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The data do not allow one to de- termine whether genetic factors may have influenced the outcome of this study lamictal 50 mg lowest price. For the age range 45–64 years discount lamictal 25mg with visa, musculo- skeletal pain prevalence was higher in all ethnic groups (about 70 to 90%) than in White subjects best 25 mg lamictal, with the latter being about 53% for both males and females order 50 mg lamictal with visa. When asked whether they had pain in “most joints,” about 6 to 8% of Whites agreed compared to about 30 to 45% in the ethnic minority groups. The authors cautioned that comparable studies need to be done in other geo- graphical locations, because the data do not permit one to readily distin- guish between differences in pain sensitivity or expression, the effects of change of culture and migration, and mental health issues. With respect to the last point, a study (Nelson, Novy, Averill, & Berry, 1996) with a relatively small sample of Black, White, and Hispanic patients in a southern U. McCracken, Matthews, Tang, and Cuba (2001), in one of the few studies of ethnic or racial group differences in the experience of chronic pain, asked 207 White and 57 African American patients seeking treatment at a pain management center about their physical symptoms, depression, dis- ability, health care use, and pain-related anxiety. The two groups did not differ in age, education, or chronicity of their pain complaint. African Ameri- cans rated their pain higher and reported more avoidance of pain and activ- ity, more fearful thinking about pain, and more pain-related anxiety. As well, they were higher on physical symptom complaints and on physical, psycho- social, and overall disability. The authors noted that many factors may ex- plain these findings, including less social support, differences in social cir- cumstances, beliefs about pain, and self-management strategies, and the 170 ROLLMAN possibility that African Americans may not seek or be referred for treat- ment unless they are suffering from high levels of distress. A study by Jordan, Lumley, and Leisen (1998) compared pain control be- liefs, use of cognitive coping strategies, and status of pain, activity level, and emotion among 48 African American and 52 White women with rheuma- toid arthritis, controlling for the potentially confounding influence of in- come, marital status, and education. There were no group differences in pain, but the African American patients were less physically active and more likely to cope with pain by praying and hoping and diverting atten- tion, whereas Whites were more likely to make coping statements and ig- nore the pain. Bill-Harvey, Rippey, Abeles, and Pfeiffer (1989) had earlier noted that 92% of low-income, urban African American arthritis patients used prayer to relieve their pain and discomfort. Cognitive behavior ther- apy and other treatments that encourage the use of increased coping at- tempts and decreased negative thinking can aid African Americans to man- age experimentally induced pain (Gil et al. Waza, Graham, Zyzanski, and Inoue (1999) found that Japanese patients who had been newly diagnosed with depression reported more total symp- toms, particularly physical ones, than patients in the United States. Twenty seven percent of the Japanese patients reported only physical symptoms, whereas only 9% of the patients in the United States presented in this man- ner. A large proportion of the Japanese had pain complaints (generally ab- dominal pain, headache, and neck pain); comparable figures for the Ameri- can patients were about 60 to 80% less. The authors propose that pain at specific body areas may arise because of cultural influences, possibly to avoid the stigma in Japan associated with emotional disorders. For exam- ple, many Japanese expressions use the term hara (abdomen) to verbalize emotion, and digestive-system complaints are the primary reason for out- patient medical visits in that country. Njobvu, Hunt, Pope, and Macfarlane (1999), in a review of pain among in- dividuals from South Asian ethnic minority groups who live in the United Kingdom, observed that they more frequently attend medical clinics and re- port greater musculoskeletal pain. This leads to the question of whether South Asians also suffer greatly from pain in their countries of origin. Hameed and Gibson (1997) provided relevant data in a study of pain com- plaints among Pakistanis living in England and in Pakistan. Those living in England reported more arthritic symptoms and more nonspecific musculo- skeletal pain, particularly among females. There are numerous possible ex- planations including the colder British climate, adjustment to life in a new 6. ETHNOCULTURAL VARIATIONS IN PAIN 171 society, and a greater willingness to report pain among the better educated Pakistanis living in Great Britain. Sabbioni and Eugster (2001) also looked at immigrants, namely, Spanish and Italians living in Switzerland. Earlier studies had found that foreign pa- tients in that country had worse medical outcomes after back injury than Swiss ones, but the migrants often worked in low-paying jobs with in- creased health hazards.

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USING ELECTRODIAGNOSIS IN PAIN MEDICINE Electrodiagnosis is useful when pain is thought to originate from neurologic discount lamictal 50 mg overnight delivery, intrinsic muscular discount lamictal 200 mg without prescription, or neu- romuscular junction disease purchase lamictal 25mg on line. As with all medical interventions generic 25mg lamictal visa, before ordering, ask yourself: Will the test be of practical value? Will an accurate diagnosis change any aspect of the treatment plan or provide other benefits? If you wish to look for or rule out particular conditions, mention them. A well- run electrodiagnostic laboratory should: Ensure the most comfortable experience possible for the patient. Control for skin temperature during NCS, and record temperatures in the report. Fibrillation Have a consistent set of norms for NCS data, and potentials (a) are short-duration potentials occurring in a regular present these norms in the report for comparison. Positive sharp waves (b) are similar to fibrillation poten- Abnormal data should be clearly marked. Complex repetitive discharges (c) may be the result of ephaptic transmission causing Compare abnormal results against the contralateral repetitive, rhythmic firing of irritable muscle fibers. The EMG signal as a EMG of the thenar muscles is quite painful and whole has a characteristic appearance and recruitment should be reserved for atypical or unusual presenta- tions where additional information is needed. Abnormalities in any of these parameters help to diagnose the type and chronicity of disease When abnormalities are found on one limb, the con- tralateral limb should also be studied. The list is incomplete; interested readers are referred to more comprehensive texts. EMG and NCS may be extremely painful in the CRPS patient, and MYOFASCIAL PAIN AND increased analgesic therapy may be required. FIBROMYALGIA SYNDROME RADICULOPATHY Electrodiagnosis is normal in these musculoskeletal pain syndromes unless there are comorbid conditions, It is essential to tailor the EMG exam to the patient’s such as carpal tunnel syndrome. No one exam Generalized neuromuscular disorders such as method is appropriate for all patients. NCS and EMG can help confirm the diagnosis and 26 III EVALUATION OF THE PAIN PATIENT identify the type and bodily distribution of neuropathy 13. Magnetic res- (eg, axonal, demyelinating, mixed; sensory, motor, onance imaging of denervated muscle: Comparison to elec- mixed; uniform, segmental). Electromyography Electrodiagnostic testing can help identify treatable and magnetic resonance imaging in the evaluation of radicu- neuropathies (eg, metabolic, toxic, vitamin defi- lopathy. Electrodiagnostic approach to patients with Electrodiagnostic testing provides valuable prognos- suspected generalized neuromuscular disorders. Phys Med tic information, and serial examinations can docu- Rehabil Clin North Am. AAEM Minimonograph #34: When polyneuropathy is suspected, complete exami- Polyneuropathy: Classification by nerve conduction studies nation requires both MNCS and SNCS, preferably on and electromyography. Wallace, MD REFERENCES Quantitative sensory testing is used to evaluate the function of individual nerve fibers (large myelinated, 1. Considerations in reference val- Aβ; small myelinated, Aδ; and small unmyelinated, ues for nerve conduction studies. Electroencephalogr Clin conclusions can be made as to what nerve fibers cor- relate with certain sensations. Electrodiagnosis in Diseases of Nerve and Methods used for quantitative sensory testing include Muscle: Principles and Practice. Philadelphia: mechanical nonpainful sensation (vibratory, von Frey Davis; 1989. AAEM Minimonograph #33: Electrodiagnostic thermal sensation, and current perception sensation approach to defects of neuromuscular transmission. An approach to electrodiagnostic medicine: The power of needle electromyography. AAEM Minimonograph #11: Needle examination large myelinated (Aβ) fiber function. Practice parameter for electrodiagnostic studies in carpal tunnel syndrome: Summary statement.

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Marital rela- tions and history of substance abuse round out the set of factors associated with poorer prognosis generic lamictal 25 mg overnight delivery. Some combination of these factors should be used to contribute to the psychologist’s recommendation regarding the likeli- hood of a successful outcome to surgery buy lamictal 25 mg free shipping. A history of childhood physical and sexual abuse has been reported to be prevalent in chronic pain patients (e generic lamictal 100mg without a prescription. Schofferman buy lamictal 100 mg with mastercard, An- derson, Hines, Smith, and White (1992) tested for an association between childhood traumas in general and outcome following lumbar spine sur- gery. Patients who had three or more of a possible five serious childhood traumas (which included abuse) had an 85% likelihood of an unsuccessful surgical outcome compared to a 5% failure rate for those without a trauma history. Although a high percentage of patients with early trauma had un- successful surgical outcomes, not all patients with abuse histories have poor surgical outcomes. It may well be that no one factor by itself is suffi- cient but combinations of factors identified by Epker and Block (2001) may be implicated. Although there is some evidence for the importance of the factors out- lined by Epker and Block (2001) and a history of abuse, there are limited data to support the predictive validity. Moreover, we need to realize that these predictors are of relatively better or poorer outcome. Data reported are based on groups and there is no guarantee that all people with the poor prognostic factors will have an equally poor treatment outcome. Such actu- arial data combined with other information may, at least, alert the referring surgeon to potential problems, some of which may be treatable and lead to improved outcomes. IMPAIRMENT, DISABILITY, AND VOCATIONAL ASSESSMENT Decisions regarding impairment and disability associated with pain are a difficult area, as pain is a subjective experience and there are no objective signs that can validate reports of pain. Thus, physicians and psychologists 234 TURK, MONARCH, WILLIAMS have to rely on base-rate information regarding functioning in response to particular physical impairments, in conjunction with history, physical ex- amination (in the case of physicians), observations, collateral information, and importantly self-reports. Four areas of functioning are particularly rele- vant in deciding the impact of pain (disability), namely, activities of daily living; social functioning; concentration, persistence, and pace; and adapt- ability to stress. Activities of daily living include the following areas: self- care, physical activities (e. In addition to the functional activities outlined, the abilities to under- stand, remember, and perform work procedures, follow instructions, and persist at tasks are central. The patient’s ability to request assistance, re- spond to criticism; get along with coworkers; and maintain socially appro- priate behavior and along with job satisfaction have been found to be related to return to work following work-related injuries (Turk, 1997). Psy- chologists can inquire about some of these areas during an interview. In ad- dition, the clinician can make use of standardized measures and may request a functional capacity evaluation from a trained occupational thera- pist to supplement report. In addition to some of the measures described, there are other instru- ments that can be used to assess functional activities. For example, re- cently an instrument labeled the Impairment Impact Inventory (I3; Turk, Robinson, Cocchiarella, & Hunt, 2001) was developed for use in assessment pain-related impairment. This measure was designed for use with the fifth edition of American Medical Association’s Guides to the Evaluation of Perma- nent Impairment (Cocchiarella & Andersson, 2001). Preliminary data on the reliability, validity, and ability to detect exaggerated responding suggest this may be a promising measure (Robinson, Turk, & Aulet, 2002; Turk, Rob- inson, & Aulet, 2002). For vocational evaluations, it is helpful to know how the patient re- sponds to changes at work and is aware of typical hazards. Many patients with chronic pain report having difficulties related to cognitive functioning. Review of the studies reveals that some chronic pain patients, who have not suffered from traumatic brain injuries or neurological disorders, dis- play deficits in attentional capacity, processing speed, and psychomotor speed (Hart et al. A gross assessment of mental status can be ob- tained with very brief measures such as the Mini-Mental State Examination (Folstein, Folstein, & McHugh, 1975). When a pain patient performs below expected levels on cognitive tests, however, results need to be interpreted in light of their pain medication use, potentially disrupted sleep, emotional factors, and other symptoms.

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Colon and Rectal Surgery Colon and rectal surgeons deal with diseases of the intestinal tract buy lamictal 25mg without prescription, anus buy lamictal 100 mg online, and rectum purchase 25mg lamictal visa. Until 1961 this specialty was called proctology because of the root proctos order 25mg lamictal otc, the Greek word for anus. Colon and rectal surgeons treat all age groups but primarily work with middle-aged and older patients. Although they are surgeons, these specialists perform a mix of medical and surgical procedures. An average day may involve some surgery but also diagnostic tech- niques such as endoscopy, discussed in Chapter 5 under the section on gastroenterology. Colon and rectal surgeons treat hemorrhoids, fissures, polyps, cancer, colitis, and diverticulitis. Many of these diseases and conditions are easy to diagnose, and treatment has a high rate of success. One of the most positive aspects of becoming a colon and rec- tal surgeon is the lack of emergency situations, so these surgeons have more control of their hours than do surgeons in many other specialties. There is a good diversity of patients, ranging from the uncomfortable to the very sick. Colon and rectal surgeons can give quick relief to patients who are suffering from painful conditions. Physicians in this specialty work out of their offices as well as in the hospital. A high degree of manual dexterity is required for this 56 Opportunities in Physician Careers specialty, both because surgery is so exacting and for the diagnos- tic procedures used. New tech- niques for care and preventive measures for colon and rectal can- cer are constantly being sought. Although their area of expertise is narrowly focused, the prerequisite training in general surgery gives these specialists a good working knowledge of internal medicine. This is important because many conditions that colon and rectal specialists treat originate elsewhere in the body. Average salaries range from $158,000 to $318,000 a year for practitioners. Colon and rectal surgeons have one of the longest training pro- grams in medicine. Completion of a five-year program in general surgery is a prerequisite to a one- or two-year residency in colon and rectal surgery. There were only 60 residents active at 37 accred- ited training programs in 2002; 14 percent were women. Neurological Surgery Neurological surgery, better known as neurosurgery, is the diagno- sis, evaluation, and treatment of disorders of the central, periph- eral, and autonomic nervous systems. Practitioners use high-tech equipment such as magnetic resonance imaging (MRI) to diagnose problems. They also meet with patients for regular physical exam- ination in the office. This can be a highly stressful and demanding specialty because it deals with the brain. The variation in outcomes is great; there are remarkable interventions and profound disappointments, as when a patient dies despite heroic intervention. The brain is a fascinating organ, and we are just beginning to understand its mysteries. Surgery and Surgical Specialties 57 The threat of malpractice is greater in neurosurgery than in some other specialties; as a result, insurance premiums are extremely high, as much as $300,000 a year in some states. The hours are long, and because neurosurgeons treat accidents and brain disorders that erupt suddenly, they may be called at any hour of the day. Because of the serious nature of the problems neurosurgeons deal with, prac- titioners get to know their patients well. Neurosurgeons treat brain and spinal cord cancers, hydrocephalus, lumbar and cervical disc disease, aneurysms, and head and spinal cord trauma.

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