliefs cheap 20 mg levitra soft with mastercard, such as discount levitra soft 20 mg free shipping, “What do you believe is the cause of your pain? In addition to gathering information through an interview cheap levitra soft 20mg free shipping, health care professionals can administer any of a number of standardized self-report measures in addition to the ones we mentioned. These instruments are ef- ficient means for obtaining relevant detailed information. Some of these measures require psychological expertise for interpretation; however, a number of instruments require little training (see Turk & Melzack, 2001). Note that many of these instruments were not developed specifically for chronic pain patients. As a result, it is always best to corroborate informa- tion gathered from the instruments with other sources, such as interviews with the patient and significant others, and chart review. An important ca- veat: The results of such brief screening should not be used to diagnose but rather to determine whether a more comprehensive psychological evaluation is warranted. PURPOSES OF A COMPREHENSIVE PSYCHOLOGICAL EVALUATION When health care professionals suspect that cognitive, emotional, or behav- ioral factors play a role in patients’ suffering (six or more items identified in Table 8. Experienced health psychologists are best able to perform these evaluations. A thorough psychological evaluation will reveal aspects of the patient’s history that are relevant to the current situation. For example, the psychologist will gather in- formation about psychological disorders, substance abuse or dependence, vocational difficulties, and family role models for chronic illness. In terms of current status, topics covered include recent life stresses, vocational, social and physical functioning, sleep patterns, and emotional functioning. The pur- pose of the evaluation is to examine whether historical or current factors are influencing the way the patient perceives and copes with pain. The psychological evaluation cannot provide definitive information about the cause(s) of pain and other symptoms. Moreover, if psychological 218 TURK, MONARCH, WILLIAMS factors are identified as contributing to pain and disability, this does not preclude the possibility of physical pathology, just as the presence of posi- tive physical findings does not necessarily preclude the possibility that psy- chological factors are contributing to the patient’s pain. PREPARATION OF PATIENTS FOR PSYCHOLOGICAL EVALUATIONS Many patients with persistent pain may not see the relevance of a psycho- logical evaluation. They tend view their symptoms as physical and they are not accustomed to a biopsychosocial approach. Many believe that identifi- cation and treatment of the physical cause of their pain is the only road to- ward finding relief for their symptoms. When compensation or litigation is- sues are involved, patients may be particularly sensitive to the implications of a psychological evaluation. They may wonder, “Is this psychologist try- ing to figure out if I am exaggerating my symptoms? Specifically, the provider can inform the patient that an evalua- tion helps his or her providers ensure that factors in the person’s life, such as stress, are not interfering with their treatment and not contributing to suf- fering. Patients can then be told that, used in conjunction with other treat- ments, patients with persistent pain have found that psychological tech- niques can reduce their symptoms and help them better manage their pain and their lives. Although it is not ideal, when referral agents do not prepare patients for psychological evaluations, pain psycholo- gists can provide the rationale for the evaluation themselves. One way to establish rapport with these patients is to begin the evaluation with less “psychologically charged” questions. Instead, begin by asking patients to de- scribe their pain and its onset. COMPONENTS OF A PSYCHOLOGICAL EVALUATION A comprehensive psychological evaluation covers the same information as screening but in much greater depth and breadth. Results of comprehen- sive psychological evaluations can be combined with physical and voca- TABLE 8. If third-party payers are to obtain information the patient will be alerted to this.

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At best purchase levitra soft 20 mg line, the loss of power in the triceps surae only hinders the foot push-off during walking discount 20mg levitra soft fast delivery. Overcorrec- tions of equinus foot after (Achilles) tendon lengthening procedures are not infrequent and result in a pes calca- neus position and thus a functional deterioration buy cheap levitra soft 20 mg on line. The consequence can be secondary contractures of the knee and hip flexors cheap levitra soft 20 mg without a prescription. Whereas an equinus foot can be managed with a func- tional spring orthosis buy discount levitra soft 20 mg online, which facilitates an almost normal gait, a rigid orthosis, which hinders walking, is required for pes calcaneus. Gait function with the latter is therefore much worse than with an equinus foot. A safer method than tendon lengthening is the aponeurotic lengthening of the triceps surae according to Baumann. Although this procedure does not lengthen the muscle as much, it also involves less of a loss of muscle power. If dorsiflexor activity fails to recover, additional measures will need to be considered: A conservative option is a foot-lifting or- thosis. A surgical alternative is to tension the dorsiflexors or transfer the muscles to compensate for the deficit. Functional clubfoot position > Definition Supination, forefoot adduction, varus of the calcaneus and an equinus position are present in varying degrees during functional use of the foot. Clearly visible through the skin is the tendon of the spastic anteriortibial weight-bearing the shape of the foot is normal. The fixation of the deformity must be pre- risk of recurrences, consistent follow-up orthotic manage- vented by bringing the foot into an anatomically correct ment is required. The foot position can also be corrected position, otherwise a progressive clubfoot deformity will with a muscle transfer with the aim of balancing the mus- result in a deterioration in walking ability. If the spasticity is strongest in the tibialis anteri- pinated during the swing phase and strikes the ground in or, the best option is to transfer the whole muscle distally this position, resulting in instability in the stance phase. Since, in addition to the clubfoot position, a bone tunnel and then sutured back on itself. However, an equinus foot is also usually present at the same time, the tibialis posterior should not be transferred completely, both deformities can be corrected with the one orthosis. The increased supination of the foot is generally based A more suitable procedure is the split transfer: The on tibialis posterior muscle hyperfunction. Provided no tendon is exposed at its distal end and divided, and the bone deformities have developed, the injection of botu- lateral half is pulled laterally behind the tibia and sutured linum toxin is an elegant method of inactivating this to the peroneus brevis tendon. Since this muscle is located deep in if the muscle has already become contracted by this stage: the tissues and is relatively thin, we prefer to perform this In this case, one half of the tendon would need to be injection under ultrasound control. But since the is also producing a deforming effect then this muscle can tendon of the tibialis posterior muscle is usually too thin be included in the injection treatment. While good results are re- and may also be indicated in those who cannot walk in ported in the literature for both muscle transfers, our own order to alleviate pain, resolve major problems or possibly experience has dampened our expectations of this opera- to simplify the provision of footwear. Nevertheless we have also used the tendon transfers all contracted muscles is a simple surgical option. If bone deformities already exist, an improvement, but not a full correction, can be achieved with purely soft tissue procedures. The arches are flattened out, the heel is in a valgus position and the forefoot is abducted. This foot position progressively leads to subluxation and a b eventually to dislocation between the talus and navicu- lar or between the navicular and the distal tarsal bones, ⊡ Fig. Schematic view of the direction of traction exerted by the Achilles tendon in the anatomical position (a) and with subluxation as well as subluxation in the lower ankle. F Direction of the Achilles tendon which, in the position of the calcaneus progresses, the 5th ray is pulled case of subluxation in the lower ankle, exerts a force in line with the laterally, in turn pulling the 1st ray as well. The triceps su- lower leg Fk and a dislocated force component Fi rae muscle becomes contracted since the deviation of the calcaneus into the valgus position brings the origin and insertion of the triceps surae muscle closer together. The contracture of the triceps surae muscle leads, in turn, to a direction, resulting in an internal rotation of the leg. This progressive valgus position, since the muscle is evidently internal rotation combined with a flexed knee simulates a not as extensible as the joint capsules in the tarsal bones pronounced valgus position. As a result, although the whole foot (including the control is good enough to benefit from mobility, a spring heel) may strike the ground, the triceps surae muscle orthosis may be used as this is less irksome.

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Torticollis is quite common and Sprengel’s deformity is seen on occasion purchase levitra soft 20 mg amex. Much like Sprengel’s deformity buy 20mg levitra soft free shipping, it is often associated with cervical ribs buy generic levitra soft 20mg, scoliosis (roughly 60 percent) discount levitra soft 20 mg with amex, congenital rib fusion order levitra soft 20 mg with amex, syndactyly, hypoplastic thumbs, and hypoplasia of the pectoralis major (Poland’s syndrome) (Pearl 6. Abnormalities of the cardiovascular system, particularly septal defects, can occur and there is a very high incidence of urinary tract abnormalities. The diagnosis is readily established by compiling the clinical manifestations and coupling them with the radiographic appearance. The role of the primary care physician is to establish the diagnosis and define the extent of multisystem involvement. Early referral is recommended to facilitate evaluation of the spinal deformity. Lateral radiograph of Klippel–Feil syndrome showing multiple Congenital dislocation of the radial head congenital cervical fusions. Associated conditions with Sprengel’s deformity very uncommon condition in which the radial and Klippel–Feil syndrome head is dislocated, usually posteriorly or laterally, and only occasionally anteriorly. It is Rib and vertebral anomalies usually unilateral but bilateral cases have been Hand anomalies reported. It is rarely detected in early life, being Cardiac abnormalities recognized much later in childhood, probably Renal abnormalities as a result of the exceptionally good function Scoliosis usually accompanying the condition. It is often detected innocuously, either by the patient who feels a bony prominence, or by the doctor during a routine examination for other problems. The ulna is usually bowed in a direction commensurate with the direction of dislocation. Although some degree of 129 Congenital radio-ulnar synostosis restriction of pronation or supination is detected on examination, it is rarely of clinical importance. A bony prominence is nearly always palpated at the location of dislocation. Acquired traumatic dislocation of the radial head is the most common condition to be differentiated. The history, the shape of the dislocated radial head, and the shape of the capitellum, are helpful in establishing the type. In a congenital dislocation, the capitellum of the humerus is grossly underdeveloped and the radial head has a rounded or ovoid shape (Figure 6. In general, treatment consists of mere observation, unless there is evidence of chronic pain with rotary movements of the elbow in adolescence and puberty. Once skeletal maturation has been achieved, painful dislocations may be dealt with surgically, but only after a conservative program of nonsteroidal anti-inflammatory medications Figure 6. Lateral radiograph of the elbow demonstrating congenital radial and corticosteroid injections. Attempts to resect the radial head prior to skeletal maturation have resulted in irreparable damage to wrist function. The vast majority of children will evolve into asymptomatic adults with excellent Figure 6. Lateral radiograph of the elbow illustrating proximal congenital function. Congenital radio-ulnar synostosis Congenital radio-ulnar synostosis, or fusion of the proximal ends of the radius and ulna, is an uncommon condition with a hereditary predisposition. Males and females are affected equally, and it occurs bilaterally in well over half of the cases. The fusion of the proximal end of the radius and ulna results in varying degrees of restriction of forearm pronation and supination (Figure 6. The diagnosis can be readily Miscellaneous disorders 130 established both clinically and radiographically. The functional impairment results from the degree of restricted supination and fixed pronation. Because of the large range of compensatory motion available through the shoulder and the elbow and wrist, unilateral cases usually present with minimal functional disability.

Exerc system study in 1975 concluded that “artificial turf Sports Sci Rev 20:339–368 best 20mg levitra soft, 1992 buy levitra soft 20 mg line. These include turf burns discount levitra soft 20 mg with amex, the common abra- lar disease: How to use C-reactive protein in clinical practice purchase levitra soft 20 mg without prescription. A study by Cantu et al attributed in large Increased incidence of turf toe levitra soft 20 mg with amex, a sprain of the plantar part a dramatic reduction in brain injury-related fatal- capsule ligament complex of the metatarsophalangeal ities from football to the adoption of NOCSAE helmet (MTP) joint of the great toe, is also associated with standards (Cantu and Mueller, 2003). Hyperextension of the MTP is went into effect in 1978 for colleges and in 1980 for the most common mechanism. Blisters are more common owing to increased criteria: the frontal crown of the helmet should sit traction. Ready-made guards are the Hard courts are associated with greater stress on the least comfortable and least protective type. Mouth lower extremities as a result of the reduced shock guards have been required equipment for high school absorbing ability and increased traction between shoe football players since 1962 and for their collegiate and court. Mouth injuries, which at one W ith its energy absorbing properties, clay is more for- time comprised 50% of all football injuries, have been giving to the upper extremities owing to reduced ball reduced by more than half since the adoption of face speed (Nicola, 1997). Cantilevered pads are named for the cantilever bridge that extends PROTECTIVE EQUIPMENT over the shoulder, dispersing impact force over a wider area. These pads offer greater protection to the The purpose of protective equipment is to prevent shoulder area and are appropriate for the majority of injury and to protect injured areas from further injury. The sternum and clavicles should be cov- ered, and the flaps or epaulets should cover the deltoid area. FOOTBALL Hip and coccyx pads are mandatory equipment and should cover the greater trochanters, the iliac crests, The NCAA mandates the use of a helmet; face mask; and the coccyx. Snap-in, girdle, and wrap-around four-point chin strap; mouth guard; shoulder pads; pads are available. Girdle pads are the most and hip, coccyx, thigh, and knee pads during football common type but also the most difficult to keep in competition. Care should be taken to ensure coverage of There are two types of helmets currently in use: (1) the iliac crest. A study by Rovere in 1987 All football helmets in use at the high school or col- actually showed an increased rate of anterior cruciate lege level must be certified by the National Operating ligament (ACL) injuries with brace use (Rovere, Committee on Standards for Athletic Equipment Haupt, and Yates, 1987). This ensures that each helmet has been carried out at West Point (Sitler et al, 1990) and 104 SECTION 1 GENERAL CONSIDERATIONS IN SPORTS MEDICINE another from the Big Ten Conference(Albright et al, LACROSSE 1994) showed a consistent trend toward a reduction of medial collateral ligament MCL injuries with use of The NCAA requires the use of a NOCSAE certified prophylactic braces. Owing to these inconsistent find- helmet with face mask, chin strap, and chin pad, as ings and the lack of demonstrated proof of efficacy, well as protective gloves and a mouthguard for all both the American Academy of Pediatrics and the male lacrosse players. Goalies are additionally American Academy of Orthopedic Surgeons have rec- required to wear chest and throat protectors. Many players also wear rib ACL functional braces are available for players with protector vests. Custom-fit braces have not been shown to perform better or offer more protection than off-the-shelf braces (Wojtys and Huston, 2001). RACQUET SPORTS Some clubs require eye protection for badminton, BASEBALL/SOFTBALL squash, and racquetball players. When a lens in a sports frame is struck, it proj- coaches, and on-deck hitters. This recommendation was Mouth guards are recommended, but not mandatory, originally made in 1984 by the Sports Eye Safety Com- to reduce risk of dental trauma. ICE HOCKEY The NCAA mandates the use of helmets with fastened WRESTLING chin straps, face masks, and an internal mouthpiece. Shin guards should pro- vical spine injuries (Reynen and Clancy, Jr, 1994). CHAPTER 17 PLAYING SURFACE AND PROTECTIVE EQUIPMENT 105 Mouth guards are recommended, especially for goal- natural grass and tartan turf. Am J Sports Med 8(1):43–47, keepers, to protect against not only dental injury but 1980. Kulund DN, Athletic injuries to the head, face, and neck, in Kulund DN (ed. Naftulin S, McKeag DB: Protective equipment: Baseball, soft- ball, hockey, wrestling, and lacrosse, in Morris MB (ed. Nicola TL: Tennis, in Mellion MB, Walsh WM, Shelton GL Albright JP, Powell JW, Smith W, et al: Medial collateral liga- (eds. Philadelphia, ment knee sprains in college football: Effectiveness of preven- PA, Hanley & Belfus, 1997, pp 816–827.

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