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Interneurons that uti- lize GABA are located throughout the spinal cord and along with those that uti- lize glycine modulate low-threshold afferent inputs order micardis 80mg with mastercard. These modifications include wind-up (progressive increases in neuronal activity throughout the stimulus duration) generic micardis 20mg on line, facilitation (magnifica- tion and prolongation of the duration of neuron response) cheap micardis 20 mg otc, action potential threshold reduction purchase micardis 40 mg mastercard, receptive field expansion discount micardis 80 mg line, oncogene induction, and long- term potentiation (strengthening of synaptic transmission efficacy after activity across the synapse). For example, action potential wind-up is dependent on the rate of membrane potential depolarization during repetitive stimulation and may be due to a number of cell-specific mechanisms including summation of slow excitatory potentials, facilitation of slow calcium channels, and recruitment of NMDA receptor activity [Baranauskas and Nistri, 1998]. Clark/Treisman 82 Excitatory amino acids such as glutamate are critical for nociceptive pro- cessing. A central glutamate transporter system regulates the uptake of endoge- nous glutamate [Sung et al. Chronic constriction nerve injury induces an initial glutamate transporter upregulation that inhibits the development of neuro- pathic pain behaviors. Subsequent glutamate transporter downregulation was associated with the emergence of thermal hyperalgesia and mechanical allodynia. Glutamate alone acts at both ionotropic and metabotropic types of receptors [Fundytus, 2001; Haberny et al. Receptors coupled directly to ion channels are activated by NMDA, -amino-3-hydroxy-5-methylisoxazole-4- proprionic acid (AMPA), and kainate but metabotropic receptors are G-protein- coupled, interact with intracellular second messengers, and are classified according to structure, signal transduction properties, and receptor pharmacology [Pin and Acher, 2002; Trist, 2000]. In addition, glutamate receptors inhibit or facilitate nociception depending upon their location throughout the CNS. Glutamate also affects aspects of opioid function as well as the broader experi- ence of pain such as depression and anxiety. When calcium enters the cell with the activation of the NMDA receptor, second messengers such as protein kinase C, cGMP, and polyphosphoinosites are generated [Riedel and Neeck, 2001]. Nitric oxide synthase is stimulated and nitric oxide diffuses into neighboring neu- rons to activate guanylyl cyclase. Adenosine may be a more subtle homeostatic modulator acting through G-protein-coupled receptors that can inhibit or enhance neuronal activity [Ribeiro et al. Adenosine receptors inhibit the develop- ment and maintenance of central sensitization of spinal dorsal horn neurons. Approximately 75% of the opioid receptors in the dorsal horn are presy- naptic and when stimulated reduce the release of neurotransmitters from pri- mary nociceptive afferents. During inflammation and nerve injury, increased NMDA activity promotes central sensitization and tolerance to opioids, chole- cystokinin interferes with opioid analgesia, morphine-3-glucuronide antago- nizes opioid analgesia, and presynaptic opioids are lost [Basbaum, 1994; Bennett, 2000]. Functional inhibition of NMDA receptors may occur as a result of activation at any of the following recognition sites: competitive primary trans- mitter, strychnine-insensitive glycine (B), polyamine NR2B selective, and phencyclidine [Parsons, 2001]. When activated, GABAB receptors suppress the presynaptic release of excitatory amino acids from primary affer- ent terminals whereas GABAA receptors have postsynaptic actions [Sivilotti and Woolf, 1994]. Neurobiology of Pain 83 Ascending Tract and Descending Inhibition Mechanisms Second order neurons project to supraspinal structures in the ascending tracts of the contralateral anterolateral spinal cord (spinothalamic, spinoreticu- lar, spinomesencephalic) although not all fibers decussate and a latent ipsilat- eral pathway is present. The ventroposterior nuclei of the thalamus represent the sensory-discriminative (temporal and spatial) aspects of pain and the medial nuclei are involved with the affective-motivational features of pain. Increased thalamic activity has been associated with acute experimental pain in contrast to chronic pain states, which are associated with decreased thalamic activity on positron emission tomography [Iadarola et al. The basal ganglia receive nociceptive information from multiple afferent sources [Chudler and Dong, 1995]. Positron emission tomog- raphy has implicated the nigrostriatal dopaminergic system in central pain modulation with increased D2 receptor binding and presumed decline in endogenous dopamine levels in the putamen of patients with burn mouth syn- drome [Hagelberg et al. Opioids produce changes in locomotion that correlate with the nigrostriatal release of dopamine [Di Chiara and Imperato, 1988]. The role of the cortical structures in pain and suffering is less well under- stood. The parietal lobes and somatosensory cortex probably contribute to the sensory-discriminative component and the cingulate cortex with the affective component of pain [Jannetta et al. Using magnetic resonance spectroscopy, reduced levels of N-acetylaspartate associated with neuronal degeneration have been found in the dorsolateral prefrontal cortex of patients with chronic low back pain and complex regional pain syndrome type I [Grachev et al. Pain can be reduced by descending inhibition as first postulated by the gate theory of Melzack and Wall [1965].

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The theory has continued to grow cheap micardis 80mg on line, assimilating new knowledge and inspiring Melzack’s recent neuromatrix model of pain proven micardis 40 mg. The theory and developments had major importance for the psychological and medical management of pain micardis 40mg sale. Also effective micardis 80 mg, it opened the door for the develop- ment and popularity of the biopsychosocial model of pain order micardis 20mg online, which is the fo- cus of chapter 2, this volume, by Asmundson and Wright. This model ac- cepts an original physical basis of pain, even when an anatomical site or pathophysiological basis cannot be established, but also recognizes the im- portance of affective, cognitive, behavioral, and social factors as contribu- tors to chronic illness behavior. An overview of cognitive behavioral and psychodynamic perspectives is also provided in this chapter. The chapter provides a comprehensive overview of the model, its origins, and its empiri- cal and theoretical support. The author recognizes that pain has been defined as a distressing, complex, multidimensional experience. This requires a focus on perceptual mechanisms and the construction of conscious experience, as well as con- sideration of affective and motivational features. The latter are often ne- glected, as importance is attached to sensory mechanisms. Psychophysical and psychophysiological work provide a solid core for these investigations. Chapman’s chapter develops the bridge between physiological mecha- nisms of pain and psychological practice by linking conscious perceptual processes with physiological functions. His concept of pain is broad (and mostly addresses “intrapersonal determinants” of the experience). Chap- man’s basic point is that if we want to provide good care, a more inclusive model of pain experience and its determinants needs to be employed. Recognizing that interpersonal phenomena are often more important than intrapersonal events when pain control is the issue, we discuss in chapter 4 the communication of pain by examining both a theoretical model of pain communication (Craig, Lilley, & Gilbert, 1996; Hadjistavrop- oulos & Craig, 2002; Prkachin & Craig, 1995) and important findings concern- ing illness behavior. Social influences on the pain experience and its expres- sion are also discussed. Communication of pain serves important adaptive functions for humans from the bioevolutionary standpoint. It can elicit res- cue, protection, treatment, and longer term care to facilitate recovery. Its social purposes warn others of danger and promote delivery of culture spe- cific care. Communication of pain is accomplished via verbal and nonverbal channels (e. This chapter discusses research on the ex- pression of pain, including the importance of the entire communicative rep- ertoire and the potential for deception, the judgmental skills and biases of potential allies and antagonists, and the advantages and disadvantages of current social systems designed to care for people communicating painful distress. Issues related to the communication of pain within families are covered, as are matters pertaining to populations with limited ability to communicate (e. Following the first part of the book that is largely focused on theoretical work, Gibson and Chambers outline important developmental consider- ations in the psychology of pain. Pain expression and experience transform with aging, reflecting ontogenetic maturation, socialization in specific famil- ial and cultural settings, and the impact of experiences with pain. An under- standing of the cognitive, affective, behavioral, and social challenges con- fronted during the various stages of life from birth to terminal illness is required. The earliest and latest stages of life presently carry substantial INTRODUCTION 9 risk of unnecessary or undermanaged pain because of an inadequate knowledge base, underdeveloped assessment procedures, and inadequate pain management. This chapter examines and systematizes developmental processes in pain experience, expression, and communication. A major source of individual differences (other than biological matura- tion) is culture. The chapter by Rollman considers the empirical and theo- retical literature on the impact of culture on the experience and expression of pain, delineating observed differences and ethnocultural variations in the meaning of pain. There is a focus on mechanisms responsible for varia- tions (acculturation and socialization), linking them to the biopsychosocial model.

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CHAPTER 17 PLAYING SURFACE AND PROTECTIVE EQUIPMENT 105 Mouth guards are recommended proven micardis 40 mg, especially for goal- natural grass and tartan turf purchase 80 mg micardis free shipping. Am J Sports Med 8(1):43–47 buy 80mg micardis otc, keepers purchase micardis 20 mg free shipping, to protect against not only dental injury but 1980 order micardis 40 mg online. 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. Powell JW, Schootman M: A multivariate risk analysis of American Academy of Pediatrics Committee on Sports selected playing surfaces in the National Football League: Medicine: Knee brace use by athletes. Am J Barret JR, Tanji JL, Drake C, et al: High- versus low-top shoes for Sports Med 20(6):686–694, 1992. A prospec- Reynen PD, Clancy WG, Jr: Cervical spine injury, hockey hel- tive randomized study. Benson BW, Mohtadi NG, Rose MS, et al: Head and neck Rovere GD, Haupt HA, Yates CS: Prophylactic knee bracing in injuries among ice hockey players wearing full face shields vs college football. Sitler M, Ryan J, Hopkinson W, et al: The efficacy of a prophy- Cantu RC, Mueller FO: Brain injury related fatalities in American lactic knee brace to reduce knee injuries in football. Am J Sports Med Gaulrapp H, Siebert C, Rosemeyer B: Injury and exertion pat- 18(3):310–315, 1990. Sportverletz Sportschaden Sitler M, Ryan J, Wheeler B, et al: The efficacy of a semirigid 13(4):102–106, 1999. A Gieck JH, Saliba EN: The Athletic Trainer and Rehabilitation, in randomized clinical study at West Point. Surve I, Schwellnus MP, Noakes T, et al: A fivefold reduction in Grippo A: NFL Injury study 1969–1972. Final Project Report the incidence of recurrent ankle sprains in soccer players using (SRI-MSD 1961). Keene JS, Narechania RG, Sachtjen KM: Tartan turf on trial: A Wojtys EM, Huston LJ: Custom fit versus off the shelf ACL func- comparison of intercollegiate football injuries occurring on tional braces. Section 2 EVALUATION OF THE INJURED ATHLETE radiography (at the cost of loosing some of fine bone 18 DIAGNOSTIC IMAGING details), the ability of radiography to depict soft tissue Leanne L Seeger, MD, FACR pathology remains inferior to cross sectional imaging Kambiz Motamedi, MD (MRI, CT, and ultrasound). Disadvantages include availability of INTRODUCTION the physician, radiation exposure, and subjectivity of the amount of stress needed. In some cases, it may There are several modalities available for the imaging exacerbate underlying pathology. The strengths and weak- Conventional arthrography delineates the synovial nesses of each modality, along with their specific indi- space and intra-articular structures by joint disten- cations are discussed in this chapter. MRI or CT, coordination is needed for scheduling scanner time to immediately follow the procedure. Arthrography may be contraindicated in patients with IMAGING MODALITIES coagulopathy. With acute or subacute injuries, soft tissue or radiography (with or without applied stress), conven- marrow edema is seen. With chronic injuries, struc- tional arthrography, magnetic resonance imaging tural abnormalities may be seen. It is of limited value (MRI), which may be combined with arthrography for evaluating bone cortex and soft tissue calcifica- (referred to as MRA), computed tomography (CT), tion. There are several relative and absolute con- which may be combined with arthrography, ultra- traindications to MRI, including claustrophobia, sonography, and radionuclide bone scans. Because of the popularity of MRI, there may be a prolonged MODALITY STRENGTHS AND wait time for obtaining an examination. WEAKNESSES CT is superior to other modalities for fine bone detail, and is an important tool for depicting the anatomy of Plain radiography is widely available, relatively inex- complex fractures.

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They also pointed out the confusion developing in the cognitive arena due to multiple overlapping instruments measuring overlapping con- structs that are studied using correlation and thus cast little light on causal processes quality micardis 20 mg. A contemporaneous review buy micardis 40 mg visa, Turk and Rudy (1992) cheap micardis 80 mg with mastercard, used an in- formation-processing model to describe patients with low expectations of control over pain or their situations purchase 20mg micardis free shipping, and as thereby inactive and demoral- ized cheap micardis 80mg with mastercard. Since these reviews in 1992, there have been exciting developments in cognitive therapy, with some concepts, predominantly catastrophizing, emerging as key variables from diverse studies in several countries (e. There has also been a recent reformulation of fear and avoidance (Lethem, Slade, Troup, & Bentley, 1983) by Vlaeyen and colleagues (Vlaeyen & Linton 2000) that is securely grounded in psychological theory of fear and phobia, and accompanied by careful modeling of change. This takes over from broader (and unsatisfactory) concepts of control and coping. The in- terest is now in specific fear rather than general neuroticism/anxiety, and avoidance as a purposeful strategy rather than an incidental event for man- aging fears of pain and injury. There is also a more confident approach to emotion and to intervention in emotion using Beckian and other tech- niques, and revised models are under development (e. CBT programs today are diverse and (unsurprisingly) none of the de- scriptions of “ingredients” coincides exactly with practice. In the absence of demonstration that each is essential to outcome (this question and at- tempts to answer it are addressed later with efficacy), one might reason- ably expect each ingredient to be based securely either in theory or in mainstream psychology practice, but it is not always so. The following are generally regarded as core components of CBT: · Education on pain, the distinction of chronic from acute pain, the disso- ciation of the pain experience from physical findings accessible to current in- vestigations, the integral place of psychology and behavior in the pain expe- rience, and the rationale for the pain management or rehabilitation model used in treatment may be delivered by medical or psychology personnel, or others. Education aims to combat demoralization and feelings of victimiza- tion and to motivate patients to take an active role in treatment (Turk & Rudy, 1989). Programs differ in the extent to which they attempt corrective hands-on physiotherapy, with some explicitly teaching nothing that the patient cannot do him- or herself at home or in a suitable sports facility. Relaxation, described earlier, is a core component of this and may be integrated to a greater or lesser extent with physical rehabilitation, and/or with management techniques described later, such as activity pacing, at- tention diversion, and stress management; it may also be applied to sleep problems. Many programs describe contingent relationships and encourage patients to self-reinforce “well behaviors” and to involve 10. PSYCHOLOGICAL INTERVENTIONS AND CHRONIC PAIN 281 those close to them in similar selective reinforcement. However, this is far from the carefully observed and formulated consistent contingency manage- ment described by Fordyce. A particular aspect of behavioral change ad- dressed in many programs is the reduction of analgesic drug use, but targets and endpoints vary considerably. Although some programs substitute nonopioid for opioid analgesics, and supply antidepressants, others aim to reduce all drug intake to nil (Keefe et al. Most involve activity scheduling, or pacing, where, starting from a modest baseline of any challenging or demanding physical activity or position, patients build by small increments their blocks of activity, inter- spersed with rest and/or change of position or activity. Blocks of activity may be defined by time or another quantum, and for many patients, taking regular breaks requires that they challenge previously unquestioned rules and standards by which they lived. It can involve any or all of the at- tention diversion methods (see Fernandez & Turk 1989), and often is used with relaxation, problem-solving strategies, and cognitive restructuring fa- miliar to cognitive therapists. Although this is sometimes described in terms of coping skills training (Keefe et al. By contrast, some programs offer such brief intervention, apparently mostly didactic, that although described as cogni- tive therapy, it cannot be deemed to approximate it. Essentially, patients are encouraged to anticipate setbacks and plan for good management. Patients with chronic pain, even if they all differ in site of pain and his- tory of previous treatments, share sufficient problems in managing pain that groups can be mixed or have a single condition. Many programs also provide additional individual sessions for specific psychological problems, for indi- vidual applications (such as work), or for unspecified reasons. Given that the format of the groups involves didactic teaching, sharing of experience, and 282 HADJISTAVROPOULOS AND WILLIAMS experiential learning, it is not clear to what extent the processes of group therapy, and its benefits, apply. Nevertheless, on a practical basis, group sharing serves to normalize the experience of isolated patients; it validates both their difficulties and their efforts to manage them; and it provides vicar- ious learning as other group members start to use pain management meth- ods taught. In CBT groups it may be more difficult to elicit emotional material from members of the group if they are not a cohesive group, but there is still the opportunity for learning from the disclosures of those who are more forthcoming with emotionally charged experiences. Multicomponent programs necessitate a range of professionals with ap- propriate training; key members are physicians, clinical psychologists, and physiotherapists or physical therapists; occupational therapists, and thera- pists with particular focus on vocational concerns may also be involved. A little-addressed aspect of multidisciplinary treatment is the extent to which the team members of different disciplines really work in an integrated way, or alternatively operate independently, and potentially with incompatibili- ties between them. Treatment on an outpatient basis provides the greatest opportunities for the patient to apply and generalize pain management techniques learned on the program to his or her own environments, but in- tensive (usually inpatient) programs may be required to enable change in more severely disabled and distressed patients (Williams et al. Evidence The Division of Clinical Psychology of the American Psychological Associa- tion (APA) published a list of 25 empirically validated psychological treat- ments for various disorders (APA, Division of Clinical Psychology, 1995).

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