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Philosophical Transactions of the Royal Society of London buy 50mg avanafil overnight delivery erectile dysfunction doctor miami, 308 buy 100mg avanafil with visa impotent rage man, 219–226. A map of serotonergic structures involved in stimulation produced analgesia in unrestrained freely moving cats. Surgery in the rat during electrical analgesia induced by focal brain stim- ulation. Analgesia produced by electrical stimulation of catecholamine nuclei in the rat brain. Postoperative pain after inguinal hemiorraphy with different types of anesthesia. The effect of peripheral nerve injury on dorsal root potentials and on transmission of afferent signals into the spinal cord. Chronic peripheral nerve section diminishes the primary affer- ent A fibre mediated inhibition of rat dorsal horn neurons. Asmundson Faculty of Kinesiology and Health Studies and Department of Psychology, University of Regina Kristi D. Wright Department of Psychology, University of Regina If we liken models of pain to facial displays of emotion, it becomes readily apparent that many expressions have evolved. Indeed, over the years there have been a large number of models proffered by individuals from varying intellectual traditions. Most of these models can be grouped within one of several general categories—traditional biomedical, psychodynamic, and biopsychosocial. The intent of all models, without exception, has been to address the enduring questions of “What is pain? To date, there have been a number of reviews written on biopsycho- social approaches to pain (e. Nonetheless, the face of pain, or at least the way we as clinical and research psychologists view it, is constantly chang- ing. Indeed, many of the earlier models have proven inadequate for patient care, and more recent research has superseded initial formulations. Take, for example, the advancement of the original conceptualizations of the gate control theory (Melzack & Casey, 1968; Melzack & Wall, 1965, 1982)—the first to integrate physiological and psychological mechanisms of pain—to the current neuromatrix model as described by Melzack and Katz in chapter 1 of this volume. Similar progress has occurred in the context of biopsy- chosocial approaches that have emerged from postulates of the gate con- 35 36 ASMUNDSON AND WRIGHT trol theory, such that our answers to the “what” and “how” questions just posed are, in our opinion, becoming more clear. To this end, the concepts presented herein provide an important piece of the foundation on which the assessment and treatment approaches described in other chapters of this volume are built. Our intent in this chapter is to provide an overview and critical analysis of the traditional biomedical and psychodynamic models, summarize ele- ments of the gate control theory that strongly influenced current conceptu- alizations of pain, and review important details of models that fall under the biopsychosocial rubric. Within the context of the latter, we include discus- sion of some of the most influential behavioral, cognitive, and cognitive- behavioral models and associated empirical findings. We conclude by posit- ing a synthesis of the various iterations of the biopsychosocial approach, place this in the context of a comprehensive diathesis–stress model (i. TRADITIONAL BIOMEDICAL MODEL The traditional biomedical model of pain dates back hundreds of years. Descartes (1596–1650) modernized it in the 17th century (Bonica, 1990; Turk, 1996a), and in that form it held considerable influence through to the mid 20th century. The model holds, in essence, that pain is a sensory experi- ence that results from stimulation of specific noxious receptors, usually from physical damage due to injury or disease (see Fig. Consider the case of Jamie, a middle-aged person with strained muscles in the low back. BIOPSYCHOSOCIAL APPROACHES TO PAIN 37 diagnosing and subsequently treating Jamie should be, for all practical pur- poses (and notwithstanding availability of adequate diagnostic, surgical, and pharmacologic technology), straightforward. Jamie’s physical pathol- ogy would be confirmed by data obtained from objective tests of physical damage and, if thorough, tests of impairment. Medical interventions would then be directed toward rectifying the muscle strain. The impact of the strain on Jamie’s social, psychological, and behavioral functioning would not be given much weight in any intervention. Indeed, other symptoms re- ported by Jamie, such as depressed mood, hypervigilance to somatic sensa- tions, and pain, would not be viewed as significant but, rather, as secondary reactions to (or symptoms of) the muscle strain. In Jamie’s case, intervention was targeted at healing the muscle strain and all symptoms subsided within 5 weeks. But, for every Jamie there is an- other person for whom application of an identical intervention does not re- solve pain and other symptoms, including disability, despite eventual heal- ing of physical pathology. As becomes evident in this chapter, the reductionistic and exclusionary assumptions of the biomedical models have not been upheld. We now know that pain involves more than sensa- tion arising from physical pathology.

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A bony prominence is nearly always palpated at the location of dislocation 100 mg avanafil overnight delivery impotence nitric oxide. Acquired traumatic dislocation of the radial head is the most common condition to be differentiated purchase avanafil 200 mg visa psychological erectile dysfunction wiki. 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. Bilateral cases in fixed pronation may occasionally require surgical repositioning of the forearm due to functional disability as a result of the inability to supinate either extremity. Congenital absence of the radius Congenital absence of the radius represents a component within the spectrum of congenital amputations of the upper extremity. It has generally been termed the radial “clubhand” in the orthopedic literature. At least 50 percent of the cases are bilateral, and the right side appears to be affected more than the left. The range of clinical abnormality may run the gamut from a slightly hypoplastic radius with a hypoplastic thumb, to a complete absence of the radius and thumb with a rigidly deformed clubhand. Not uncommonly it is associated with systemic disorders; the most worrisome of which are blood dyscrasias and cardiac anomalies (Fanconi’s anemia, TAR syndrome, and the Holt–Oram septal defect syndrome). Anteroposterior radiograph demonstrating complete absence essential, because of potential multisystem of the radius and radial clubhand. The deformity is readily identifiable at birth, and the diagnosis is easily established by the clinical deformity combined with the radiographic appearance (Figure 6. Not only is the hand, wrist, and forearm involved but the elbow joint may also be stiff and contracted. As in all congenital limb absences, the soft tissues are abnormally affected in the hand and forearm. In addition to the muscles and nerves, the ulnar artery may be the only major vascular supply in the forearm and hand. Functional impairment in a bilateral case may be profound and necessitate extensive surgical management. The basic approach to treatment consists of early orthotic management combined with surgical attempts to reposition the wrist and hand on the forearm and maximize the use of functioning digits. The role of the primary care physician is with early diagnosis and appropriate orthopedic referral. Congenital coxa vara (developmental coxa vara) Congenital coxa vara is also termed developmental or infantile coxa vara. It is a rare condition characterized by a cartilaginous defect in the femoral neck metaphysis in which a radiolucent line develops in the metaphysis of the proximal femoral neck of the femur attached to the epiphyseal growth plate. The defect is associated with an increasing varus deformity of the proximal femur and limb shortening. The etiology of the condition is unknown, although heredity seems to be operative in a number of cases. The etiology of the primary defect seen in radiographic appearance is also unknown, although the influence of weight bearing and chronic slow trauma has been implicated. As the degree of varus increases, the epiphyseal growth plate becomes more vertical and less horizontal. A vicious cycle takes place in which increasing weight bearing forces tend to add to the increasing deformity.

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An initial compre- hensive dental examination should be performed discount avanafil 100mg overnight delivery impotent rage definition, including chief complaint buy generic avanafil 100mg line impotence losartan potassium, health history, intraoral and extraoral examination, and radiographs where appli- cable; then the dentist will recommend a recall sched- 31 INFECTIOUS DISEASE ule as needed dictated by the evaluation. AND THE ATHLETE Oral jewelry has become a recent fad with the youth of this country. Dental professionals are advised to John P Metz, MD give these patients information about the problems that can occur with the jewelry. Dental professionals should also inform patients that INTRODUCTION the jewelry should be removed prior to any contact sporting participation. In a 1989 Runner’s World survey, erosion of the lingual enamel of the teeth, bilateral 60. Neutrophil counts increase with acute intense exer- cise, and several hours later. Long-term moderate IMMUNOLOGY AND EXERCISE exercise seems to elicit an increase in neutrophil activity, but chronic intense exercise seems to sup- The immune system has two parts, the innate and the press it (Woods et al, 1999; Pyne, 1991). The innate, composed of barrier and non- The acquired immune system, mainly T- and B-lym- barrier elements, is nonspecific regarding host phocytes and plasma cell-secreted antibodies, attacks defense. The acquired protects the body against spe- specific foreign particles that invade the body cific infectious agents. Overall lymphocyte counts increase The body’s first lines of defense are physical barriers, with any type of acute exercise. Lymphocyte counts and such as the skin and mucous membranes that can be B-cell function are decreased after intense exercise but impaired by temperature, wind, sun, humidity, and not after moderate exercise (Pedersen and Toft, 2000). Cross-country skiers and cyclists have low base- and mucosal immunoglobulin-A (IgA) activity affect line salivary IgA levels that drop after racing (Eichner, airborne respiratory pathogens (Nieman, 1999). Longitudinal studies of salivary IgA in elite pended until they reach the bronchi and bronchioles swimmers, however, have reported increases where the mucous barrier, rich in IgA, impedes fur- (Bruunsgaard et al, 1997), decreases (Gleeson et al, ther invasion (Shephard and Shek, 1999). Depressed IgA levels have been noted in cross- (Bruunsgaard et al, 1997), male triathletes showed country skiers, cyclists, and swimmers (Eichner, diminished skin test measures of cellular immunity 48 h 1993; Nieman, 1999; Brenner, 1984). There is thus a decreased clearance of infectious peting triathletes and recreational athletes. NK counts (Woods, 1999) and natural killer cell organisms are theoretically more likely to invade the activity (NKCA) (Nieman, 1999) increase immedi- host and cause an infection (Nieman, 1999; Shephard ately after high intensity exercise lasting less than and Shek, 1999; Brenner, 1984; Pedersen et al, 1 h, but fall soon after to below preexercise levels 1996). NKCA is elevated chronically in elite versus untrained athletes (Nieman, 2000), but not with moderate exercise (Woods et al, 1999). Chronic exercise attenuates this Marathon runners have a higher incidence of self- response, but macrophage function is greater than reported upper respiratory tract infections (URI’s) after in nonathletes (Woods et al, 1999). Danish elite orienteers have increased cytokines, like tumor necrosis factor-alpha (TNF- incidence of URI compared to controls (Linde, 1987). High levels of self-reported exercise, occupational, Gleeson (Gleeson et al, 1999) found an inverse corre- and leisure time activities were associated with a lation between pretraining salivary IgA levels and risk 20–30% decrease in the annual incidence of URI of infection in elite swimmers and controls, and pre- in healthy, nonathletic, and middle-aged adults dicted an additional infection for each 10% drop in (Matthews et al, 2002). A similar study of healthy, elderly people noted an infections, however. A follow-up study (Gleeson et al, inverse relationship between the amount of energy 2000) showed no correlation between salivary IgA expended in daily moderate activities and URI levels and infection risk. Runners in short races (5K, 10K, half-marathon) decreased salivary IgA an average of 27. There was a negative correlation found running 16–26 mi a week increased the risk between salivary IgA levels and number of days of ill- of having ≥1 URI compared to running <9 mi a ness and flu symptoms, but not days of cold symptoms. Running 9–16 mi or >26 mi a week con- Studies of immune marker changes with exercise have ferred intermediate risk. Moderate exercise lowers infection risk to below that of being sedentary, while strenuous In premenopausal women, no exercise or a 15-week exercise imposes the highest risk of all (Nieman, walking program made no difference in NK cell 2002). NKCA was significantly increased in the More evidence is needed, however, as the link training group at 6 weeks, but was elevated equally in between moderate exercise and infection is less clear both groups at 15 weeks. Most studies of infection 50% fewer days with URI symptoms, but the same and exercise are relatively small and rely on patient number of separate URIs compared to controls. Also, other fac- NKCA at 6 weeks was negatively correlated with URI tors such as pathogen exposure, stress, sleep, nutri- symptom days (Nieman et al, 1990b). The exercise group, however, had significantly fewer URIs than the control group (3/14 vs. A comparison group of elite elderly athletes had significantly higher NKCA and lymphocyte activity and even fewer URIs (1/12). NKCA and lymphocyte proliferative response were significantly higher in the rowers. Days of self-reported URI symptoms, however, were similar in both groups and did not correlate with immunologic changes. Transillumination and FEVER radiographs of the sinuses are generally not useful (Fagnan, 1998). Analgesics and decongestants in doses discussed all caloric and oxygen demand and insensible fluid above. Nasal saline rinses, 1/ tsp of table salt in 8 oz of 4 increased risk of injury (Brenner et al, 1984). Placing a warm washcloth over (650–1000 mg q 4–6 h) and nonsteroidal anti-inflam- the affected sinus and its corresponding nostril may matory drugs (NSAIDs) like ibuprofen (800 mg TID) also help.

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This plate section is exposed to traction forces produced by the patellar ligament buy discount avanafil 200 mg line impotence juicing, which is inserted at this point 200 mg avanafil with visa erectile dysfunction levitra, and can thus be considered as an apophysis from the functional standpoint. In physiological respects, these anterior sec- tions are the last to undergo physeal closure towards the end of growth. Diagnosis Clinical features The tibial head (and thus the proximal epiphysis and metaphysis) is readily inspected and palpated, at least in its anterior sections, thanks to the thin soft tissue cover- ing. Epiphyseal fractures usually lead to hemarthrosis, while metaphyseal fractures, in contrast with the cor- ⊡ Fig. The size is Fractures of the intercondylar eminence correspond to frequently underestimated on the x-ray because of the bony avulsions of the distal anterior cruciate ligament cartilaginous section. Epiphyseal fractures (Salter-Harris types III and IV – The accident mechanism in such cases corresponds to chapter 4. They hemarthrosis and increased anterior tibial translation in occur predominantly during adolescence. The latter is the most sensitive test for ligament lesions or menisci trapped in the fracture gap anterior cruciate ligament lesions: The anterior transla- are often identified only secondarily or during surgical tion of the tibia is tested in the supine patient at approx. The ligaments should not be tested, Compression fractures are stable, are not associated however, after recent trauma, partly because this is a pain- with any misalignment and heal without complications. The following Epiphyseal separations (Salter-Harris types I and II) degrees of displacement are differentiated: are the result of indirect valgus forces or hyperextension ▬ type I: No displacement. The latter produce anterior displacement of the ▬ type II: The fragment is elevated anteriorly like a like a epiphysis, including the tuberosity. As a consequence, the tongue the posterior hinged part is still in contact with now prominent metaphysis may compromise the popli- the tibial plateau. Epiphyseal fractures of the proximal tibia: Avulsion ity (b), epiphyseal fracture without (Salter III; c) and with (Salter IV; d) of the intercondylar eminence (a), avulsion of the tibial tuberos- metaphyseal wedge a b c d e ⊡ Fig. The tibial tuberosity is part of the epiphysis and is also separation without (Salter I; a – lateral view in b) and with (Salter II; detached during epiphyseal separations c) metaphyseal wedge. Usually there is no 3 Metaphyseal bowing fractures of the proximal tibia: genuine correction, rather the proximal and distal epiphy- sis realign themselves horizontally, while the deformity in The initial valgus deformity is usually so slight that it is the shaft grows, resulting overall in an S-shaped defor- easily overlooked if there is no consistent check for split mity. Top priority is accorded therefore to the elimination fractured sections on the medial side and the axial relation- of all primary valgus and varus deviations. If the initial deformity younger than 10 years old, any (rare) deformities of up is left untreated there is a high risk of a progressive valgus to around 20° in the sagittal plane can be left to correct deformity (see below for complications; ⊡ Fig. Avulsions of the tibial tuberosity typically affect ado- lescent athletes after a sudden, strong quadriceps con- Conservative treatment traction or forced knee flexion while the quadriceps is Non-displaced fractures: Initial immobilization in a plaster activated, e. Extra-articular avulsions slab, replaced by an encircling cast after the swelling has are considered to be displaced if there is more than 5 mm subsided, usually after a few days. In all cases a cylinder be differentiated from malignant tumors even on the basis cast is applied for 4 weeks. Young female endurance athletes should be ques- Eminence fractures: tioned specifically about a possible female athlete triad: Type II: The fragment can usually be reduced by anorexia, osteoporosis and amenorrhea are the key ele- closed manipulation with knee extension under im- age intensifier control. Failure to produce a complete reduction may be due to interposition of the anterior horn of the lateral meniscus or, more commonly, the transverse genicular ligament, which can be freed by arthroscopy (⊡ Fig. For multifragment avulsions, sutures may be inserted in the distal part of the cruciate ligament, which are then passed distally through 2 small holes drilled in the tibia and knotted over the proximal tibia. A slight lowering of the avulsed fragment below the a b c level of the surrounding cartilage compensates for the ⊡ Fig. Growth disorder after metaphyseal bowing fracture of plastic elongation of the ligment. The already existing valgus deformity will be exacerbated, the result fixed percutaneously with crossed Kirschner resulting in a unilateral genu valgum wires (⊡ Fig. For epiphyseal fractures, the guidelines for the man- agement of joint fractures apply (⊡ Fig. Displaced tuberosity avulsions frequently involve an interposed periosteal flap. After the flap is freed, the frac- ture is reduced, with the knee extended, and the result fixed by lag screw osteosynthesis. Predominantly perios- teal avulsions of the patellar ligament can be managed by bone sutures, secured if necessary by tension-band wiring (⊡ Fig. Duration of immobilization Three weeks for compression fractures, 4–5 weeks for ⊡ Fig. Treatment of displaced eminence fractures: All patients with a displaced eminence fracture should be investigated arthroscopi- the other fractures. The eminence itself should be reduced is worn until the swelling subsides and the wound has arthroscopically and, wherever possible fixed by an epiphyseal screw (a). Mobilization can then begin immediately on the If this cannot be performed by arthroscopy, the fragment is resecured motorized splint. Because of the potential risk of growth disturbances, subsequent controls are justified for at least 2 years following trauma while the growth plates are still open, excluding compression fractures.

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