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By W. Uruk. University of Wyoming. 2018.

Nevertheless discount diltiazem 60 mg without prescription symptoms 8 days after ovulation, there is evidence that sug- gests that contextual factors influence fundamental sensory buy diltiazem 60 mg mastercard medications prescribed for depression, affective, and cognitive features of the experience of pain (Craig, 1986). Study of social and cultural factors in pain receives little attention rela- tive to the emphasis on biological mechanisms in pain. Pain undoubtedly has been con- served through the phylogenetic development, given its adaptive role. It protects and enhances survival by warning of real or impending tissue dam- age and by motivating avoidance of further harm and efforts to recuperate (Wall, 1999). Associated behavior can be observed in non-human animals, including mammals and non-human primates. These parameters are observable when pain displays are reliably followed by an observer’s actions which promote re- covery and survival, protection from danger, and assistance with life- sustaining requirements (Prkachin, 1997; Prkachin, Currie, & Craig, 1983). For example, animals are frequently sensitive to alarm in other members of their species and use various signals communicating warning to engage in protective be- havior. Certain bird species will fake injury to distract predators from searching for their nest. De Waal (1988) described a chimpanzee who would exaggerate injury by limping pitifully to avoid the brutality of an alpha male in the colony only when he was in that animal’s field of vision. Evidence of physical dysfunction can have more complex social implications. PSYCHOLOGICAL PERSPECTIVES: CONTROVERSIES 313 (1995) provided the following anecdote from Goodall (1986) to illustrate the implications of sick role behavior in non-human species: A polio epidemic struck the chimpanzee troop that Goodall (1986) was ob- serving, and a few of the animals became partially paralyzed. According to Goodall, “When the other chimpanzees saw these cripples for the first time, they reacted with extreme fear; as their fear decreased, their behavior (to- ward the cripples) became increasingly aggressive. The course of human adaptation to its current ecological niche re- quired several million years in progenitor hominids, and perhaps 150,000 years in our species, Homo sapiens. The evolutionary process led to brains with unique mechanisms that allow for language, and a capacity to engage in the intricacies of complex social living that distinguish humans from other species. One can learn a great deal about pain by observing the be- havior and biological mechanisms in nonhuman animals. It is noted that there is considerable cross-species consistency in behavior following injury (Walters, 1994). Nonetheless, a good understanding of human pain would be expected to take into account the evolved features of the human brain that have enabled uniquely human adaptations (Preuss, 2001). It must be understood that human biological predispositions (relating to pain) reflect natural selection pressures to be sensitive to social context (Williams, 2003) and to engage in flexible, adaptive behavior. They also demand integration in models of pain that acknowledge the roles of both nature and nurture as determinants of human pain and illness behavior. The sociocommunications model of pain, described in chapter 4, and adapted to understand pain assessment (Hadjistavropoulos & Craig, 2002), facial expression of pain (Prkachin & Craig, 1995), and pain in infants and children (Craig, Lilley, & Gilbert, 1996; Craig, Prkachin, & Grunau, 2001), ap- pears suited to describe both social complexities and biological predisposi- tions to engage in certain types of pain reactions. It acknowledges key roles for life histories and the current social context as determinants of the suf- fering person’s pain experience, patients’ pain expression, observing per- sons’ (e. An appreciation of the role of pain in complex human organizations remains to be pursued. Introduction of the operant model of pain (Fordyce, 1976; Fordyce, Fowler, Lehmann, & DeLateur, 1968) effectively transformed thinking about the meaning of pain behavior. This approach provided clear evidence that verbal and nonverbal behavior are not necessarily the automatic or reflex- 314 CRAIG AND HADJISTAVROPOULOS ive product of tissue damage, but also may be under the control of external reinforcement contingencies in the form of sympathetic attention from oth- ers, release from aversive responsibilities, potent psychoactive medica- tions, and avoidance of pain. Substantial evidence has accumulated de- scribing the mechanisms and parameters of this perspective (e. Also, there is often a neglect of the costs to the person who finds her or himself suspected of fictional complaint and is often undertreated (Wil- liams, 2003). Nonetheless, the operant model has made a valuable contribu- tion to a formulation of pain behavior recognizing the importance of social learning, contextual, and interactional factors, and it has led to innovations in clinical practice (Fordyce, 1976). Despite its positive impact in our understanding of pain, the operant model has also led to controversies. The operant model is often misinter- preted as suggesting that people in pain purposefully seek insurance bene- fits, even though the model does not include suggestions about conscious deliberation (Badali, 2002; Williams, 2003).

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During sexual maturation order diltiazem 60 mg free shipping medicine nausea, the anabolic effect The growth plate normally adopts a position at right an- of the androgens predominates cheap diltiazem 180mg overnight delivery medicine advertisements, while estrogens acceler- gles to the force resultants. The anabolic effect of jected to compressive and shear forces and, more rarely, the testosterones is responsible both for the faster growth to tensile forces. Typical growth cartilage plates subjected of male animals (and boys) and for the decline in the to tension are those of the lesser trochanter and humeral mechanical strength of the epiphyseal plate at the onset epicondyle. Unlike androgens, estrogens do not have any plays an important role in the strength of the connec- obvious effect on protein synthesis. At low doses, they tend tion between the epiphyseal plate and the metaphysis. During puberty estrogens slow down the activity of the epiphyseal plate possesses indentations and notches the epiphyseal plate, resulting in an acceleration of the mat- of varying depth. This probably explains why shear forces, but do not play a major role in resisting the phase of epiphyseal plate weakening lasts longer, and is tensile forces. Ultimate tensile strength of the anterior cruciate liga- plate in rats according to age and sex. This is markedly reduced during ment after partial division compared to the sham-operated opposite the pubertal growth spurt (between the 30th and 50th days of life), side in young and full-grown rabbits. Experiments have demonstrated that just 15 minutes of loading is required to stimulate osteoblast growth by extracellular signal-regulated kinase (ERK). Ligaments Stiffness, tensile strength and the collagen concentration of ligaments increase with age, whereas their water con- tent decreases. Effect of sex hormones on the tensile strength of the anterior cruciate ligament of juvenile rabbits has a lower proximal tibial epiphyseal plate in rats: a untreated normal male rats, b castrated male rats, c castrated male rats treated with testosterone, tensile strength but a higher elasticity compared to that of a’ untreated female rats, b’ castrated female rats, c’ castrated female full-grown animals (⊡ Fig. The bone in small ligaments increases steadily from birth until the end of children under 6 years of age also has a lower bending puberty, but that the anchorage between ligament and strength than that of adults (150 Pa vs. The im- bone is the critical point during this time, and that a sig- mature bone bends to a greater extent when stressed and nificant reduction in tensile strength occurs in later life. In other words it is The strength of ligaments and their anchorage in bone more plastic and less elastic than mature bone. Strength and stiffness It follows therefore that the bone of small children subsequently decline with increasing age. In Muscle tissue does not appear to represent a criti- clinical terms, this plastic deformation is demonstrated by cal structure in respect of loading capacity during the the greenstick fractures typically seen in children. Muscles possess considerable functional tunately, since the above-mentioned study failed to mea- adaptability and protect themselves against damage due sure the tensile strength of bone, no direct comparison to fatigue. They develop neurologically controlled vol- is possible with epiphyseal cartilage. Our own tests have untary forces and thus represent the active part of the 50 2. But the greatest loads occur pas- probability of suffering a shaft fracture of a long bone is sively, e. These forces are neutralized in bones, ligaments Epiphyseal fractures are much rarer at this age than dur- and cartilaginous tissue and, to a lesser extent, in muscle ing adolescence, and lesions exclusively involving the liga- 2 tissue. So the critical struc- ture in toddlers is not the growth cartilage, and not even Articular cartilage the ligamentous apparatus, but rather the bone. Articular cartilage is subjected primarily to compres- The situation is completely different for adolescents. This reduction in mechanical strength is the cartilage in neonates possesses an undifferentiated struc- cause of several typical disorders and overload syndromes ture, whereas young adults show a highly differentiated whose occurrence depends on the growth rate and the morphology, the extent of which is greatly dependent load. In other words, the loading capacity of which involves a disparity between the actual loading and cartilage appears to be trainable, although this is a very the loading capacity of the cartilaginous endplates of the gradual process. This condition is much to 1000% during the course of growth and is matched by a more common in boys than in girls and predominantly concurrent increase of 100% in the proportion of collagen affects tall adolescents. So what is the current view on the influence of sport- ing activity on the occurrence of this disease? Older Clinical observations statistical analyses show that the disease occurs more Physiological adaptive processes frequently in practitioners of certain sports, particularly The most well-known adaptation process is the increase athletes, ski racers, rowers and racing cyclists. We ficult, however, to compare the various studies with each have already mentioned the changes in articular cartilage. One study will consider the occurrence of a effect of the intensity of exercise on height has been dem- single Schmorl nodule sufficient to secure the diagnosis, onstrated to date, growth in the width of bone does while others refer to Scheuermann disease only in cases of appear to occur, since measurements have shown that fixed total kyphosis of more than 50°. Consequently some the bones of an adolescent undertaking sporting activity statistical analyses report the disease occurring in 50% of are thicker than those of inactive adolescents.

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TABLE 9-10 Results of Osteochondral Autografts AUTHOR N LOCATION MEAN FOLLOW-UP RESULTS Hangody et al purchase diltiazem 180mg online medications dictionary, 2001 461 F >1 year 92% good/excellent 93 P/Tr >1 year 81% good/excellent 24 T >1 year 80% good/excellent Kish discount 60 mg diltiazem mastercard treatment 6th nerve palsy, Modis, and 52 F in competitive athletes >1 year 100% good/excellent Hangody, 1999 63% returned to full sports 31% returned to sports at lower level 90% <30 years returned to full sports 23% >30 years returned to full sports Bradley, 1999 145 18 months 43% good/excellent 43% fair 12% poor Hangody et al, 1998 57 F, P 48 months 91% good/excellent ABBREVIATIONS:F= femur; Tr = trochlea; P = patella; T = tibia. TABLE 9-11 Results of Osteochondral Allografts AUTHOR N LOCATION MEAN FOLLOW-UP RESULTS Aubin et al, 2001 60 F 10 years 84% good/excellent Mean age 27 years 20% failure Bugbee, 2000 122 F 5 years 91% success rate at 5 years Mean age 34 years 75% success rate at 10 years 5% failure Chu et al, 1999 55 F, T, P 75 months 76% good/excellent Mean age 35 years 16% failure Gross, 1997 123 F, T, P 7. CHAPTER 9 ARTICULAR CARTILAGE INJURY 53 TABLE 9-12 Survivorship Analysis of Osteochondral Allografts AUTHOR N LOCATION 5/7. DECISION MAKING of disease progression, primary versus secondary treatment and patient activity demand. This algorithm The choice of surgical intervention is complex and is currently evolving and will undoubtedly change as involves the consideration of many factors, including we acquire new information from animal studies and defect size, depth, location, chronicity, response to clinical trials. Multiple options often exist for similar lesions and there is not necessarily a consensus regarding the opti- REFERENCES mal treatment. Ann rently amenable to a menu-driven decision making Pharmacother 32:574–579, 1998. Clin Orthop 253:197–202, These include: location and size of the injury or extent 1990. A survivor- ular defects in osteochondritis dissecans of the lateral femoral ship analysis. Blevins FT, Steadman JR, Rodrigo JJ, et al: Treatment of articu- Ghazavi MT, Pritzker KP, Davis AM, et al: Fresh osteochondral lar cartilage defects in athletes: An analysis of functional out- allografts for post-traumatic osteochondral defects of the knee. Gill TJ, Steadman JR, Rodrigo JJ, et al: Indications and long- Osteologie 9:17–25, 2000. Gillogly SD, Voight M, Blackburn T: Treatment of articular car- Brittberg M, Lindahl A, Nilsson A, et al: Treatment of deep car- tilage defects of the knee with autologous chondrocyte implan- tilage defects in the knee with autologous chondrocyte trans- tation. New York, NY, Marcel Dekker 1992, Buckwalter, JA: Articular cartilage injuries. Grande D, Pitman M, Peterson L, et al: The repair of experimen- Buckwalter JA, Mankin HJ: Articular cartilage I: Tissue design tally produced defects in rabbit articular cartilage by autologous and chondrocyte-matrix interactions. Gross AE: Fresh osteochondral allgorafts for post-traumatic knee Buckwalter JA, Mankin HJ: Articular cartilage II: Degeneration defects: Surgical technique. Gross AE, Aubin P, Cheah HK, et al: A fresh osteochondral allo- J Bone Joint Surg 79A:612–632, 1997b. Buckwalter JA, Mow VC: Cartilage repair in osteoarthritis, in Hangody L, Feczki P, Bartha L, et al: Mosaicplasty for the treat- Moskowitz RW, Howell DS, Goldberg VM, Mankin HJ (eds. Hangody L, Kish G, Karpati Z, et al: Mosaicplasty for the treat- Buckwalter JA, Rosenberg LA, Hunziker EB: Articular cartilage: ment of articular cartilage defects: application in clinical prac- Injury and repair, in Woo SL, Buckwalter JA (eds. Park Ridge, IL, Hjelle K, Solheim E, Strand T, et al: Articular cartilage defects in American Academy of Orthopaedic Surgeons 1988, pp 465–482. Buckwalter JA, Rosenberg LA, Hunziker EB: Articular cartilage: Hubbard MJ: Articular debridement versus washout for degener- Composition, structure, response to injury, and methods of ation of the medial femoral condyle. Buckwalter JA, Hunziker EB, Rosenberg LC, et al: Articular car- Khanna BAJ, Cosgarea AJ, Mont MA, et al: Magnetic resonance tilage: Composition and structure, in Woo SL, Buckwalter JA imaging of the knee. Park Ridge, IL, American Academy of Orthopaedic Surgeons Kish G, Modis L, Hangody L: Osteochondral mosaicplasty for 1988, pp 405–425. Chu CR, Convery FR, Akeson WH, et al: Articular cartilage Mandelbaum BR, Romanelli DA, Knapp TP: Articular cartilage transplantation. Cole BJ, Frederick R, Levy A, et al: Management of a 37 year old Martin JA, Buckwalter JA: The role of chondrocyte-matrix inter- man with recurrent knee pain. J Clin Outcomes Manag actions in maintaining and repairing articular cartilage. Curl W, Krome J, Gordon E, et al: Cartilage injuries: A review of Meyers MH, Akeson W, Convery F. J Bone Joint Surg 71A:704–713, DaCamara CC, Dowless GV: Glucosamine sulfate for oste- 1989. Micheli LJ, Browne JE, Erggelet C, et al: Autologous chondro- Finerman GAM, Noyes FR (eds. Clin J Sports Med 11:223–228, American Academy of Orthopaedic Surgeons 597, 1992. CHAPTER 10 MUSCLE AND TENDON INJURY AND REPAIR 55 Minas T: Autologous chondrocyte implantation for focal chon- This chapter will review injury and repair of muscle dral defects of the knee.

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It might be difficult to reach consensus on the nonviolence issue in this case discount diltiazem 180 mg visa medicine man aurora. If we discount 180mg diltiazem with mastercard treatment 7th march bournemouth, as a society, were ever prepared to argue that euthanasia to termi- nate unremitting pain is ethical, we would also have to ask the question as to who should make such decisions for people with severe cognitive impair- ments. We all know that par- 332 HADJISTAVROPOULOS ents and relatives often make mistakes. We also know that the extreme stress that can be associated with illness and disability in the family (e. When it comes to the Latimer case, the truth is that we will never know exactly how much pain Tracy was in and what she would want. In various research projects that we conducted we demonstrated that biases (e. For instance, in one study we showed that trained health professionals observing videos of peo- ple undergoing a painful medical procedure attributed less pain to the pa- tients than did untrained observers (Hadjistavropoulos et al. Any one individual making this decision for Tracy may have been influenced by factors that are not necessarily relevant to her pain experience. Separate from the issue of euthanasia, there is a second ethical concern that relates to the Latimer case. This relates to the obligation of psycholo- gists to help ensure that people with severe cognitive impairments have ac- cess to adequate pain assessment and management. This issue is less con- troversial than the ethical questions raised by Tracy’s death because the perspectives of deontolology (e. Nonetheless, as McGrath (1998) pointed out, our field as a whole has failed the Latimer family both in terms of our ability to systemati- cally and accurately assess pain and in terms of our ability to manage it. ETHICAL STANDARDS ADOPTED BY IASP AND APS A basic background in ethics philosophy sets a foundation for pain clini- cians and researchers who consult and study codes of ethics and stan- dards. Generally, such documents stress the im- portance of respect for dignity, caring, and the need for sound research de- signs where pain needs to be studied. IASP Guidelines The International Association for the Study of Pain (IASP, 1983, 1995) has published guidelines for pain research relating to the study of pain in both humans and animals. The IASP (1995) guidelines concerning humans stress that dignity, safety, and health are paramount in research and that the re- searcher always has the ultimate responsibility for maintaining high ethical standards. Moreover, IASP’s guidelines stress the need for appropriate and thorough ethics review of research by a well-constituted ethics committee or board. This im- plies that the elements of mental capacity and adequate information should also be present (Rozovsky, 1990). However, it is not always possible to clearly determine what constitutes “adequate information” in situations where consent is being sought. In making this determination it is important to know the type of information that potential research participants expect and want. Casarett, Karlawish, Sankar, Hirschman, and Asch (2001) set out to clarify this issue by presenting pain patients with vignettes describing various research studies and subsequently interviewing them about the type of information they would have liked to have had before enrolling. Par- ticipants stressed the need for information about study-related changes in medications, contingency plans, and assurances about how increased pain would be treated. They also raised concerns about addiction to opioids as a result of participation in the study (this is likely to arise when psychologists conduct research within the context of broader studies involving medical professionals). Most patients indicated that they would want to know how knowledge generated from their study might help them, as well as about burdens and inconveniences associated with study participation. Thirty- eight percent stated that they would like to know how study participation might give them improved access to a health care provider, 55% desired information about treatment availability following the completion of the study, 62% desired information about changes in medication and dose, 78% of patients described concerns about increased pain as a result of study participation, 70% said that they would want information about previous re- lated studies of the treatment, and all patients indicated that they wanted information about potential treatment risks and side effects. Patients also wished to know whether they would have continued access to the treat- ment used in the study after the trial is over. Similar investigations focusing specifically on psychological studies of pain would be useful. With respect to the IASP guidelines concerning the importance of written consent, we note that for some cultural groups in our society written con- sent may not be considered appropriate. In some instances, for example, it may be appropriate (for research ethics boards and institutional review committees) to approve consent by traditional native ceremony as long as this is fully voluntary and informed.

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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 buy generic diltiazem 60mg online keratin intensive treatment. As a rule discount 180mg diltiazem visa medications that interact with grapefruit, however, the func- Capitate and hamate bones 2 months tional gain is limited since the lengthening of the muscles results in a loss of power, and the surgery tends rather to Triquetrum bone 1. Middle phalanges 2 years Naturally the muscles must be rearranged and modi- fied in order to produce a genuine pinch grip. Since this patient was unable to wedge objects in her elbow, a stump lengtheningprocedure with the Ilizarov apparatuswas performed at 15 years of age. The mobility in the elbow was a preserved, producing a significant functional gain 470 3. Occupational therapy is particu- larly important in the postoperative phase, for example, if the pinch grip has to be taught after a pollicization procedure. Prosthetic provision may be considered if signifi- cant parts of the hand are lacking. Only very simple braces have proved effective, for example those that 3 allow something to be wedged or that can be used as a counter support. Complex prosthesis offering numerous functions are almost never used in practice for unilateral deformities since the unimpaired hand can take over all the relevant tasks with the exception of counter support which, in any case, only requires a simple appliance. Even mechanical prostheses with shoulder traction, el- bow movement or a grasp function with a hook are rarely used by patients with a unilateral deformity. For certain occupations, however, a hook may be needed to perform the work, although this factor only comes into play after completion of growth. A powerful pinch grip is now possible known, and clubhand usually occurs sporadically. The clubhand may be associated with the following other congenital anomalies: ▬ thrombocytopenia (TAR syndrome = thrombocyto- experience. If the outcome is successful, however, the penia absent radius syndrome): A normal thumb may operation is of great benefit to the patient. Much more be present in this syndrome, despite the absence of the problematic is the transfer of toes to the hand. The radius nerve supply is uncertain and, since the toe can always Fanconi syndrome be identified as such, the aesthetic gain is very limited. Holt-Oram syndrome (hereditary form, associated In the peromelia type of symbrachydactyly, however, a with atrial septal defect, see chapter 4. In VACTERL syndrome (anomalies of the vertebral individual cases, rotational or wedge osteotomies may be column, anal atresia, cardiac anomalies, tracheo- appropriate for correcting abnormal positions of rudi- esophageal fistula, renal malformation and limb de- mentary fingers. Conservative treatment At birth, the forearm is shortened and the hand deviates Conservative treatment consists, on the one hand, of oc- in the radial direction. The forearm is around 25–50% cupational therapy and, on the other, of prosthetic provi- shorter than normal. However, since this usually improves to enable the child to use the malformed hand as much spontaneously, treatments should not start at too early a as possible in the most effective way. Apart from contracture of the elbow, stiffness of the taught to use the arm stump as a counter support, wedge metacarpophalangeal and proximal interphalangeal joints objects in the elbow or use any rudimentary fingers as may also be present. The 1st metacarpal In the centralization procedure, the ulna is transferred is always hypoplastic. But the deformity affects not only to the middle of the carpus beneath the lunate bone and the bone structures, but also the soft tissues. The flexor stabilized with an osteoperiosteal flap, leaving the muscles pollicis longus muscle is usually missing, the flexor carpi in place. In the radialization procedure, on the other radialis is usually present, but the radial carpal extensors hand, the ulna is transferred right over to the radial side are weak or completely missing. The extensors of the beneath the navicular bone, while the radial muscles are index finger and the middle finger are hypoplastic and transferred to the dorsoulnar side of the wrist. In the event of any erations are capable of producing a stable configuration. Nevertheless, it is usually possible to produce an opposable thumb with this Treatment procedure, which is, of course, particularly important for At birth, the hand can usually be corrected from its ab- a bilateral deformity.

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