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By K. Elber. Western Michigan University.

This operation can An awareness of this rare anomaly is important for the improve the abductability of the arm by 50° on aver- differentiation from the clavicular fracture that occurs as age purchase imitrex 25mg fast delivery, and the cosmetic results are also very satisfactory imitrex 25mg low cost. In contrast with a fresh fracture cheap imitrex 50 mg, Positive results are also reported with a vertical scapular the edges of the pseudarthrosis are rounded (⊡ Fig generic imitrex 50 mg free shipping. The differential diagnosis must consider the possibil- ity of a cleidocranial dysostosis ( Chapter 4. A striking clinical finding at the age of 2–3 years is a painless swelling in the area of the clavicles, combined with asym- metry of the shoulders. In order to prevent worsening of the deformity, surgical correction with a wide resection of the pseudarthrotic tissue, including the periosteum, cancellous bone graft and stable fixation, should be per- formed around the age of 5 years [8, 24]. The lack of a trauma history does not neces- sarily rule out a traumatic cause of the dislocation. Factors suggestive of a congenital form include bilateral occur- rence, excessively long radius, convex instead of concave shape of the proximal surface of the radial joint and the lack of any deformation of the ulnar shaft. Under no circumstances should an attempt be made to reduce the radial head in the congenital form. The symptoms and functional restriction are usually minimal in this form, although the excessively long radius may cause problems and can be treated by resection of the head on completion of growth. The left scapula stands 6 cm higher than the right one, is smaller and is in contact with the posterior part of the skull. X-ray of the clavicle in a 2-year old boy with congenital picture pseudarthrosis in the center of the shaft 479 3 3. A wide variety of hand deformities are also fre- dromes and in arthrogryposis. The Apert syndrome is quently observed in Klippel-Trenaunay-Weber syndrome discussed in detail in chapters 4. Fricker, specialists in hand surgery at our hospital, for the The treatment consists of separation of the syndac- critical perusal of this chapter and their many suggestions. Al-Qattan M (2001) Classification of hand anomalies in Poland’s a rigid plate that can only be used as a whole, rather like syndrome. Arch Orthop Un- with Apert syndrome are additionally handicapped in the fallchir 62: 225–46 upper extremities by movement restrictions at the elbow 4. Blauth W, Olason AT (1988) Classification of polydactyly of the and shoulder joints. Bradbury ET, Kay SP, Hewison J (1994) The psychological impact Patients with Poland syndrome suffer much less im- of microvascular free toe transfer for children and their parents. This non-inherited condition is described in Hand Surg (Br) 19 (6): 689–95 chapter 4. Buck-Gramcko D (1985) Radialization as a new treatment for radial cles and syndactylies, occasionally with missing middle club hand. Buck-Gramcko D, Behrens P (1989) Klassifikation der Polydaktylie für Hand und Fuß. Cadilhac C, Fenoll B, Peretti A, Padovani JP, Pouliquen JC, Rigault P cantly impaired. Castilla EE, da Graca Dutra M, Lugarinho da Fonseca R, Paz JE (1997) Hand and foot postaxial polydactyly: two different traits. Cleary JE, Omer GE Jr (1985) Congenital proximal radio-ulnar syn- ostosis. Cole RJ, Manske PR (1997) Classification of ulnar deficiency according to the thumb and first web. Cowell HR (2005) Polydactyly, triphalangism of the thumb, and carpal abnormalities in a family. Czeizel AE, Vitez M, Kodaj I, Lenz W (1993) An epidemiological study of isolated split hand/foot in Hungary, 1975–1984. Eulenberg M (1863) Casuistische Mitteilungen aus dem Gebiete der Orthopädie. Foulkes GD, Reinker K (1994) Congenital constriction band syndrome: A seventy-year experience. Green WT (1957) The surgical correction of congenital elevation of the scapula (Sprengel’s deformity).

However effective 25mg imitrex, the short-term nature of the dis- tress and pain associated with brief but painful medical and dental proce- dures may simply not be viewed as justifying the time and personnel costs needed to implement many psychological interventions for acute pain (Lud- wick-Rosenthal & Neufeld order 50 mg imitrex fast delivery, 1988) order imitrex 25 mg free shipping. Moreover buy generic imitrex 50 mg online, the absence of a psychiatric di- agnosis to justify provision of a psychological intervention, which is typi- cally a requirement for purposes of insurance reimbursement, may be a practical barrier to having psychological acute pain interventions be ad- ministered by psychologically trained staff. Brief and simple techniques that can be implemented quickly either through automated procedures (e. PSYCHOLOGICAL INTERVENTIONS FOR ACUTE PAIN 263 a memory-based positive emotion induction requiring less than 5 minutes of time has been shown to diminish acute pain sensitivity and pain-related physiological arousal, and could be carried out by nursing staff with limited training (Bruehl et al. Distraction techniques also require little effort to implement, and therefore may be more widely useful. Our clinical experience indicates that unless significant skills acquisition and practice time are available prior to exposure to the acute pain situa- tion, the benefits of using more elaborate interventions (e. Ideally, there would be sufficient contact time with the patient on a separate day prior to exposure to the pain stimulus for mutual selection of an acceptable intervention, for the intervention to be taught, and for patients to practice the skills on their own prior to the pain (using taped intervention instructions if appropriate). If less time is available, it is im- portant to select interventions that are reasonable for the patient to learn and practice adequately in the time that is available. Information provision and distraction interventions are most amenable to limited practice time, followed in (approximate) ascending order of difficulty by coping self- statement interventions, breathing relaxation, imagery techniques, hypno- sis, progressive muscle relaxation, and combined approaches. Patient acceptance and adherence may be another barrier to effective use of psychological interventions. Passive distraction techniques such as listening to relaxing music are likely to be accepted easily by patients. How- ever, unless patients are provided with a compelling rationale for use of in- terventions that require active practice (e. Even when intervention skills have been learned, results of a large-scale efficacy study of relaxation for postsurgical pain indicate that reminders to practice the technique are required for ben- eficial effects to be achieved (Good et al. CONCLUSIONS Results of controlled clinical trials testing the efficacy of psychological in- terventions for acute pain associated with burn management, labor, medi- cal diagnostic procedures, venipuncture, dental procedures, and surgery suggest that these interventions are often effective for pain reduction and do not appear to be harmful. However, controlled trials have rarely tested the efficacy of individual strategies, but rather have examined various com- binations of information-provision, relaxation-related, and cognitive strate- gies. It is therefore not possible to make determinations as to the clinical superiority of one type of intervention over another based on available tri- 264 BRUEHL AND CHUNG als. Audiotaped relaxation-related interventions do appear to be effective in some situations, although “live” intervention delivery by trained staff for the initial session is likely to optimize results if time and resources permit. There is little evidence to justify the use of psychological interventions as an alternative to standard pharmacological approaches, although there is much evidence that they have significant clinical utility in conjunction with pharmacological approaches. Although there are some indications that individual difference variables may impact on efficacy of various types of psychological interventions, there are insufficient data available to use indi- vidual difference variables for selection of optimal intervention types in routine clinical decision-making. Given the limitations of the available re- search, factors such as time constraints, resources, and patient preference are likely to be the most useful in selection of interventions. ACKNOWLEDGMENT The authors gratefully acknowledge the assistance of Pamela Ward in the preparation of this chapter. A comparison of the effects of flupentixol and re- laxation on laboratory pain: An experimental study. Age related response to lidocaine–prilocaine (EMLA) emulsion and effect of mu- sic distraction on the pain of intravenous cannulation. Coping with aversive stimulation: The effects of training in a self-management context. The comparative effects of postoperative analgesic therapies on pulmo- nary outcome: Cumulative meta-analyses of randomized controlled trials. Emotional and sensory focus as mediators of dental pain among patients differing in desired and felt dental control. Training children to cope and parents to coach them during routine immunizations: Effects on child, parent, and staff behaviors.

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Also purchase imitrex 25mg amex, chin tuck decreases the space between the base of the tongue and the posterior pharyngeal wall generic imitrex 25mg visa, and so creates increased pharyngeal pressure to move the bolus through the pharyngeal region Aspiration – Aspiration discount 25 mg imitrex with visa, by definition discount imitrex 50 mg overnight delivery, is the penetration of a substance into the laryngeal vestibule and below the vocal folds (true vocal cords) into the trachea – Aspiration is missed on bedside swallowing evaluations in 40% to 60% of patients (i. If a patient is believed to be at high risk of recurrent aspiration after bedside and/or videofluoroscopic evaluation, he/she should be kept NPO and enterally fed, initially via NGT, and then via G-tube or J-tube if long-term enteral feeding is required. Uplifting the soft palate prevents nasal speech (speech abnormally resonated in the nasal cavities). APHASIA Aphasia is an impairment of the ability to utilize language due to brain damage. Characterized by paraphasias, word-finding difficulties, and impaired comprehension. Also common, but not obligatory, features are disturbances in reading and writing, non- verbal constructional and problem-solving difficulty and impairment of gesture TABLE 1–11 Aphasias Fluent Nonfluent + COMPREHENSION – COMPREHENSION + COMPREHENSION – COMPREHENSION REPETITION REPETITION REPETITION REPETITION ⇓ ⇓ ⇓ ⇓ + – + – + – + – conduction Transcortical Wernicke’s Transcortical Broca’s Mixed Global NAMING sensory motor transcortical + – Fluent Non-fluent Wernicke’s Broca’s Transcortical sensory Transcortical motor Conduction Global Anomia Mixed transcortical STROKE 39 ANATOMIC LOCATION OF MAJOR SPEECH AREAS 40 STROKE STROKE 41 Transcortical mixed aphasia: Lesions in border zone of frontal, parietal, and temporal areas Characteristics: Poor comprehension Nonfluent (decrease rate and initiation of speech) Preserved repetition (echolalia) Note: Language areas are anatomically clustered around the sylvian fissure of the domi- nant hemisphere—left hemisphere in 95% of people. Paraphasias: Incorrect substitutions of words or part of words Literal or phonemic paraphasias: similar sounds (e. In the majority of cases of patients with aphasia spontaneous recovery does not seem to occur after a year. However, there are reports of improvements many years after their stroke in patients undergoing therapy. MEDICAL MANAGEMENT PROBLEMS Poststroke Depression Etiology: – Organic: May be related to catecholamine depletion through lesion-induced damage to the frontal nonadrenergic, dopaminergic and serotonergic projections (Heilman and Valenstein, 1993) – Reactive: Grief/psychological responses for physical and personal losses associated with stroke, loss of control that often accompany severe disability, etc. Seizures Can be classified as occurring: – At stroke onset – Early after stroke (1–2 weeks) – Late after stroke (> 2 weeks) In prospective study after first time stroke, 27 of 1099 (2. FACTORS THAT PREDICT MORTALITY AND FUNCTIONAL RECOVERY IN STROKE PATIENTS Mortality Factors Mortality of ischemic strokes in the first 30 days ranges from 17%–34% Hemorrhagic strokes are more likely to present as severe strokes and with mortality rate reported to be up to 48% STROKE 43 Mortality in the first year after stroke 25% to 40% The risk of another stroke within the first year 12% to 25% RISK FACTORS FOR ACUTE STROKE MORTALITY — 30 DAY MORTALITY Stroke severity Low level of consciousness Diabetes mellitus Cardiac disease Electrocardiograph abnormalities Old age Delay in medical care Elevated blood sugar in non-diabetic Brainstem involvement Hemorrhagic stroke Admission from nursing home Functional Recovery and Disability Factors As stroke mortality has declined in the last few decades, the number of stroke survivors with impairments and disabilities has increased There are 300,000 to 400,000 stroke survivors annually 78% to 85% of stroke patients regain ability to walk (with or without assistive device) 48% to 58% regain independence with their self-care skills 10% to 29% are admitted to nursing homes RISK FACTORS FOR DISABILITY AFTER STROKE Severe stroke (minimal motor recovery at 4 weeks) Low level of consciousness Diabetes mellitus Cardiac disease Electrocardiograph abnormalities Old age Delay in medical care Delay in rehabilitation Bilateral lesions Previous stroke Previous functional disability Poor sitting balance Global aphasia Severe neglect Sensory and visual deficits Impaired cognition Incontinence (>1–2 weeks) 44 STROKE Negative Factors of Return to Work (Black-Shaffer and Osberg, 1990) Low score on Barthel Index at time of rehabilitation discharge Prolonged rehabilitation length of stay Aphasia Prior alcohol abuse (Barthel Index is a functional assessment tool that measures independence in ADLs on 0–100 scale) STROKE 45 REFERENCES Adams RD, Victor M, Ropper AH. Stroke incidence, prevalence, and sur- vival: secular trends in Rochester, Minnesota, through 1989. Motor testing procedures in hemiplegia: based on sequential recovery stages. Prediction of reflex sympathetic dystrophy in hemiplegic patients by electromyo- graphic study. Endarterectomy for moderate symptomatic carotid stenosis: Interim results from the MRC European Carotid Surgery Trial. Clinical assessment and management of swallowing difficulties after stroke. Three-phase bone studies in hemiplegia with reflex sympathetic dys- trophy and the effect of disuse. Hamilton MG, Spetzler RF: The Prospective Application of a Grading System for Arteriovenous Malformations. Reflex sympathetic dystrophy in the hands: clinical and scintographic cri- teria. Low-molecular-weight heparin for the treatment of acute ischemic stroke. Proprioceptive Neuromuscular Facilitation: Patterns and Techniques, 2nd ed. National Institute of Neurologic Disorders and Stroke rt-PA Stroke Study Group. The American Heart Association Consensus Statement on guidelines for carotid endarterec- tomy. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. Brunnstrom’s Movement Therapy in Hemiplegia: A Neurophysiological Approach, 2nd ed. Significance of Factors Contributing to Surgical Complications and to Late Outcome After Elective Surgery of Cerebral Arteriovenous Malformations. Reflex sympathetic dystrophy syndrome in stroke patients with hemilegia—three-phase bone scintography and clinical characteristics. An analysis of perioperative sur- gical mortality and morbidity in the asymptomatic carotid atherosclerosis study.

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It is most commonly located in the heel area imitrex 50mg overnight delivery, phalanx and McBride operation slightly less frequently in the forefoot area buy imitrex 25 mg online, while the A varus 1st metatarsal without hallux valgus does not require midfoot is affected only in exceptional cases purchase 50mg imitrex free shipping. Severe treatment deformities can cause pain as a result of the concentra- tion of stresses at a non-physiological site (see also chapters 3 imitrex 25mg overnight delivery. Diffuse pain can be induced by References neuromuscular disorders ( Chapter 3. Aronson J, Nguyen L, Aronson E (2001) Early results of the modi- often painful, and the possibility of a neurological cause fied Peterson bunion procedure for adolescent hallux valgus. Pediatr Orthop 21: 65–9 This chapter addresses the causes of pain in those feet 2. Cook DA, Breed AL, Cook T, DeSmet AD, Muehle CM (1992) Ob- that appear outwardly normal. The differential diagnosis server variability in the radiographic measurement and classifica- of the aforementioned disorders should always take into tion of metatarsus adductus. Crevoisier X, Mouhsine E, Ortolano V, Udin B, Dutoit M (2001) The account the possibility of a tumor ( Chapter 3. Farsetti P, Weinstein SL, Ponseti IV (1994) The long-term func- tional and radiographic outcomes of untreated and non-opera- Tarsal coalition is one of the most important tively treated metatarsus adductus. J Bone Joint Surg (Am) 76: and most frequently overlooked causes of foot 257–65 pain in children and adolescents. Ferrari J, Watkinson D (2005) Foot pressure measurement differ- are described in chapter 3. Grace D, Delmonte R, Catanzariti A, Hofbauer M (1999) Modified Lapidus arthrodesis for adolescent hallux abducto valgus. Kilmartin TE, Barrington RL, Wallace WA (1991) Metatarsus primus Definition varus. J Bone Joint Surg (Br) 73: 937–40 Temporary circulatory disturbance with aseptic osteo- 9. Kilmartin TE, Wallace WA (1992) The significance of pes planus in necrosis of the tarsal navicular, usually occurring during juvenile hallux valgus. Kilmartin TE, Barrington RL, Wallace WA (1994) A controlled pro- ▬ Synonyms: Aseptic bone necrosis, juvenile osteo- spective trial of a foot orthosis for juvenile hallux valgus. Kristen K, Berger C, Stelzig S, Thalhammer E, Posch M, Engel A (2002) The SCARF osteotomy for the correction of hallux valgus deformities. J Primary aseptic necrosis of the tarsal navicular was first described by Bone Joint Surg (Am) 49 1675–83 Köhler in 1908, who subsequently reported on 26 cases in 1913. Two well-docu- This is a very rare disease that occurs 4 times more often mented studies with observation periods of over 30 years in girls than in boys. It typically manifests itself between have demonstrated the excellent long-term prognosis of the ages of 3 and 8 years. Etiology There is evidence to indicate that the disease develops as a result of repeated mechanical compression forces. Irregularities crosis of a bone in the forefoot, usually occurring during of ossification are common. A circulatory problem can adolescence, typically affecting the heads of the 2nd or occur as a result of the compression forces. Clinical features, diagnosis ▬ Synonyms: Osteonecrosis of the metatarsal heads, Os- The affected children complain of load-related pain in teochondrosis of the metatarsal heads aseptic bone the midfoot and over the back of the foot, and walk necrosis, juvenile osteonecrosis with a protective limp, rolling from heel-to-toe over the lateral edge of the foot. The x-ray shows condensa- Historical background tion, and possibly fragmentation and flattening of the Osteonecrosis of the metatarsal heads was first mentioned in 1914 by Freiberg. Köhler subsequently published a more detailed descrip- navicular (⊡ Fig. In German-speaking countries it is commonly can take several years to return to normal, and residual known as »Köhler II« disease, whereas the term »Freiberg’s disease« is deformation of the bone may persist. Occurrence This condition affects the 2nd–4th metatarsal heads, Treatment predominantly in girls between 10 and 18 years old, If the symptoms are severe, a below-knee cast may need to and typically occurs in combination with splayfoot.

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We also thank Debra Riegert of Lawrence Erlbaum Associates for her support and enthusiasm about this project purchase 50mg imitrex amex. Craig An Introduction to Pain: Psychological Perspectives Thomas Hadjistavropoulos University of Regina Kenneth D purchase imitrex 25mg. Craig University of British Columbia Pain is primarily a psychological experience cheap 25 mg imitrex overnight delivery. It is the most pervasive and universal form of human distress and it often contributes to dramatic re- ductions in the quality of life discount imitrex 50mg overnight delivery. As demonstrated repeatedly in the chapters to follow, it is virtually inevitable and a relatively frequent source of dis- tress from birth to old age. Episodes of pain can vary in magnitude from events that are mundane, but commonplace, to crises that are excruciating, sometimes intractable, and not so common, but still not rare. The costs of pain in human suffering and economic resources are extraordinary. It is the most common reason for seeking medical care, and it has been estimated that approximately 80% of physician office visits involve a pain component (Henry, 1999–2000). The distinction between pain and nociception provides the basis for fo- cusing on pain as a psychological phenomenon. Nociception refers to the neurophysiologic processing of events that stimulate nociceptors and are capable of being experienced as pain (Turk & Melzack, 2000). Instigation of the nociceptive system and brain processing constitute the biological sub- strates of the experience. But pain must be appreciated as a psychological phenomenon, rather than a purely physiological phenomenon. Specifically, it represents a perceptual process associated with conscious awareness, selective abstraction, ascribed meaning, appraisal, and learning (Melzack & Casey, 1968). Emotional and motivational states are central to understand- ing its nature (Price, 2000). Pain requires central integration and modula- tion of a number of afferent and central processes (i. This formulation acknowledges the importance of various levels of anal- ysis of pain. The biological sciences (molecular biology, genetics, neuro- physiology, pharmacological sciences, etc. Ultimately, however, a unified theory of pain must integrate this understanding with the product of work in the behavioral and social sciences, as well as the hu- manities, because pain cannot be understood solely at the level of gene ex- pression, neuronal firing, and brain circuitry. Many of the serious problems in understanding and controlling pain must be understood at the psycho- logical and social level of analysis. What accounts for some people reacting dispassionately and others with great distress to what appears to be the same degree of tis- sue damage? The discipline of psychology must play a central role in the study, as- sessment, and management of pain. It is not surprising that Ronald Melzack, one of the developers of the most influential theory in the field of pain, is a psychologist. Nor is it unexpected that at least 2 of the 10 most influential clinicians and researchers in the field of pain (as assessed by survey of a random sample of members of the International Association for the Study of Pain [IASP]) are psychologists (Asmundson, Hadjistavropoulos, & Anto- nishyn, 2001). These two individuals (Ronald Melzack and Dennis Turk) are contributors to this volume. In this book we have tried to capture major features of the psychology of pain and the most influential contributions of psychologists to pain re- search and management. We are primarily interested in the ultimate impact of advances in understanding and controlling pain. Hence, although much of the volume covers applied issues, basic processes are also given careful consideration. FROM DESCARTES TO THE NEUROMATRIX Historical trends demonstrate the importance of psychological mechanisms. Descartes’s (1644/1985) early mechanistic conceptions of pain resulted in the biomedical specificity theory that proposed that a specific pain system transmits messages from receptors to the brain. This theory is sometimes referred to as “the alarm bell” or “push button” theory (Melzack, 1973), INTRODUCTION 3 because of its apparent simplicity.

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