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C. Agenak. Morningside College.

This chapter examines the most commonly employed approaches to the treatment of chronic pain as well as the empir- ical evidence (or lack thereof) pertaining to their efficacy order super p-force 160mg without a prescription smoking causes erectile dysfunction through vascular disease. Widely used cog- nitive/behavioral approaches are featured purchase 160 mg super p-force erectile dysfunction treatment operation, but psychodynamic perspec- tives are also examined. The manner in which medication usage relates to 10 HADJISTAVROPOULOS AND CRAIG psychological treatment (e. More- over, a discussion of how psychological interventions can be applied with postsurgical and presurgical pain patients is included. The last section of the volume focuses on current controversies and ethi- cal issues. Craig and Thomas Hadjistavropoulos reviews current controversies, including critical analyses of the definition of pain, frequent unavailability of psychological interventions for chronic pain, the use of self-report as a gold standard in pain assessment, fears about the implementation of certain biomedical interventions and others. The final chapter by Thomas Hadjistavropoulos presents a discussion of ethical standards put forth by organizations of pain researchers and psy- chological associations. The presentation of these standards is supple- mented by a discussion of ethical theory traditions on which such stan- dards are based. The chapter also provides coverage of various ethical concerns that are unique to the field of pain, as well as an overview of con- cerns that are especially relevant to psychologists. We hope that the views presented herein will provide both a better ap- preciation of state-of-the-art developments in the psychology of pain and a greater appreciation of the richness and complexity of the pain experience. Sex-related differences in the effects of morphine and stress on visceral pain. Prevalence of chronic pain in the British population: A telephone survey of 1037 households. Gender differences in pain ratings and pupil reactions to painful pressure stimuli. An application of behavior modification tech- nique to a problem of chronic pain. A theoretical framework for understanding self- report and observational measures of pain: A communications model. Sensitivity to cold pressor pain in dysmenorrheic and non-dysmenorrheic women as a function of menstrual cycle phase. Montreal: Canadian Consortium on Pain Mechanisms, Diagnosis and Management. Abdominal pain and ir- ritable bowel syndrome in adolescents: A community-based study. International Association for the Study of Pain Ad Hoc Subcommittee for Psychology Curricu- lum. The tragedy of dementia: Clinically assessing pain in the confused, non- verbal elderly. Sensory motivational and central controlled determinants of pain: A new conceptual model. An epidemiologic analysis of pain in the elderly: The Iowa 65+ Rural Health Study. Sex differences in the an- tagonism of swim stress-induced analgesia: Effects of gonadectomy and estrogen replace- ment. Gender differences in pain per- ception and patterns of cerebral activation during noxious heat stimulation in humans. Expressing pain: The communication and interpretation of facial pain signals. Some embryological, neurological, psychiatric and psychoanalytic impli- cations of the body scheme. CHAPTER 1 The Gate Control Theory: Reaching for the Brain Ronald Melzack Department of Psychology, McGill University Joel Katz Department of Psychology, Toronto General Hospital Theories of pain, like all scientific theories, evolve as a result of the accumu- lation of new facts as well as leaps of the imagination (Kuhn, 1970). The gate control theory’s most revolutionary contribution to understanding pain was its emphasis on central neural mechanisms (Melzack & Wall, 1965). The the- ory forced the medical and biological sciences to accept the brain as an ac- tive system that filters, selects, and modulates inputs.

The anabolic effect of jected to compressive and shear forces and super p-force 160mg sale impotence at 55, more rarely super p-force 160mg free shipping erectile dysfunction caused by low testosterone, 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. It is equally possible that these dif- where we apply stricter criteria, we observed the disease ferences are indicative of the average constitution of the in 11–17% of athletes compared to 1–2% of the gen- sporting adolescent and that constitution type inherently eral population.

The main problem with this measurement is that the back of the tibial condyle at knee level is rounded buy generic super p-force 160 mg line erectile dysfunction treatment san diego, thereby prevent- ing any clear axis to be determined purchase 160 mg super p-force free shipping erectile dysfunction 3 seconds. But since therapeutic measures only need to be considered if the values are very abnor- mal, we believe that the inaccuracy of this measurement ⊡ Fig. The knee axes can be through the femoral necks, the femoral condyles, the tibial condyles measured radiographically on AP x-rays, with smaller and the malleoli to enable the axis to be determined. Increased children standing on both legs and older children stand- femoral anteversion and increased lateral torsion of the lower leg are ing on one leg. We consider the anteversion to be pathologi- The derotation is much better in children who are able cal from an angle of 50° and above. Gait in- shown that the increased anteversion usually returns to vestigations have also shown that the load transfer differs normal during the course of growth. However, dero- greatly during an intoeing gait compared to a normal gait tation fails to occur in isolated cases, i. If the increased anteversion were offset by increased angle still remains 50° and above at completion of growth. Various investigations have ▬ the presence of a (minimal) cerebral palsy, shown a positive correlation between femoral and tibial ▬ compensation of the increased anteversion at the fem- torsion. The problem, however, lies in the fact that the knee is rotated in an intoeing gait and is not aligned with the The physiological correction of the increased anteversion is direction of walking. The derotation of the femoral neck can be described On the other hand, the increased anteversion does not as a »physiological slip of the capital femoral epiphysis have any long-term consequences for the hip. No », since the direction of movement of the femoral head increased incidence of osteoarthritis of the hip has been in relation to the shaft corresponds to that in epiphyseal observed, for example. And this is logical, since the separation, which shows that the dynamic forces during internal rotation of the femur during walking produces upright walking produces this alignment of the femoral a physiological position at the femoral neck. A recent study has shown a correlation between the position of the knee that is pathological. In contrast increased anteversion, reduced hip extension and motor with the increased anteversion of the femoral neck, ret- development. We therefore consider that the supramalleolar tibial quires correction [6, 16]. The best age for this is between derotation osteotomy is indicated if there is a lateral 8 and 10. Up until the age of 8 we await the outcome of torsion of more than 40° or a reduced tibial torsion spontaneous developments, although the lateral torsion of 5° and under. The supramalleo- lar tibial derotation osteotomy can be carried out at this Genua vara are always pathological. This is a minor and safe procedure associated with occur after the start of walking, particularly in children minimal morbidity and gives the child the chance to dero- who start walking at a very early age, i. This operation should not be performed after the varus axis can take on dramatic proportions at the age age of 10. It is usually associated with pronounced if the fibula is osteotomied as well. Fixation is more com- medial torsion of the tibia, making the genua vara appear plicated and spontaneous derotation of the femur can no even more extreme. The prognosis for these idio- such cases unless the torsion of the femoral neck were also pathic cases of genu varum is very good in small children corrected, which – when performed bilaterally – is quite provided there is no underlying pathology. Pathological forms occur in with a genu varum, but is very atypical in clubfoot. This condition involves a necro- Consequently, the externally rotating tibial derotation sis in the area of the proximal medial tibial epiphysis, osteotomy is rarely indicated in clubfoot. AP and lateral x-rays of the left knee in a 3-year old boy with osteonecrosis of the medial femoral condyle (Blount’s disease) 552 4. In addition to the infantile form, there is a juvenile variant, which can involve the spontaneous formation of a medial bridge across the epiphyseal plate and necrosis of the proximal medial tibial epiphysis. Rickets can be related to the diet or occur as a vitamin D-resistant condition ( Chapter 4. A varus position with an intercondylar distance of more than 2 cm should be corrected, particularly if a rotational deformity is also present in the lower leg. Up until the age of 8–10 years a gap between the malleoli is apparent in most children when the knees are approximated. The persistence of genua valga beyond the age of 10 is rare and almost always caused by rela- tively pronounced overweight.

If be performed via the traditional access routes (which are possible super p-force 160 mg visa erectile dysfunction remedies, this consultation process generic super p-force 160mg on-line erectile dysfunction medicine list, including a discussion usually crossed by vessels and nerves), but always 1–2 cm of the radiographic findings, should clarify the following away, through the muscle proceeding directly to the bone. In addition to matrix formation (osteoid, The differential diagnostic ranking will produce vari- chondro-osteoid, hyaline cartilaginous or myxoid car- ous options for substantiating or ruling out clinical tilage matrix), the cellular composition of the lesion in conditions by means of additional investigations. An particular should be examined, and the pathologist will undifferentiated sarcoma, for example, can be identi- need to establish, whether any matrix is formed from fied as an osteosarcoma if enzyme histochemical tests tumor cells or whether e. However, this very immature, pseudosarcomatous new bone formation test can only be performed on unfixed tissue that is is involved. The same applies to molecular biologi- cells occur in numerous lesions and can frequently con- cal investigations and the detection of the transloca- fuse the diagnostician. Microbiological Pseudocystic, blood-filled cavities are also not neces- investigations should be arranged if osteomyelitis is sarily synonymous with the diagnosis of an aneurysmal suspected. The possibility of callus-like quired therapeutic procedures be implemented on new bone formation with superimposed microfractures site? For these reasons, the tentative The answer to this question is of crucial importance histological diagnosis should always be checked against to the subsequent outcome. If any discrepancies arise between diagnostic and therapeutic experience, irreparable the radiological and the histological diagnosis, and if mistakes that impair the prognosis can be made even these are not satisfactorily resolved in the interdisciplin- at the biopsy stage. Consequently, the decision as to ary discussion, even including one with experienced spe- whether the patient can subsequently be treated on cialists, a further biopsy should be performed, possibly in site or will need to be transferred to a specialist hospi- a center with corresponding diagnostic and therapeutic tal must be made before the biopsy. Remarks on the biopsy procedure If the differential diagnostic alternatives are clear and the 4. The surgeon Once the diagnosis has been confirmed, the overall situa- should collect a sufficiently large tissue sample – approx. The usual staging system for tu- the periphery to the center of the tumor. The pathologist must possess pre- not involved (since they are rarely affected) and, on the cise knowledge, on the basis of the x-ray, of the biopsy site. For these reasons Enneking as possible (ideally under frozen section conditions) and has introduced a separate staging system for bone tu- forwarded for further investigations. Imprint cytology can mors that takes account of the following parameters: be used to prepare unfixed biopsy material and samples the histological differentiation grade (G), shock-frozen for additional investigations (see above). A the anatomical situation of the tumor (T) frozen section diagnosis is then required only if it involves (i. As a rule, all In principle, a bone tumor becomes extracompartmental 594 4. Metastases are either not detectable (M0) or Like bone tumors, soft tissue tumors must also be staged. Ac- Apart from the histological differentiation grade (G), the cordingly, benign tumors can be divided into three stages anatomical situation of the tumor (T) – i. Staging of the tumor enables the orthopaedist to presence of metastases, the regional lymph nodes should decide on the appropriate treatment ( Chapter 4. Staging of malignant soft tissue tumors according to the UICC Staging System Stage Histological differentiation Anatomical situation Lymph nodes Metastases (= M) (Grade = G) (Site = T) (Nodes = N) IA G1 (differentiated) T1a/b (≤5 cm) N0 (none) M0 (none) G2 (moderate) T1a/b (≤5 cm) N0 (none) M0 (none) IB G1 (differentiated) T2a (>5 cm) N0 (none) M0 (none) G2 (moderate) T2a (>5 cm) N0 (none) M0 (none) IIA G1 (differentiated) T2b (>5 cm) N0 (none) M0 (none) G2 (moderate) T2b (>5 cm) N0 (none) M0 (none) IIB G3 (dedifferentiated) T1a/b (≤5 cm) N0 (none) M0 (none) G4 (dedifferentiated) T1a/b (≤5 cm) N0 (none) M0 (none) IIC G3 (dedifferentiated) T2a (>5 cm) N0 (none) M0 (none) G4 (dedifferentiated) T2a (>5 cm) N0 (none) M0 (none) III G3 (dedifferentiated) T2b (>5 cm) N0 (none) M0 (none) G4 (dedifferentiated) T2b (>5 cm) N0 (none) M0 (none) IV G1–4 T1–2 N1 (present) M0 (none) G1–4 T1–2 N0/1 (±) M1 (present) 595 4 4. Foukas A, Deshmukh N, Grimer R, Mangham D, Mangos E, Taylor S ⊡ Table 4. Tumor staging in the UICC system (2002) Stage-IIB osteosarcomas around the knee. J Bone Joint Surg Br 84: 706–11 Stage Size and anatomical situation of the tumor 5. Hefti FL, Gächter A, Remagen W, Nidecker A (1992) Recurrent giant-cell tumor with metaplasia and malignant change, not as- T1a Tumor diameter ≤5 cm, no infiltration of the fascia sociated with radiotherapy. J Bone Joint Surg (Am) 74: 930–4 T1b Tumor diameter ≤5 cm, with infiltration of the fascia 6. Hefti F, Jundt G (1994) Welche Tumoren können in der Epiphyse entstehen? Eine Untersuchung aus dem Basler Knochentumor- T2a Tumor diameter >5 cm, no infiltration of the fascia Referenzzentrum.