Public Interest Law Initiative


By E. Bram. College of Mount Saint Vincent.

The muscle dysfunction can also manifest itself in the form of weakness or complete paresis purchase phenergan 25mg fast delivery anxiety symptoms returning. The pareses are > Definition always flaccid order phenergan 25 mg fast delivery anxiety symptoms racing thoughts, and spasticity never occurs. The presence Nerve lesions outside the central nervous system involve of sensation and/or motor function rules out a complete the spinal nerve roots, the peripheral nerves and the ana- nerve lesion. But if complete lesions are present, only the tomical structures in plexus form located between the 4 course of the condition will show whether the neuronal two. Since the lesions affect only the axons of the nerve structures are actually interrupted or not. The lesions are subdi- that are not clinically detectable and thus enable a more vided into plexus palsies and peripheral nerve injuries. The neural structures can be Etiology and pathogenesis depicted directly on an MRI scan. Moreover, in the case of Peripheral neural structures in children can be damaged plexus injuries, the roots can be shown in their pouches as a result of a variety of injuries. Accidents are by far the most Treatment and prognosis common cause of these lesions. Unfortunately, damage Measures for nerve lesions are basically curative or pal- can also occur during birth or as a result of therapeutic liative. Nerves can be injured by conservative treat- A curative procedure is suturing of the damaged ments such as plaster casts or dynamic splints (peroneal nerve, with or without interposition. The prognosis is nerve paresis as a result of pressure exerted by a cast on better for early than for late interventions and better for the fibular head is a familiar example). On a proximal extrem- Damage to the peripheral nervous system can also ity, a success rate of 80–90% can be expected after early occur during major treatments such as limb lengthen- reconstruction. The results are not so good for a lower ing procedures or, during surgery, by positioning aids extremity, particularly if the peroneal nerve is involved or surgical instruments. For secondary procedures, the results are worse outside the CNS can vary according to the frequency and by 10–20% [1, 7, 8]. A pathophysiological distinction Prognostically negative factors in relation to the results is made between a neurapraxia, an axonotmesis and a after reconstructive operations: neurotmesis. In extension of the lesion, axonotmesis the axons are interrupted, although the key certain nerves (e. The axons re- grow at a rate of 1 mm/day along the key structures from Contractures and movement restrictions in the affected the proximal end. If the latter are interrupted or refixed section of the extremity must be prevented so that the with staggered alignment, defective innervation results. Neurotmesis refers to the complete Reconstructive procedures on nerves are not always severance of the axons and key structures. But modern microsurgical anastomosis techniques now provide the option of a free Clinical features and diagnosis muscle transfer in which a power generator is transferred Sensory and motor function are impaired or completely from a remote site (where the deficit does not matter so absent in the area of the affected nerve or nerve roots. Kallio PK, Vastamaki M (1993) An analysis of the results of ▬ The muscle anatomy of the transferred muscle must late reconstruction of 132 median nerves. J Hand Surg (Br) 18: 97–105 match that of the replaced muscle as closely as pos- 8. Kallio PK, Vastamaki M, Solonen KA (1993) The results of second- sible so that it can exert its full power at a length at ary microsurgical repair of radial nerve in 33 patients. Surg (Br) 18: 320–2 ▬ Normal innervation of the transferred muscle and 9. Lijftogt HJ, Dijkstra R, Storm van Leeuwen JB (1987) Results of good motor coordination. Neth J Surg 39: 170–4 ▬ Correct phasic activity of the transferred muscle (this 10. Millesi H, Meissl G, Berger A (1976) Further experience with inter- is easier to achieve for a former synergist than for a fascicular grafting of the median, ulnar, and radial nerves.

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Investigations showed that these types of treatment programs do promote changes in pain-specific beliefs generic phenergan 25mg otc anxiety 05 mg, coping style purchase 25mg phenergan with amex anxiety 4 weeks after quitting smoking, and behavior, as well as pain severity (e. Indeed, it was specifically dem- onstrated that increased perceived control over pain and decreased catas- trophizing are associated with decreases in pain severity ratings, functional disability, and physiological activity (e. FEAR-AVOIDANCE MODELS Model Summary The role of fear and avoidance behavior as they relate to chronic pain have received considerable attention over the past decade (for recent reviews, see Asmundson et al. Indeed, the literature in this area has grown to the point where state-of-the-art theory and research are being published in the form of an edited book (Asmundson, Vlaeyen, & Crombez, 2003). The postulates of fear-avoidance models have their roots in early observations of significant anxiety in the pathology of pain (e. BIOPSYCHOSOCIAL APPROACHES TO PAIN 49 Several fear-avoidance models have been proposed to account for chronic pain behavior. The fear-avoidance model of exaggerated pain per- ception (Lethem, Slade, Troup, & Bentley, 1983), for example, attempted to explain the process by which the emotional and sensory components of pain become desynchronous (i. Extending postu- lates of the operant model of chronic pain, Philips (1987) incorporated ele- ments of the cognitive theory of avoidance (Seligman & Johnson, 1973) to explain cases where behavioral withdrawal was observed to continue in the absence of adequate reinforcement. Avoidance was viewed as a product of pain severity, a preference for minimizing discomfort, and cognitions (com- prising expectancies, feelings of self-efficacy, and memories of past expo- sures) that reexposure to certain experiences or activities will result in pain and suffering. Reprinted from Vlaeyen and Linton, “Fear- avoidance and its consequences in chronic musculoskeletal pain: A state of the art,” p. Reproduced with kind permission from the In- ternational Association for the Study of Pain, 909 NE 43rd Ave, Suite 306, Seat- tle, WA, USA. In this context, then, confrontation is conceptualized as an adaptive re- sponse that is associated with behaviors that promote recovery. Avoid- ance, on the other hand, is viewed as a maladaptive response that leads to a number of undesirable consequences. These include limitations in activ- ity, physical and psychological consequences that contribute to disability, continued nociceptive input (which, like the Glasgow model, may not neces- sarily be related to original injury; also see Norton & Asmundson, 2003), and further catastrophizing and fear. Empirical Overview Vlaeyen and Linton (2000) published a state-of-the-art review showing an ever-increasing number of findings that corroborate postulates of fear- avoidance models. Precursors of pain-related fear, including anxiety sensi- tivity and health anxiety (i. For example, in a sample of chronic musculoskeletal pain patients, Asmundson and Taylor (1996) found that anxiety sensitivity directly influences fear of pain, which, in turn, directly influences self-reported escape/avoidance behavior. There is converging evidence demonstrating that fear of pain affects the way people attend and respond to information about pain (As- mundson, Kuperos, & Norton, 1997; Eccleston & Crombez, 1999; Hadjistav- ropoulos, Craig, & Hadjistavropoulos, 1998; McCracken, 1997; Peters, Vlae- yen, & Kunnen, 2002; Snider, Asmundson, & Weise, 2000). Likewise, there is mounting evidence that fear of pain influences physical performance and is more strongly related to functional disability than are indices of pain sever- ity (Crombez, Vervaet, Lysens, Baeyens, & Eelen, 1998; Crombez, Vlaeyen, Heuts, & Lysens, 1999; McCracken, Zayfert, & Gross, 1992; Vlaeyen et al. Finally, at the practical level, specifically treating the “fear” component using techniques known to be effective in reducing fears (i. METHODOLOGY IN WASHBACK STUDIES 51 musculoskeletal pain (Linton, Overmeer, Janson, Vlaeyen, & de Jong, 2002; Vlaeyen, de Jong, Geilen, Heuts, & van Breukelen, 2001; Vlaeyen, de Jong, Onghena, Kerckhoffs-Hanssen, & Kole-Snidjers, 2002). TOWARD AN INTEGRATED DIATHESIS–STRESS MODEL Our presentation of the various faces of pain shows, to a large degree, a de- velopmental progression from the simplistic notions of somatogenic and psychogenic causation through to the increasingly elaborate yet parsimoni- ous postulates of the contemporary multidimensional, biopsychosocial ap- proaches. In scanning the essential elements of the various models consid- ered under the rubric of “biopsychosocial,” certain consistencies and themes are apparent. These include recognition of the importance of (a) some physiological pathology (which may not remain the same as that as- sociated with initial nociception), (b) some form of vulnerability (diathesis), (c) a tendency to catastrophically misinterpret somatic sensations and re- spond to them in maladaptive ways, and (d) the development of a self- reinforcing vicious cycle that serves to exacerbate and maintain symptoms and functional disability. Taking an approach similar to that employed by Sharp (2001) in his recent reformulation of Turk and colleagues biobe- havioral model of pain (Turk, 2002; Turk & Flor, 1999; Turk et al. It is important to keep in mind that pain and pain behaviors do not occur in isolation. Rather, they are communicated in (see Hadjistavropoulos & Craig, 2002) and influenced, for better or worse, by one’s social, interper- sonal, and cultural milieu (e. For example, a supportive environment can facilitate efforts to cope with pain; however, if there is not enough or, indeed, too much support (i. This appears to hold true for interactions with signifi- cant others as well as those responsible for medical care, litigation, and other such responses (see Sharp, 2001). Similarly, social modeling and social learning experiences influence strongly the way in which one interprets and responds to signs and symptoms of illness (e. So, interpre- tation and behavioral responses to pain depend, to some degree, on what is learned from seeing others in pain and from cultural norms. This is recog- nized, to varying degrees, in all of the biopsychosocial models discussed ear- lier and provides the umbrella under which our model is placed.

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Apophyseal injuries occur most commonly around the pelvis generic 25mg phenergan anxiety icd 9, with the most frequent sites being the ante- rior inferior iliac spine purchase phenergan 25 mg free shipping 8 tracks anxiety, anterior superior iliac spine, 2. Acute avulsion Physeal Injuries injuries are seen on the plain radiograph as crescentic osseous fragments and may heal with abundant callus Damage to the physis may lead to temporary or per- due to associated haematoma (Fig. Growth plate inju- lead to unusual radiographic appearances, which can ries are usually classified according to the Salter- be mistaken for tumour. MR imaging may help to Harris system where the higher the value assigned clarify the diagnosis and avoid a potentially mislead- to a fracture pattern the worse the prognosis. Note that healing fractures may exhibit of these fractures are apparent on plain radiographs, cellular change that can be similar to that seen in which may demonstrate epiphyseal displacement. Other signs include widening of the physis, and Clinically, it is often difficult to distinguish loss of definition of the opposing surfaces of the between a simple muscle strain and an apophyseal epiphysis and metaphysis. The plain radiograph may be unhelpful if of growth-plate injury occurs during adolescence, the ossification centre of the apophysis has not yet perhaps due to increased exposure to high-energy formed. However, in young athletes the correct diag- trauma combined with weakening of the growth nosis is necessary to establish the appropriate treat- plate that occurs with puberty. This involves avulsion of the largely unossi- fied distal pole of the patellar in the form of an osteo- An apophysis is a growth centre where a tendon attaches chondral avulsion. Its cartilaginous growth plate remains weaker haemarthrosis and an inability to straight-leg raise. Applying disruption (high-lying patellar) with an intraarticu- the principle of failure at the weakest link, it is pre- lar fracture (lipohaemarthrosis) and osteochondral dictable that a sudden forceful muscular contraction fragment (Fig. Young athletes are visualize radiographically although it is well dem- 22 P. The arrowheads outline haematoma tracking deep to the proximal tendon (Image courtesy of Dr P. The patient presented acutely following injury while sprinting with pain and an inability to straight-leg raise. The radiograph shows effusion (asterisks) and elevation of the patella (P) relative to the femur (F). The arrows outline faint calcification within an osteochondral frag- ment Trauma and Sports-related Injuries 23 onstrated at US. This injury is differentiated from a chondral fracture is non-radiopaque, and the den- an osteochondral body by the fact that the patellar sity of osteochondral fragments depends on the tendon remains attached to the fragment (Fig. Frac- ture fragments may become more apparent as loose bodies when their cartilage undergoes degenerative 2. Osteochondral fragments have char- Acute Osteochondral Injuries acteristic appearances at US with hypoechoic car- tilage attached to a variable amount of subchondral Abnormal joint motion leading to shearing, rotatory bone (Fig. Diagnosis of osteochondral fracture or impaction forces may fracture one or both of the therefore requires a high index of clinical suspicion opposing joint surfaces. Resultant fracture fragments based on knowledge of the mechanism of injury. MR may consist purely of cartilage (chondral fracture) or imaging is of value in demonstrating the donor site cartilage attached to a bony fragment (osteochondral of displaced fragment. These injuries may be difficult to deduce lish the extent of any bone, cartilage and internal from the plain radiograph in the acute phase, since joint disruption, and is useful for planning treatment Fig. US demonstrates a large cartilaginous component (C) compared to the subchon- dral bone avulsion (arrows) with the diagnosis of patel- lar sleeve fracture confirmed by demonstrating attach- ment of the patellar tendon (PT) to the osteochondral fragment Fig. Most non-displaced lesions in patients with quate lateral radiograph is not obtained. Transphy- open physis will heal with conservative management, seal supracondylar fractures can be clearly shown but displaced fragments or skeletal maturity often with US. Unstable lateral humeral condyle frac- require surgical intervention. It is well tolerated by an injured child considered necessary to distinguish between the who may find positioning for radiographs distress- conservatively treated stable fracture, and the surgi- ing. Certainly, it is preferable to MR imaging which cally treated unstable fracture, which extends to the may require a general anaesthetic. However, ultrasonography has recently cians have found it to be helpful in guiding the reduc- been shown to be capable of ruling out joint involve- tion of difficult paediatric forearm fractures.

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More superficial thoracic burns can cause a similar defect as thoracic compliance is decreased slowly by edema that develops during resuscita- tion with fluids buy phenergan 25 mg with amex anxiety symptoms with menopause. Dyspnea buy 25mg phenergan free shipping anxiety love, hoarseness, and coughing are often present initially in burn pa- tients but often resolve spontaneously. Stridor should be differentiated from hoarseness as a more ominous sign. High-pitched inspiratory noise over the upper airway is characteristic of critical narrowing of the airway. In the context of fluid resuscitation for burn injuries, this can be rapidly progressive and demands immediate evaluation and probably intervention as well. Other signs of airway obstruction include use of accessory respiratory muscles, sternal and suprasternal retractions, and paradoxical thoracoabdominal movement. Evaluation of the impact of an inhalation injury must take into account the presence of associated injuries. The combination of full-thickness burns with inhalation injury requires a larger volume of fluid for resuscitation than for the burns alone. Underresuscitation as well as overresuscitation of cutaneous burns can exacerbate the effects of an inhalation injury. The ability of a patient to compensate for an inhalation injury is diminished by injuries that make breathing difficult (e. None of the above observations from the history and physical examination can be considered 100% sensitive and specific for inhalation injury. The value of these clinical indicators increases when multiple risk factors coexist. It has been stated that the diagnosis of inhalation injury becomes easier with the passage of time. However, morbidity is minimized by early diagnosis and treatment of inhalation injury. Diagnostic Studies History and physical examination will identify patients at risk for inhalation injury as well as those who urgently need intubation and mechanical ventilation. For patients at risk for injury but not currently experiencing respiratory failure, addi- tional information is necessary. Diagnostic studies can provide objective informa- tion about extent of injury and physiological status (Table 4). TABLE 4 Diagnostic studies for evaluation of inhalation injury Pulse oximetry Arterial blood gas analysis Chest radiograph Fiberoptic bronchoscopy Pulmonary function tests Radionuclide ventilation–perfusion scans can be critical for timely decisions. Serial measurements may be necessary for some studies because the pathophysiological changes develop with time. Pulse Oximetry Pulse oximetry provides a sensitive and continuous means of assessing oxygena- tion. The continuous tone produced by the instrument allows practitioners to monitor oxygenation constantly while concentrating on other aspects of patient care. A change in tone is readily recognized by experienced clinicians despite other distracting noises or activities. The plethysmograph function of the pulse oximeter can be used to help assess peripheral perfusion in extremities that may be compromised by tense edema or vascular injury. Loss of pulse oximeter signal in a finger or toe may indicate deterioration in perfusion. Since function requires an extremity with a pulse, it may be difficult to find a suitable site for the probe in some patients. In addition, standard pulse oximeters cannot identify carboxyhemoglobin. This means that patients with tissue hypoxia due to carbon monoxide toxicity cannot be diagnosed using pulse oximetry. Arterial Blood Gas Analysis Arterial blood gas analysis provides a definitive measure of pulmonary gas ex- change. Initial measurement of PaO2 is an insensitive marker for inhalation injury because there is usually some delay in development of gas exchange impairment after smoke inhalation. Although this method is an insensitive prognostic marker, early hypoxia is an ominous sign of severe injury. Analysis of arterial blood gases provides useful information in patients with inhalation injury, especially in the presence of cutaneous burns.

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