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Behavioral treatment for chronic low back pain: A systematic review within the framework of the Cochrane Back Review Group discount duetact 16mg free shipping. Fear-avoidance and its consequences in chronic musculo- skeletal pain: A state of the art order duetact 16 mg with visa. Surface electromyography in the identification of chronic low back pain patients: The development of the flexion relaxation ratio order duetact 16mg with amex. Craig Department of Psychology duetact 17mg online, University of British Columbia Thomas Hadjistavropoulos Department of Psychology buy generic duetact 16mg online, University of Regina Controversies abound concerning the role of psychological features of pain and their use in pain management. Although pain has been clearly identi- fied as a psychological experience, one does not have to spend much time talking to people or reading the literature to discover disagreements about the nature of this experience. Contested issues include a willingness to dis- miss the importance of patient thoughts and feelings, questions about the meaning of behavioral displays of pain, debates about the role of social contexts, disagreements about how one should assess pain, and whether and how one should attempt to control painful distress. Similar disagree- ments concerning pain mechanisms and intervention approaches are found when considering anthropological, nursing, pharmacological, surgical, neurophysiological, 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.

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This often to leave the medical area cheap duetact 16mg fast delivery, but do not require further identifies areas that had not been considered in the ini- care generic duetact 16mg otc. This group is continuously observed and encour- tial planning and execution phases of the event cheap 16 mg duetact otc. 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 generic 17 mg duetact with amex. These athletes Preparing order duetact 16 mg otc, 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. Persistent altered mental status An additional responsibility of the medical director is with relatively normal rectal temperatures should be the assurance of medical staff liability coverage. FINANCE AND LOGISTICS CONCLUDING COMMON FINANCIAL PLANNING SENSE PRINCIPLES The conduct of mass participation events both Medical planning and preparation are absolute requires and has the potential to generate money. The lines, and remembering limitations with a focus on medical director must be involved in any plans affect- competitor and staff safety invariably results in a ful- ing the event that may have medical implications. MEDICAL AID STATION LOCATION REFERENCES The spacing of medical aid stations throughout the Armstrong LE, Epstein Y, Greenleaf JE, et al: America College course is determined by many variables. The course of Sports Medicine: Position statement on heat and cold ill- must be previewed and the location of medical aid sta- nesses during distance running. Med Sci Sports Exerc tions established based on anticipated need, appropri- 28:i–vii, 1996. Hiller WD, O’Toole ML, Fortess EE, et al: Medical and physio- TRANSPORTATION PLAN logic considerations in triathlons. If this decision is realized in the Laird RH: Medical care at ultraendurance triathlons. Med Sci middle of the course, a plan for the removal of these Sports Exerc 21(5):S222–S225, 1989. Maron BJ, Poliac LC, Roberts WO: Risk for sudden cardiac Many races have a “sweep” vehicle that follows the death associated with marathon running. J Am Coll Cardiol last competitor and can transport these participants to 28:428–431, 1996. Other transport arrangements may be Mayers LB, Noakes TD: A guideline to treating ironman triath- available depending on the nature of the event, but letes at the finish line. Physician Sports Med 28(8):33–50, must be anticipated prior to the event. The CPSC does not lapse: An algorithmic approach to race day management part I provide data on injury specifics nor does it include of II. Physician Sports Med 28(9):71–76, The National Collegiate Athletic Association (NCAA) 2000. Associations (NFSH) review injury epidemiology Speedy DB, Noakes TD, Holtzhausen LM: Exercise-associated annually and publish a rules book for each sport with collapse. EPIDEMIOLOGY 6 CATASTROPHIC SPORTS For all sports followed by the NCCSIR, the total INJURIES direct and indirect incidence of catastrophic injuries is Barry P Boden, MD 1 per 100,000 high school athletes and 4 per 100,000 college athletes (Mueller and Cantu, 2000). The most common etiol- failure owing to exertion while participating in a ogy of sudden cardiac death is HCM for those under sport. Noncardiac conditions that cause fatalities are three categories: fatal, nonfatal, and serious. A nonfa- heat illness and miscellaneous diagnoses such as tal injury is any injury where the athlete suffered a rhabdomyolysis, status asthmaticus, and electrocution permanent, severe, functional disability. CARDIAC CONDITIONS The CPSC operates a statistically valid injury and review system known as the national electronic injury Most young athletes who die suddenly have HCM. The These athletes typically have prodromal symptoms NEISS estimates are calculated using data from a such as presyncope or syncope with or without exer- sample of hospitals that are representative of emergency cise prior to the fatal event. A systolic murmur is often CHAPTER 6 CATASTROPHIC SPORTS INJURIES 25 appreciated only in the standing position or with a may result in a variety of life-threatening problems, Valsalva maneuver. Hydration should include both oral intake and intravenous (IV) EPIDEMIOLOGY fluids. Rehydration with sports drinks containing Heat illness is the third most common cause of death electrolyes is preferred over water. Emergency medical serv- respiratory or gastrointestinal (GI) viral illness, sickle ices (EMS) should be contacted for athletes with heat cell trait, stimulants, supplements such as ephedrine, exhaustion and heat stroke. PREVENTION Heat illness usually occurs during unseasonable hot The incidence of heat illness can be significantly conditions at times of extreme exertion.

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Despite repeated Symbrachydactyly Finger stabilization 1–2 years attempts with bilateral prostheses generic 16mg duetact fast delivery, the patient no longer uses them but performs all tasks using his feet and legs buy 16mg duetact free shipping, which he has learned Delta phalanx Osteotomy 3–4 years to manipulate with an extremely high degree of dexterity safe duetact 16 mg. The lack of any sensation in the prosthetic hands means that they are not suitable Radioulnar synostosis Osteotomy 7–8 years for everyday tasks counseling may be required purchase 17 mg duetact with visa, in which case the correspond- is that the child has to lean forward more and thus hold ing specialists should be on hand order 17mg duetact with visa. However, the risk of Surgical measures are required for various defor- the development of scoliosis as a result of this posture is mities, and choosing the right time for the operation low. With a rudimentary forearm stump the child can also requires considerable experience. The earlier the op- hold objects in the crux of the elbow, making a prosthesis eration, the greater the potential for adaptation. Nevertheless, children should at least other hand, the surgical procedure is technically more be offered the option of an artificial prosthesis so that difficult, the smaller the extremity. For certain proce- they themselves can decide whether to wear one or not. Moreover, it If the amputation is located at upper arm level, however, is not possible to obtain the cooperation of very small a prosthesis is useful since the reach of such a malformed children in the postoperative phase. Even a lightweight cosmetic pros- gives an indication of the most favorable ages for surgery thesis can be used as a counter support for the other hand, the exact timing must be based on the individual to enable the child to pick up objects or stabilize a piece situation of the patient and family and the surgeon’s own of writing paper. Devices are ic provision must also be considered, and will require close also available for holding a spoon or fork so that the child cooperation with an orthotist. The provision of a myoelectric however, that children with unilateral amputations below prosthesis should be reserved for children with a bilateral the elbow almost never require a prosthesis, or else use an amputation. The artificial replace- ment does not provide any functional benefit for such It should always be borne in mind that even the children. If the affected child has one dexterous hand, he best and most sophisticated arm prosthesis cannot or she can largely compensate for the absence of the other provide the most important element, i. With writing, for example, the primary task of the hand primarily as a tool. Only when a hand is lack- non-writing hand is to hold the paper steady, but this task ing do we realize that the non-dominant hand is can also be achieved with the elbow. The amputation is the latest prostheses can move almost as fast as a normal very often at the level of the proximal third of the forearm, hand and incorporate a tactile grasp function, i. The following basic buds project from the skin at the end of the stump and are movement directions can be incorporated in a prosthesis: highly sensitive. More proximal or distal transverse de- elbow flexion and extension, wrist pronation and supina- formities are less common. A more common finding, of all three functions makes the prosthesis extremely however, is shortening of the finger joints (brachyphalan- complex and thus very difficult for the child to manage. Here too, inter- The child has to learn how to activate a completely differ- calary deficiencies are much more common than terminal ent set of muscles in the upper arm in order to produce a deficiencies. If central fingers are missing com- pletely the condition is known as a split hand. Clinical features, diagnosis If the metacarpals end in rudimentary phalanges Transverse deficiencies can be terminal or intercalary. This intercalary mal- dactyly are described as mono-, bi- and triphalangeal 469 3 3. The teratological series in symbrachydactyly is as Treatment follows (with increasing severity of the damage): short- The following surgical options are available: finger type, monodactylous type, split hand type and stabilization of the finger buds with free bone grafts, peromelia type. A crucially important factor is Lengthening osteotomies are an effective option for whether the thumb is opposable and whether a pinch grip achieving functional improvement and, in some cases, is possible. Knowledge of the age at which the ossification a cosmetic benefit as well. It should always be borne in centers appear is useful for the radiological evaluation mind, however, that muscle function is invariably made (⊡ Table 3. Thus, for example, the lengthening of an extremely short forearm stump will allow objects to be wedged in the elbow or pro- duce a better fit for a forearm prosthesis (⊡ Fig. Age at which the ossification centers appear on the x-ray of the hand Even the surgical lengthening of the phalanges can produce a functional improvement if it facilitates opposi- Ossification center Age tion and thus a pinch grip.

Lang IM generic duetact 16 mg line, Hughes DG buy duetact 16 mg online, Williamson JB order 16mg duetact fast delivery, et al (1997) MRI 53(4):239–246 appearance of popliteal cysts in childhood cheap 17 mg duetact with mastercard. Woertler K cheap duetact 16mg without prescription, Lindner N, Gosheger G, et al (2000) Osteochon- 27(2):130–132 droma: MR imaging of tumor-related complications. Fornage BD, Tassin GB (1991) Sonographic appearances of Radiol 10(5):832–840 superficial soft tissue lipomas. Rubens DJ, Fultz PJ, Gottlieb RH, et al (1997) Effective ultra- 220 sonographically guided intervention for diagnosis of mus- 17. Inampudi P, Jacobson JA, Fessell DP, et al (2004) Soft-tissue culoskeletal lesions. J Ultrasound Med 16(12):831–842 lipomas: accuracy of sonography in diagnosis with patho- 35. Radiology 233(3):763–767 graphically guided core needle biopsy of bone and soft 18. Miller GG, Yanchar NL, Magee JF, et al (1998) Lipoblastoma 16(5–6):458–461 and liposarcoma in children: an analysis of 9 cases and a 19. Giovagnorio F, Valentini C, Paonessa A (2003) High-reso- review of the literature. Can J Surg 41(6):455–458 lution and color doppler sonography in the evaluation of 37. Bramer JA, Gubler FM, Maas M, et al (2004) Colour Doppler 178(3):557–562 ultrasound predicts chemotherapy response, but not sur- 22. Laor T (2004) MR imaging of soft tissue tumors and tumor- vival in paediatric osteosarcoma. Torabi M, Aquino SL, Harisinghani MG (2004) Current Am Acad Dermatol 48(4):477–493; quiz 494–496 concepts in lymph node imaging. Alvarez-Mendoza A, Lourdes TS, Ridaura-Sanz C, et al 1518 Interventional Techniques 85 6 Interventional Techniques David Wilson CONTENTS stances are in suspected tumours of bone or soft tissue and when the nature and type of infection is 6. From the imaging the biopsy may be great advantages of limiting the extent of tissue planned. There should be form al consultation damage, reducing the need for anaesthesia and with the surgeon who would remove the lesion if shortening the stay in hospital. Whilst most of the it proves to be malignant and the pathologist who procedures listed are performed in adults using seda- will interpret the biopsy. Open biopsy will be pre- tion, it is common practice in children to perform a ferred when there is risk of sampling errors and light general anaesthetic or at least to administer a where the lesion is small and an excision for symp- heavy sedative. CT or US may be used to place needles next to a mass that is to be removed surgically. It is inevitable that soft tissue and bone biopsies will be required in children. Wilson, FRCP, FRCR Parental consent is mandatory, but it is wise to include Department of Radiology, Nuffield Orthopaedic Centre, NHS the child in the process asking for example “is it alright Trust, Windmill Road, Headington, Oxford OX3 7LD, UK if I ask your parents permission to do this? Has the advantage that the needle is clearly seen and structures to be avoided are apparent [2, 3]. Also there is a lag between Although most children will not be at risk from moving the needle and obtaining the image which coagulation defects, if there is doubt then coagula- may be a risk and will prolong the procedure. The room should radiation dose will mount which may be a particular be quiet and the minimum of staff present. It is wise to ask one member of the medical team to be aware that the parent may US allows the direct visualization of the needle as it need support and care. If the needle is at 90° to the US beam it If general anaesthesia is used then it is still wise is especially clear. Lesions in limbs are especially easy to use local anaesthetic to reduce discomfort after to biopsy with US guidance as the needle may enter the procedure. The Guidance needle tip may be the only part seen as sound reflects off the obliquely placed needle shaft away from the Image guidance will depend on the location of the imaging area. It should permit visualization of the area or the tip of the needle as a bright oscillating object. Care should be take to keep the US plane pointing For example, if there is risk of puncturing bowel, CT is along the needle track or the tip may be lost. Most soft tissue of the needle is lost it is best to ignore the screen for masses will be best biopsied using US guidance. The needle is introduced at close to 90° to the ultrasound beam allowing visualiza- tion of the shaft Interventional Techniques 87 patient and the needle. MR has the potential attractions of being free from radiation and allowing the operator to stand next to the patient although an open system is far preferred 6.

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