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By H. Fraser. Keiser University.

These were originally thought to support the operant for- mulation generic bupron sr 150 mg amex, by demonstrating the association of spouse solicitousness and patient disability cheap 150mg bupron sr free shipping. However buy bupron sr 150 mg mastercard, even these studies and further replications show relationships between patient and spouse behavior to be mediated by gender order bupron sr 150 mg visa, state of the relationship generic bupron sr 150 mg on line, and mood: The picture is substantially more complicated than suggested by the dominant study paradigms and measures of the 1980s and 1990s (Newton-John & Williams, 2000). FAMILY AND MARITAL THERAPY Background and Description Family and or marital therapy is also used as an adjunct to the treatment of chronic pain in adults, and more directly in relation to pain and related be- havior in children and adolescents, but much less is written regarding the topic (Kerns & Payne, 1996). The interest in treating the family of the chronic pain patient comes from recognition that not only the patient but also the spouse and other family members suffer the impact of pain. All family members are likely to experience reductions in leisure activities, changes in responsibilities and roles, and changes in how emotions are ex- pressed (Turk et al. Some therapists take a traditional family systems approach and focus on how the family may or may not be using or developing resources and capacities to meet the de- mands of chronic pain (Patterson & Garwick, 1994). With this approach, the therapist attempts to restore a comfortable balance in the family system in light of the pain (Moore & Chaney, 1985). Alternatively, a family therapist may take an operant approach as described earlier. Fordyce (1976) in his early writings recommended that in some cases patients be refused treat- ment without spouse involvement, although today this would be regarded as ethically unacceptable. In this approach, the focus is on how pain behav- iors are maintained by contingent social reinforcement (Fordyce, 1976) and draws on evidence showing that pain behavior can be influenced by 288 HADJISTAVROPOULOS AND WILLIAMS spousal reactions to pain (e. Family mem- bers are encouraged to withhold pain-contingent attention and instead rein- force well behaviors. Central to this approach is the belief that family members help patients understand the painful condition, and make judgments about the family and patient’s ability to meet the challenge of the condition. The family develops beliefs about pain, disability, and emotional responses, which in turn influence how the patient and family members deal with the challenges of chronic pain (Kerns & Weiss, 1994). With this treatment approach, family members and the patient are encouraged to identify and develop strategies for cop- ing with the effects of pain (Moore & Chaney, 1985), and to express the pa- tient’s needs directly and verbally, rather than indirectly and through pain behaviors—hence, the teaching of assertion skills and the recognition of the need to negotiate for help and exchange of favors, rather than one-way helping, which ultimately benefits neither patient nor family caregivers. Evidence Despite strong clinical assumptions that the family is important in deter- mining response to chronic pain (e. Moore and Chaney (1985) evaluated the efficacy of out- patient group treatment of chronic pain and the effect of the spouse in- volvement in treatment; they randomly assigned patients to couples group treatment, patient-only group treatment, or waiting list control. Both groups showed improvement on several measures, including pain behavior and functioning, marital satisfaction, and health care utilization. Improvements were no greater for those receiving couples group treatment compared to the patient-only group treatment. The study is not without limitations, in- cluding small sample size and the fact that the spousal involvement did not appear to be clearly delineated. They examined a larger sample of rheumatoid arthritis patients and contrasted four groups: (a) behavior therapy with family involvement (e. It should be noted that the behavioral conditions followed more of a CBT approach than a pure behavioral approach, in that treatment in- volved a cognitive component along with instruction in relaxation and oper- 10. At immediate follow-up the behavioral intervention with family involvement was superior to all other conditions on disease activity measures, but did not differ from the behavior therapy group without fam- ily support at 2-month follow-up. In terms of marital therapy, the research in this area is even more scant. Saaraijarvi (1991) provided some support for couples therapy using a sys- tems approach, but not necessarily in terms of impact on pain and disabil- ity. In this study, chronic low back pain patients were randomized to either a control group or a couples therapy treatment group. At follow-up 12 months later, couples in the therapy group reported improved marital com- munication compared to those in the control group; no differences between the groups on health beliefs were observed, however. Commentary More questions than answers exist in this area, and there is a strong need for further research, especially given strong clinical assumptions regarding the importance of family. Would a traditional family systems approach be as effective as an operant or CBT approach involving the spouse? With the described CBT approaches, would more attention to family issues that do not revolve around pain assist with outcomes? Would clinical work with in- dividual families be of greater benefit than family group treatment? Should issues or family interactions that are independent of illness-specific family issues also be addressed in therapy?

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Immunol Allergy Clin enough to prevent the athletes from bunching up and North Am 15(3):447–475 buy bupron sr 150 mg online, 1995 buy generic bupron sr 150mg on-line. It should also have necessary facilities and resources to allow the athletes to properly cool down and recover after the event and easy access to medical treatment areas best 150 mg bupron sr. Water temperature quality bupron sr 150mg, sea conditions order bupron sr 150 mg on line, road condi- tions, transition, acceleration and deceleration areas, and protective equipment must be carefully scrutinized. GOALS EPIDEMIOLOGY Mass participation events are those sporting events in which many people participate and are generally INJURY RATE spread out over several miles and variable terrain. This also stresses the impor- of participants, course peculiarities, and environmen- tance of a reliable injury data tracking system. Often this is furthest from the minds of race organizers especially with competing priorities of The level of medical care that will be available on the sponsor, financial and community concerns. CHAPTER 5 MASS PARTICIPATION EVENTS 21 This may differ among the aid stations throughout the and hand-held radios. These systems should be tested course with the most robust resources usually being well before the event and a backup plan should be provided at the finish area. His or her responsibilities include advanced planning, event day medical decision making, and med- MEDICATION PLAN ical troubleshooting. The medical support staff, event director, and media—all benefit from having one iden- Adecision must be made as to the provision of med- tified contact, rather than a committee, to answer all ication on the race course and in the medical aid sta- medical issues. It is recommended that these medications be It is also recommended that each aid station have an tightly controlled and kept to a minimum if dispensed assigned medical leader well versed in the event med- at all. This medical leader can organize the In longer events it is not uncommon for athletes to support staff and coordinate medical care provided carry and take their own medication during the event. This must be anticipated to best treat the competitor and prevent overprescribing. Most are better versed in med- ical care within a clinical or hospital facility than in Medical aid stations may or may not have basic labo- the field environment. The ability to assess an athletes’ The medical plan, chain of command and level of care blood glucose and sodium levels will assist with their provided must be reviewed with the medical staff. It is rapid evaluation and allow for the appropriate treat- helpful although not always practical to provide an ment of a collapsed athlete (Davis, et al, 2001). COMMUNICATION PLAN COMPETITORS It is vital that medical support assets have the ability to communicate with each other, EMS assets, local Participants should also be given medical informa- hospitals, and the event director before, during, and tion prior to the event. Additions to event web- include cellular phones, computer networks, ham radio, sites, handouts to accompany the race packet pick-up 22 SECTION 1 GENERAL CONSIDERATIONS IN SPORTS MEDICINE and information posters displayed in common areas are important in the evaluation, treatment, and disposi- are several examples. Fortunately most and health warnings has been used with success at complaints are nonsevere in nature and can be quickly numerous events (Cianca et al, 2001). These can be quickly differentiated from nonsevere conditions by MEDICAL AND NONMEDICAL SUPPORT the evaluation of mental status, rectal temperature (Roberts, 2000), blood pressure, and pulse. Serum glu- The appropriate staffing of medical treatment areas cose and sodium levels may also aid in the diagnosis. The some of these severe conditions may be treated at the composition and number of this staff will vary medical aid station or transported via EMS to the most depending on the location and nature of the event. MUSCULOSKELETAL College of Sports Medicine (Armstrong et al, 1996) is to provide the following medical personnel per 1000 run- Medical conditions, such as exercise associated col- ners: 1 or 2 physicians, 4–6 podiatrists, 1–4 emergency lapse, heat stroke, chest pain and hyponatremia can be medical technicians, 2–4 nurses, 3–6 physical thera- triaged from muscle cramps, blisters, and extremity pists, 3–6 athletic trainers, and 1–3 assistants. Approximately 75% of these personnel should be sta- This separation of care allows the assignment and tioned at the finish area. This also allows injured athletes, documentation, medical tracking, those with more severe conditions to be treated in the and provide information within the medical aid station same area where they can be more closely moni- and to event staff. This area is reserved for athletes who are waiting for transporta- After the event it is most important to elicit feedback tion for nonsevere conditions or who are not prepared from both medical and nonmedical staff. This often to leave the medical area, but do not require further identifies areas that had not been considered in the ini- care. This group is continuously observed and encour- tial planning and execution phases of the event. COLLAPSE The majority of cases of exercise associated collapse TRIAGE AND TREATMENT GUIDELINES are the result of predictable physiologic events associ- ated with exertion and respond rapidly to positioning The majority of the medical conditions presenting at a with the head down and legs and pelvis elevated posi- given event can be predicted well in advance. These athletes Preparing, training, and practicing for these conditions generally have normal mental status. CHAPTER 5 MASS PARTICIPATION EVENTS 23 Individuals with altered mental status should be rap- MEDICAL-LEGAL idly evaluated with a rectal temperature for hyperther- mia or hypothermia.

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In this way the child problems cheap 150 mg bupron sr, and you will often see children over a period comes to learn to trust you and feel as if it is being taken of years order bupron sr 150 mg otc, if not decades discount 150mg bupron sr fast delivery. I always check the pelvic tilt and ex- always insist that the child should reply by rephrasing amine the back in the forward-bending test (I note the the question differently and asking the child again bupron sr 150mg overnight delivery. You fingertip-floor distance and the presence of rib or lum- can draw certain conclusions about the psychological bar prominences) order 150 mg bupron sr free shipping. The child might examine the hip, knee and ankle mobility, the arch of the say: »It doesn’t hurt anywhere! In such cases, also, the child should be given a chance There are two reasons for this thorough examination: to make further clarifying remarks. If the child says that Firstly, it would be inexcusable for an orthopaedist to nothing hurts, then the level of suffering is obviously not overlook a scoliosis in an adolescent girl presenting with so serious. Secondly, the examination Frequently the parents will dramatize the pain, while has an important psychological effect. Having talked to the doctor you already realize, having taken the history, that a child you will naturally want to obtain specific details peripatellar pain syndrome is involved. The parents should be allowed girl to pull up her pant leg, briefly palpate the patella and to present their version of the problem, but always in the then declare that nothing’s wrong and it doesn’t need to presence of the child. I refuse, as a matter of principle, any be treated, the patient will feel as if she is not being taken request of the parents to send the child out of the room, as seriously and will not accept this non-treatment. The child would feel doctors are aware of this scenario many will prescribe as if it were being deceived and not taken seriously, and treatment in order to fob the patient off as quickly as pos- would sense that people were talking about it behind its sible. While it is not important for the child to understand treatment, so it must be a serious problem, and the doctor everything that is said, if the child asks for an explanation has taken her seriously even though he spent very little this must be provided. If the problem persists despite the treatment, the same already ticked or highlighted in red. Unfortunately, doctor will prescribe a different treatment at the next this strategy now often proves cheaper than perform- consultation, and so it continues until the patient perhaps ing targeted individual investigations. The next doctor, who like- This approach is also possible in orthopaedics. The wise appears to be in a mad rush, learns from the patient patient presents with knee pain and the doctor pre- that three different conservative treatments have failed scribes a bone scan, a CT scan and an MRI. The to banish the pain, and therefore proposes surgical treat- radiologist will then report on the site of the problem. The patient gives her consent because, after all, the In my view this is the most undiscriminating way of conservative treatment proved ineffective. It is also hugely expensive and unnecessary operation is performed that likewise proves therefore unacceptable in the face of increasing cost ineffective, since it is unable to resolve the underlying pressures on the healthcare system. Only rarely will problem, namely the muscle imbalance resulting from the you establish the correct diagnosis by this method. This is followed by more operations, until clinical examination findings. Only for a limited num- the circulation to the patella is so bad that lifelong pain is ber of conditions is the radiologist, who is unaware the result. Unfortunately, such cases are not particularly of the patient‘s clinical situation, able to correctly rare, and all this simply because the first doctor failed to evaluate and rate the changes on the images. Since take the situation seriously and spend sufficient time on he is, moreover, under pressure to provide a diagno- the patient’s problem. The above) are perfectly prepared to accept that the peri- discrepancy between radiological findings and clini- patellar pain syndrome is a temporary problem during cal relevance is at its most extreme for degenerative growth that does not require treatment. In this situation the x-ray on its they still want to be taken seriously, for it does hurt after own is almost meaningless. If you are going to tell the patient of your intention so extreme in pediatric orthopaedics, most findings not to provide any treatment you, as the doctor, will can still only be assessed in connection with the clini- need to much more time to explain this than if you were cal examination. The complete physical examination has an important psychological effect and helps you avoid unnecessary costs and the possible consequences of surgery. Diagnostic procedure In establishing the diagnosis, most doctors proceed ac- cording to one of the following approaches: 1. Systematically according to an algorithm: Algorithms are decision trees, in some cases with complex branch- ings, which plot the stepwise procedure to be followed in each case according to the outcome of certain inves- tigations. While this is certainly an efficient approach, almost no-one is able to remember such algorithms. It is fairly laborious, and there are always those patients who do not follow the specified paths of the algorithm and show findings that do not fit anywhere, obliging the doctor to pursue other avenues. Investigate everything: At the onset of a symptom, the complete battery of tests is performed on the assump- tion that a pathological result will emerge from some- where and thus reveal the diagnosis.

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